"Just One": Applying Leadership Principles in Hospital Settings

Background: Expectations for student nurses to be competent in applying leadership skills at graduation remain unmet. New nurses have difficulty demonstrating necessary leadership skills after graduation. Adapting to a new work environment while using clinical skills and nursing judgment gained from the school setting occupies most of the new nurse’s focus. Problem: Observation of upper level student nurses during assigned in-patient care showed a lack of initiative and ability to apply leadership principles. Discussion with students identified a need for clear guidance for practice of leadership concepts in hospital clinical with faculty oversight followed by debriefing. Goal: Create a plan of action for student nurses to apply one leadership principle on each in-patient clinical day. Method: Evaluate didactic content, past performance on leadership concepts in standardized testing, and review the literature for current, high-need leadership principles in the clinical setting. Experiential learning was identified as the methodology to transform knowledge into action. The essence of servant leadership was threaded into the application strategy to guide students in communication with staff and patients. Principles identified: Delegation, patient advocacy, and response to incivility were the key principles for the pilot study. Application: A one-page handout provided to students the morning of clinical included the definition of the principle with a clear description of the expected action for the day, and an application vignette as an example. During rounds, faculty assessed student attention to the principle of the day. Debriefing, sharing experiences, and a written reflection at the end of the day allowed for the development of connections between the defined principle and the experience of performing the leadership skill in a real patient setting. Evaluation: Student feedback during debriefing validated the need for direction to facilitate successful application of the assigned principle. The use of clear expectations, encouragement, and peer feedback lessened feelings of intimidation and reluctance to venture into unknown practice. The order of principles progressed from the most common and easily understood from didactic to one less frequently encountered in the work environment with a higher degree of anticipated confrontation. Reflective writings were analyzed for key words and phrases to identify themes related to application of each principle. Specific questions in the guided reflections were used to elicit more connections of concepts. Debrief discussion included a review of key concepts for each principle to promote recall and practice of these new skills. Students positively described focus on just one prescribed principle as relieving anxiety while requiring action. All students expressed a desire for this type of application for more abstract skills in the future and stated it was a positive way to learn. Next phase: Validation of positive student responses was key for the pilot study. In the upcoming semester, a brief pre-test about the selected leadership principles before clinical application will occur. A post-test requiring placing actions in order, select-all-that-apply, and multiple choice application questions will assess for improved understanding. Means between the study group and past cohorts on the leadership principles in standardized end of course exams will be compared. Ongoing thematic analysis of debriefing reflections will evaluate student perception and success using the focus on one principle a day approach. An end of course evaluation of the experience will address 1) anxiety before and after accomplishing the skill, 2) success using one principle a day approach, 3) feedback on the expectations, 4) suggestions for improvement, and 5) recommendations for inclusion of additional principles.