Identifying and Measuring Nurse Leader Communication Behaviors

In the clinical setting, communication is a primary nursing activity, accounting for 62-84% of total nursing time.^1-5 In the United States, communication has been identified as the third leading root cause for sentinel events accounting for over 20% in root cause analyses,⁶ whereas a Danish study found verbal communication errors in 52% of root cause analyses. A core leadership competency in healthcare,⁷ effective communication behaviors foster collaborative relationships and ineffective communication behaviors act as a barrier.^8,9

Nurse leader communication has been identified as a component of structural empowerment that impacts empowerment of nurses.¹³ According to the theory of structural empowerment, the hierarchic structure of the organization influences behaviors of leaders and their followers.¹⁰ Empowerment of staff nurses by nursing leaders has been associated with positive outcomes such as trust, job satisfaction and performance.^10-12

Negative leadership behaviors, such as decreased leader communication, is correlated with lower perceptions of productivity and morale.¹⁴ These toxic behaviors include belittling or embarrassing employees, boasting, yelling and criticizing in front of others.^14,15 Communication behaviors associated with bullying, such as raising of eyebrows, snide remarks, abrupt responses, lack of openness, bickering, and complaining about others have been associated with absenteeism, intention to leave and staff turnover.^16-18

A gap exists, however, in how to assess and develop these leader communication behaviors to assist in shaping a healthy work environment. The communication assessment tools currently available, either in the literature or publicly, rely primarily on self-assessment. The literature indicates that self-assessment conducted individually is not necessarily accurate or reliable,^19,20 especially for persons with the least developed skills and most confidence within the assessed area.²¹ A recommendation is to integrate external feedback with self-assessments.²²

The purpose of this study was to identify and measure the characteristics of nurse leader communication behaviors through external feedback. The primary aim was to develop a survey instrument that measured the characteristics of nurse leader communication behaviors as perceived by staff nurses. The secondary aim was to determine if these behaviors are related to staff nurse psychological empowerment.

This exploratory instrument development study used the following steps recommended by DeVellis:²³1) identify constructs, 2) generate items, 3) test content and face validity, 4) evaluate construct validity, and 5) evaluate criterion related validity. The coded and aggregated findings from four focus groups of inpatient nurses and nurse leaders (n = 16) were used to validate the a priori concepts from the literature. After the research team developed 208 initial items, four experts in research and/or nursing leadership reviewed the items for content validity. Based on the feedback, the items were modified and reduced to 125 items that were then reviewed by four staff nurses from the target population for face validity. The 108 final items are currently being piloted in a small convenience sample of inpatient staff nurses concurrently with a 12-item Psychological Empowerment Scale for criterion-related validity. With a current response rate of 34, efforts are being made to increase the response rate to at least 50 prior to data analysis.

The ordinal survey item data will be analyzed for item means, variances, and item-scale correlations. Although controversial, a preliminary confirmatory factor analysis will be conducted to guide further refinement of the items in the developed instrument. The correlation between communication behaviors and nurse psychological empowerment will be explored using the frequency of positive communication behaviors by nurse leaders as the explanatory variable (or variables) and the PES scores as the criterion variable. The results are currently pending.

The developed instrument may help shape communication behaviors by nurse leaders as they have a direct impact on a healthy work environment. Focused external feedback on leader communication behaviors could bridge the gap in the existing available tools for leadership development. Through identification of specific strengths and areas for improvement in the nursing leaders within a facility, targeted educational interventions or even one-on-one mentorship could be implemented to improve the environment. A core leadership competency, positive or empowering communication is essential in creating and sustaining a healthy work environment.