Nurses are recognized as having critical knowledge and awareness of patients, families, and communities and are the most trusted professionals (Institute of Medicine [IOM], 2010). Nevertheless, nurses are not perceived as important decision makers by the public and often do not self-identify as leaders. The deficit of leadership competencies is particularly evident at the sharp end of the healthcare system and is characterized as an international crisis in frontline, or clinical leadership (Fitzpatrick, Modic, Van Dyke, & Hancock, 2016; Grindel, 2016). Despite the perceived leadership crisis among direct-care nurses, few studies have objectively and rigorously examined the actual leadership practices and competencies of this population (Mianda & Voce, 2018). The aims of this study were to examine the range of leadership practices among direct-care medical-surgical nurses and identify contextual conditions that may influence leadership development.
Methods:
A descriptive cross-sectional electronic self-report survey design in a convenience sample of registered nurses caring for medical-surgical patients recruited through social media (July 2017-April 2018) was used. Nurses in indirect care roles and previous managerial experience were excluded. Leadership practices were assessed with the Leadership Practices Inventory (LPI) (Posner,2016); participation in leadership activities was assessed with the Participation in Leadership Activities (PLAS) inventory; and contextual variables were assessed using items on a demographic survey. The range of leadership behaviors was examined using descriptive statistics for the LPI total score (30 items; 10-point response scale; possible range 30-300) and five LPI subscale scores: (6 items each; possible range 6-60): Model the Way; Inspire a Shared Vision; Challenge the Process; Enable Others to Act; and Encourage the Heart. The frequency of participation in leadership activities was examined using descriptive statistics for the PLAS (22 items; 4-point response scale; possible scores 22-88). Associations between total LPI scores and continuous contextual variables were examined using Pearson correlations; associations between categorical contextual variables and LPI scores were examined using Chi Square with LPI cut score for the top quartile to distinguish high performers.
Results:
Participants (n=1856) were primarily female (93%) and employed full time (88%) as staff nurses (70%) in Magnet designated (57%) acute care hospitals (76%). Moreover, they were professionally educated (57% baccalaureate) with a national certification (79%). All instrument scales and subscales were determined reliable based on Cronbach alpha results: Model the Way α=.75; Inspire a Shared Vision α=.89; Challenge the Process α=.84; Enable Others to Act α=.77; Encourage the Heart α=.83; and PLAS α=.92. Mean LPI scores and standard deviations were: total LPI=221.09 (37.34); Model the Way=46.68 (7.75); Inspire a Shared Vision=40.10 (10.82); Challenge the Process=41.86 (9.40); Enable Others to Act=49.06 (6.64); and Encourage the Heart=45.39 (8.55). The mean PLAS score was 50.03 (14.31). Contextual variables with a weak to moderate association with leadership behavior included: timing of highest academic education in relation to the Future of Nursing report, previous leadership education, experience in charge nurse role, hospital practice setting, hospital size (>/= 500 beds), hospital ownership, and participation in leadership activities. In contrast, neither age, experience (nursing or current unit), academic degree, certification status, or Magnet designation were associated with leadership behaviors. The effect of participation in leadership activities on leadership behaviors was strongest in the areas of Inspire a Shared Vision (r=.399) and Challenge the Process (r=.397).
Conclusion:
Direct-care medical-surgical nurses engage in leadership behaviors at a rate slightly lower than what is reported in the LPI normative database (Posner, 2016), studies of direct care nurses (Fitzpatrick et al., 2016); and studies of nurses in managerial positions (Herman, Gish, & Rosenblum, 2015; Herman, Gish, Rosenblum, & Herman, 2017; Kelly, Wicker, & Gerkin, 2014). Areas of leadership strength for direct-care medical-surgical nurses include personal accountability (Model the Way) and attending to relational needs of co-workers (Enabling Others to Act). Like other disciplines, engagement in leadership behaviors among direct-care medical-surgical nurses is lowest in the areas of Inspiring a Shared Vision and Challenging Processes (Posner, 2016). Moreover, the gap between leadership performance of direct-care medical-surgical nurses and LPI normative means was greatest in these two areas. Special challenges for leadership development in these areas are associated with the organization of nurses’ work and the socialization of nurses as clinicians and employees. Shift work directs one’s focus on completing present tasks and current workloads leave little time for looking outward and developing a future-oriented vision. Through academic institutions and employer orientation programs direct care nurses are socialized to view established rules and processes through the lens of patient safety. Standardization and compliance are the measuring rods for safety and nonconformance potentially places patients (and organizations) at risk. Therefore, challenging traditional processes, even for the sake of patient safety, may produce a level of cognitive dissonance that is difficult for direct-care nurses to resolve (D’Lima, Murray, & Brett, 2018; Price, Duffy, McCallum, & Ness, 2015). Leadership development initiatives are needed for direct-care medical-surgical nurses across all practice settings; however, special attention to smaller hospitals and non-hospital settings is warranted. Leadership development among direct care nurses may be positively influenced by targeted leadership education, intentional modeling, and specific experiences in the practice setting that facilitate skill development in creating a shared vision within a team and leading change for improvement (Curtis, Sheerin, & de Vries, 2011; Ennis, Happell, & Reid-Searl, 2016; Kelly, Wicker, & Gerkin, 2014). Opportunities for service on committees and in the charge nurse role are particularly suited for skill development in these areas (Krugman, Heggem, Kinney, & Frueh, 2013).