Greta G. Cummings

Leadership styles and outcome patterns for the nursing workforce and work environment: A systematic review

CONTEXT Numerous policy and research reports call for leadership to build quality work environments, implement new models of care, and bring health and wellbeing to an exhausted and stretched nursing workforce. Rarely do they indicate how leadership should be enacted, or examine whether some forms of leadership may lead to negative outcomes. We aimed to examine the relationships between various styles of leadership and outcomes for the nursing workforce and their work environments. METHODS The search strategy of this multidisciplinary systematic review included 10 electronic databases. Published, quantitative studies that examined leadership behaviours and outcomes for nurses and organizations were included. Quality assessments, data extractions and analysis were completed on all included studies. FINDINGS 34,664 titles and abstracts were screened resulting in 53 included studies. Using content analysis, 64 outcomes were grouped into five categories: staffsatisfaction with work, role and pay, staff relationships with work, staff health and wellbeing, work environment factors, and productivity and effectiveness. Distinctive patterns between relational and task focused leadership styles and their outcomes for nurses and their work environments emerged from our analysis. For example, 24 studies reported that leadership styles focused on people and relationships (transformational, resonant, supportive, and consideration) were associated with higher nurse job satisfaction, whereas 10 studies found that leadership styles focused on tasks (dissonant, instrumental and management by exception) were associated with lower nurse job satisfaction. Similar trends were found for each category of outcomes. CONCLUSION Our results document evidence of various forms of leadership and their differential effects on the nursing workforce and work environments. Leadership focused on task completion alone is not sufficient to achieve optimum outcomes for the nursing workforce. Efforts by organizations and individuals to encourage and develop transformational and relational leadership are needed to enhance nurse satisfaction, recruitment, retention, and healthy work environments, particularly in this current and worsening nursing shortage.

The Impact of Hospital Nursing Characteristics on 30-Day Mortality

BACKGROUND Evidence indicates that hospital nursing characteristics such as staffing contribute to patient outcomes. Less attention has been given to other hospital nursing characteristics central to optimal professional practice, namely nurse education and skill mix, continuity of care, and quality of the work environment. OBJECTIVE To assess the relative effects and importance of nurse education and skill mix, continuity of care, and quality of work environment in predicting 30-day mortality after adjusting for institutional factors and individual patients characteristics. METHOD A cross-sectional analysis of outcome data for 18,142 patients discharged from 49 acute care hospitals in Alberta, Canada, for diagnoses of acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, pneumonia, or stroke between April 1, 1998, and March 31, 1999, was done. Mortality data were linked to patient demographic and comorbidity factors, institutional characteristics, and hospital nursing characteristics derived from a survey of all registered nurses working in acute care hospitals. RESULTS Using multilevel analysis, it was determined that the log-odds for 30-day mortality varied significantly across hospitals (variance = .044, p < .001). Patient comorbidities and age explained 44.2% of the variance in 30-day mortality. After adjustment for patient comorbidities and demographic factors, and the size, teaching, and urban status of the study hospitals in a fixed-effects model, the odds ratios (95% confidence interval) of the significant hospital nursing characteristics that predict 30-day mortality were as follows: 0.81 (0.68-0.96) for higher nurse education level, 0.83 (0.73-0.96) for richer nurse skill mix, 1.26 (1.09-1.47) for higher proportion of casual or temporary positions, and 0.74 (0.60-0.91) for greater nurse-physician relationships. The institutional and hospital nursing characteristics explained an additional 36.9%. DISCUSSION Hospital nursing characteristics are an important consideration in efforts to reduce the risk of 30-day mortality of patients.

The relationship between nursing leadership and patient outcomes: a systematic review update

AIM Our aim was to describe the findings of a systematic review of studies that examine the relationship between nursing leadership practices and patient outcomes. BACKGROUND As healthcare faces an economic downturn, stressful work environments, upcoming retirements of leaders and projected workforce shortages, implementing strategies to ensure effective leadership and optimal patient outcomes are paramount. However, a gap still exists in what is known about the association between nursing leadership and patient outcomes. METHODS Published English-only research articles that examined leadership practices of nurses in formal leadership positions and patient outcomes were selected from eight online bibliographic databases. Quality assessments, data extraction and analysis were completed on all included studies. RESULTS A total of 20 studies satisfied our inclusion criteria and were retained. Current evidence suggests relationships between positive relational leadership styles and higher patient satisfaction and lower patient mortality, medication errors, restraint use and hospital-acquired infections. CONCLUSIONS The findings document evidence of a positive relationship between relational leadership and a variety of patient outcomes, although future testing of leadership models that examine the mechanisms of influence on outcomes is warranted. IMPLICATIONS FOR NURSING MANAGEMENT Efforts by organisations and individuals to develop transformational and relational leadership reinforces organisational strategies to improve patient outcomes.

Influence of organizational characteristics and context on research utilization.

Background: Despite three decades of empirical investigation into research utilization and a renewed emphasis on evidence-based medicine and evidence-based practice in the past decade, understanding of factors influencing research uptake in nursing remains limited. There is, however, increased awareness that organizational influences are important. Objectives: To develop and test a theoretical model of organizational influences that predict research utilization by nurses and to assess the influence of varying degrees of context, based on the Promoting Action on Research Implementation in Health Services (PARIHS) framework, on research utilization and other variables. Methods: The study sample was drawn from a census of registered nurses working in acute care hospitals in Alberta, Canada, accessed through their professional licensing body (n = 6,526 nurses; 52.8% response rate). Three variables that measured PARIHS dimensions of context (culture, leadership, and evaluation) were used to sort cases into one of four mutually exclusive data sets that reflected less positive to more positive context. Then, a theoretical model of hospital- and unit-level influences on research utilization was developed and tested, using structural equation modeling, and 300 cases were randomly selected from each of the four data sets. Results: Model test results were as follows-low context: &khgr;2 = 124.5, df = 80, p <. 001; partially low: &khgr;2 = 144.2, p <. 001, df = 80; partially high: &khgr;2 = 157.3, df = 80, p <. 001; and partially low: &khgr;2 = 146.0, df = 80, p <. 001. Hospital characteristics that positively influenced research utilization by nurses were staff development, opportunity for nurse-to-nurse collaboration, and staffing and support services. Increased emotional exhaustion led to less reported research utilization and higher rates of patient and nurse adverse events. Nurses working in contexts with more positive culture, leadership, and evaluation also reported significantly more research utilization, staff development, and lower rates of patient and staff adverse events than did nurses working in less positive contexts (i.e., those that lacked positive culture, leadership, or evaluation). Conclusion: The findings highlight the combined importance of culture, leadership, and evaluation to increase research utilization and improve patient safety. The findings may serve to strengthen the PARIHS framework and to suggest that, although it is not fully developed, the framework is an appropriate guide to implement research into practice.

Factors Contributing to Nursing Leadership: A Systematic Review

Objectives: Leadership practices of health care managers can positively or negatively influence outcomes for organizations, providers and, ultimately, patients. Understanding the factors that contribute to nursing leadership is fundamental to ensuring a future supply of nursing leaders who can positively influence outcomes for health care providers and patients. The purpose of this study was to systematically review the multidisciplinary literature to examine the factors that contribute to nursing leadership and the effectiveness of educational interventions in developing leadership behaviours among nurses. Methods: The search strategy began with 10 electronic databases (e.g. CINAHL, Medline). Published quantitative studies were included that examined the factors that contribute to leadership or the development of leadership behaviours in nurse leaders. Quality assessments, data extraction and analysis were completed on all included studies. Results: A total of 27,717 titles/abstracts were screened resulting in 26 included manuscripts reporting on 24 studies. Twenty leadership factors were examined and categorized into four groups - behaviours and practices of individual leaders, traits and characteristics of individual leaders, influences of context and practice settings, and leader participation in educational activities. Specific behaviours and practices of individual leaders, such as taking on or practising leadership styles, skills and roles, were reported as significantly influencing leadership in eight studies. Traits and characteristics of individual leaders were examined in six studies with previous leadership experience (three studies) and education levels (two of three studies) having positive effects on observed leadership. Context and practice settings had a moderate influence on leadership effectiveness (three of five studies). Nine studies that examined participation in leadership development programs all reported significant positive influences on observed leadership. Conclusion: These findings suggest that leadership can be developed through specific educational activities, and by modelling and practising leadership competencies. However, the relatively weak study designs provide limited evidence for specific factors that could increase the effectiveness of current nursing leadership or guide the identification of future nurse leaders. Robust theory and research on interventions to develop and promote viable nursing leadership for the future are needed to achieve the goal of developing healthy work environments for health care providers and optimizing care for patients.

Emotional intelligence and nursing: An integrative literature review

AIM The purpose of this paper is to present findings of an integrative literature review related to emotional intelligence (EI) and nursing. BACKGROUND A large body of knowledge related to EI exists outside nursing. EI theory and research within nursing is a more recent phenomenon. A broad understanding of the nature and direction of theory and research related to EI is crucial to building knowledge within this field of inquiry. METHOD A broad search of computerized databases focusing on articles published in English during 1995-2007 was completed. Extensive screening sought to determine current literature themes and empirical research evidence completed in nursing focused specifically on emotional intelligence. RESULTS 39 articles are included in this integrative literature review (theoretical, n=21; editorial, n=5; opinion, n=4 and empirical, n=9). The literature focuses on EI and nursing education, EI and nursing practice, EI and clinical decision-making, and EI and clinical leadership. Research that links EI and nursing are mostly correlation designs using small sample sizes. CONCLUSION This literature reveals widespread support of EI concepts in nursing. Theoretical and editorial literature confirms EI concepts are central to nursing practice. EI needs to be explicit within nursing education as EI might impact the quality of student learning, ethical decision-making, critical thinking, evidence and knowledge use in practice. Emotionally intelligent leaders influence employee retention, quality of patient care and patient outcomes. EI research in nursing requires development and careful consideration of criticisms related to EI outside nursing is recommended.

Mitigating the impact of hospital restructuring on nurses: the responsibility of emotionally intelligent leadership.

BackgroundA decade of North American hospital restructuring in the 1990s resulted in the layoff of thousands of nurses, leading to documented negative consequences for both nurses and patients. Nurses who remained employed experienced significant negative physical and emotional health, decreased job satisfaction, and decreased opportunity to provide quality care. ObjectiveTo develop a theoretical model of the impact of hospital restructuring on nurses and determine the extent to which emotionally intelligent nursing leadership mitigated any of these impacts. MethodsThe sample was drawn from all registered nurses in acute care hospitals in Alberta, Canada, accessed through their professional licensing body (N = 6,526 nurses; 53% response rate). Thirteen leadership competencies (founded on emotional intelligence) were used to create 7 data sets reflecting different leadership styles: 4 resonant, 2 dissonant, and 1 mixed. The theoretical model was then estimated 7 times using structural equation modeling and the seven data sets. ResultsNurses working for resonant leaders reported significantly less emotional exhaustion and psychosomatic symptoms, better emotional health, greater workgroup collaboration and teamwork with physicians, more satisfaction with supervision and their jobs, and fewer unmet patient care needs than did nurses working for dissonant leaders. DiscussionResonant leadership styles mitigated the impact of hospital restructuring on nurses, while dissonant leadership intensified this impact. These findings have implications for future hospital restructuring, accountabilities of hospital leaders, the achievement of positive patient outcomes, the development of practice environments, the emotional health and well-being of nurses, and ultimately patient care outcomes.

Determinants of hospital nurse intention to remain employed: Broadening our understanding.

Title Determinants of hospital nurse intention to remain employed: broadening ourunderstanding. Aim This paper is a report of a study to identify nurse reported determinants of intention to remain employed and to develop a model explaining determinants of hospital nurse intention to remain employed. Background A worsening shortage of nurses globally suggests that efforts must be made to promote retention of nurses. However, effective retention promotion strategies depend on understanding the factors influencing nurse retention. Methods A descriptive study using focus group methodology was implemented. Thirteen focus groups including 78 nurses were carried out in two Canadian provinces in 2007. Thematic analysis strategies were incorporated to analyse the data. Findings Eight thematic categories reflecting factors nurses described as influencing their intentions to remain employed emerged from focus groups: (1) relationships with co-workers, (2) condition of the work environment, (3) relationship with and support from one’s manager, (4) work rewards, (5) organizational support and practices, (6) physical and psychological responses to work, (7) patient relationships and other job content, and (8) external factors. A model of determinants of hospital nurse intention to remain employed is hypothesized. Conclusion Findings were both similar to and different from previous research. The overriding concept of job satisfaction was not found. Rather, nurse assessments of satisfaction within eight thematic categories were found to influence intentions to remain employed. Further testing of the hypothesized model is required to determine its global utility. Understanding determinants of intention to remain employed can lead to development of strategies that strengthen nurse retention. Incorporation of this knowledge in nurse education programmes is essential.

Predicting research use in nursing organizations : a multilevel analysis

Background: No empirical literature was found that explained how organizational context (operationalized as a composite of leadership, culture, and evaluation) influences research utilization. Similarly, no work was found on the interaction of individuals and contextual factors, or the relative importance or contribution of forces at different organizational levels to either such proposed interactions or, ultimately, to research utilization. Objective: To determine independent factors that predict research utilization among nurses, taking into account influences at individual nurse, specialty, and hospital levels. Design: Cross-sectional survey data for 4,421 registered nurses in Alberta, Canada were used in a series of multilevel (three levels) modeling analyses to predict research utilization. Methods: A multilevel model was developed in MLwiN version 2.0 and used to: (a) estimate simultaneous effects of several predictors and (b) quantify the amount of explained variance in research utilization that could be apportioned to individual, specialty, and hospital levels. Findings: There was significant variation in research utilization (p <.05). Factors (remaining in the final model at statistically significant levels) found to predict more research utilization at the three levels of analysis were as follows. At the individual nurse level (Level 1): time spent on the Internet and lower levels of emotional exhaustion. At the specialty level (Level 2): facilitation, nurse-to-nurse collaboration, a higher context (i.e., of nursing culture, leadership, and evaluation), and perceived ability to control policy. At the hospital level (Level 3): only hospital size was significant in the final model. The total variance in research utilization was 1.04, and the intraclass correlations (the percent contribution by contextual factors) were 4% (variance = 0.04, p <.01) at the hospital level and 8% (variance = 0.09, p <.05) at the specialty level. The contribution attributable to individual factors alone was 87% (variance = 0.91, p <.01). Conclusions: Variation in research utilization was explained mainly by differences in individual characteristics, with specialty- and organizational-level factors contributing relatively little by comparison. Among hospital-level factors, hospital size was the only significant determinant of research utilization. Although organizational determinants explained less variance in the model, they were still statistically significant when analyzed alone. These findings suggest that investigations into mechanisms that influence research utilization must address influences at multiple levels of the organization. Such investigations will require careful attention to both methodological and interpretative challenges present when dealing with multiple units of analysis.

Increasing retention of new graduate nurses: a systematic review of interventions by healthcare organizations.

With the nursing shortage and the high incidence of turnover among new graduate nurses (NGNs) within the first year of employment, there is an increased need to investigate the effectiveness of retention strategies aimed at retraining NGNs. The purpose of this articled was to determine which organizational strategies increase the retention rates of NGNs. A systematic review of the research literature was conducted to examine published studies that focused on a retention strategy implemented to influence NGNs to stay in their place of employment. Data were extracted, and the quality of each study was assessed. Sixteen published studies were included in this review. Of these, 13 did not use true experimental study designs. Based on the studies with the strongest designs, the highest retention rates were associated with retention strategies that used a preceptor program model that focused on the NGN as well as a program length of 3 to 6 months. Evidence for the effectiveness of implementation strategies is limited; however, it is apparent from all the studies reviewed that implementing a retention strategy is effective for increasing retention rates of NGNs.