Within the field of nursing, there is a general consensus that the development of leadership capacity among nurses is important to ensure high-quality professional practice and positive patient outcomes (Dumas, Blanks, Palmer-Erbs, & Portnoy, 2009; Fleiszer, Semenic, Ritchie, Richer, & Denis, 2015; Harris, Bennett, & Ross, 2014; Harvath et al., 2008; Squires, Tourangeau, Spence Laschinger, & Doran, 2010). This multidimensional capacity has been described as a process “that exerts direct and indirect influence on individuals, their environment, and organizational infrastructures” (Gifford, Davies, Edwards, Griffin, & Lybanon, 2007, p. 128).
A confluence of factors in the 21st century makes leadership capacity particularly relevant to nursing practice in long-term care (LTC). A growing older population with complex needs, combined with high regulatory standards but limited health care resources, means nurses working in LTC face a particular set of challenges. Furthermore, the clinical workforce in LTC has a high percentage of unregulated care providers, which means nurses have greater responsibilities for delegation and supervision within the LTC context (Berta, Laporte, Deber, Baumann, & Gamble, 2013; McGilton, Hall, Wodchis, & Petroz, 2007). In a field of practice with relatively high rates of nursing turnover, higher leadership practice scores have been associated with lower rates of nursing turnover (Chu, Wodchis, & McGilton, 2014). These conditions have led to calls for further study on how best to provide nursing leadership training in LTC homes (Bakerjian et al., 2014; Rankin, 2015).
Many studies have focused on management leadership styles and their impact on various outcomes, including work environments and patient/resident safety (Cummings et al., 2010; Rankin, 2015; Squires et al., 2010). However, much less work has been done on examining the development of leadership skills for nurses involved with direct resident care. In a 2008 review of programs designed to enhance nursing leadership in LTC, Harvath et al. (2008) recommended that “the quality of care and the work environment in nursing homes may improve more by increasing the leadership skills of bedside nurses who are in close daily contact with direct-care workers and residents” (p. 195). This type of clinical nurse leader has been previously defined by Cook (2001) as “a nurse directly involved in providing clinical care that continuously improves care through influencing others” (p. 39).
One study that included LTC nurses involved in direct resident care concluded that it was “possible to deliver leadership development interventions to both established and aspiring nurse leaders that result in fairly rapid improvements in observed leadership practices” (Tourangeau, Lemonde, Luba, Dakers, & Alksnis, 2003, p. 92). This study involved a 5-day residency program and a 2-day “booster” weekend 5 months after the initial training. Another study that included LTC nurses involved in direct patient care concluded that evidence exists for enhanced leadership practices following a sustained and intensive training period of 8 days over 6 months (Vogelsmeier, Farrah, Roam, & Ott, 2010). Although both intervention studies showed some measurable degree of success, they involved considerable time commitment, travel, and financial cost.
This form of intensive training presents a potential barrier to nurses who cannot afford the time off or other costs associated with attending interventions provided through leadership academies or institutes. Therefore, the objectives of the current study were (a) to investigate the perceived leadership education needs of nurses working in LTC along with preferred methods for delivering this learning, and (b) to evaluate the perceived impact of leadership training designed using these insights.
The current study was conducted in and involved LTC organizations located within a region of Ontario, Canada. Research ethics approval was obtained through the Bruyère Research Ethics Board prior to data collection. A three-phase, sequential mixed-methods case study approach was used to address the research questions (Creswell, 2009; Yin, 1994). Table 1 provides an overview of the research sequence and associated methods.
Overview of Research Sequence and Methods
Phase 1 involved an assessment of perceived learning needs and preferred mode of education delivery using quantitative (web-based survey) and qualitative (focus groups) approaches. Purposive sampling was used to obtain perspectives from key informants, including administrators and educators, from a variety of LTC settings for survey and focus group data. The web-based survey was available in French and English. Nursing administrators and educators were included to provide a complementary perspective on clinical nursing education needs and because they are essential for supporting leadership development for nurses providing direct resident care.
Perspectives from nurses involved in daily resident care were further investigated using focus groups. Focus groups were conducted in French and English. The purpose of conducting focus groups was to explore issues raised in survey data as well as to identify other concepts that fell outside pre-defined survey dimensions. This format allowed a shared perspective to emerge that was enhanced by participant discussion (Krueger & Casey, 2014).
Recruitment for all phases of the study involved sending e-mails and posting information about the study in places where staff would see it (e.g., communication books, bulletin boards). The Research Ethics Board and Director of Care at each institution approved e-mail and poster scripts that were used to inform potential participants about study details. All recruitment materials emphasized that participation in the study was voluntary.
The Phase 1 survey was designed using a conceptual framework described by Harvath et al. (2008) and included four dimensions of leadership training: (a) interpersonal, (b) clinical, (c) organizational, and (d) management skills. One item related to student supervision and mentoring was added. Additional questions regarding preferred approach to educational program delivery and available technology were included. Participants were asked to rate leadership skills and delivery formats using Likert scales. The Phase 1 survey was translated into French using a professional translator and reviewed by bilingual investigators (V.F., T.L.) for accuracy. Survey results were analyzed using descriptive frequency statistics.
Focus group questions aimed to further explore participant perceptions on the role of a clinical leader in LTC and associated competencies, along with learning needs and preferred educational strategies. Directed content analysis (Hsieh & Shannon, 2005) was used to analyze focus group notes. Research questions were used as predetermined categories, and participants' responses were coded according to whether they related to role definition, educational need, or preferred learning method. Data were also analyzed for emergent concepts that fell outside predetermined categories.
Insights gained from Phase 1 (data collected by V.F. and T.L.) were used to tailor and deliver a leadership education intervention for nurses. This intervention was evaluated during Phases 2 and 3 (data collected by A.H.). Phase 2 involved collection of survey data from nurses and nurse administrators following delivery of a 2-day education intervention. Phase 3 involved the collection of survey data from both groups of participants 3 months following the intervention. Due to resource constraints, the intervention and subsequent evaluation were conducted in English.
Evaluation surveys were designed with two overall objectives in mind. The first was to have nursing staff self-assess the level of improvement on the leadership skills rated most highly in the needs assessment using a 7-point Likert scale for level of agreement. The survey tools used were modeled after surveys used in similar research (Mann et al., 2008; McLean & Moss, 2003) and adapted for this context. Likert scales have been widely used in nursing research to provide a numerical measure of perception which can then be explored further using qualitative methods (Balasubramanian, 2012; Ho, 2016). The second objective of the survey was to elicit open-ended feedback on the application of leadership knowledge and skills in the workplace (specifically on the ways in which leadership skills were applied), challenges of application, and perceptions on support required for further development.
Analysis of evaluation survey data was conducted using descriptive frequencies for Likert scale responses. Directed content analysis (Hsieh & Shannon, 2005) of open-ended responses was performed for the purpose of providing further insight into how leadership training could be improved. Primary analysis was conducted by A.H. while T.L. and V.F. reviewed data to verify interpretation of open-ended responses. Interpretation was performed through multiple lenses, including those of health administration (A.H.), nursing (V.F.) education (V.F., T.L.), and health research (T.L.G.).
Results for each phase of the research are presented along with a description of how needs assessment data from Phase 1 informed the subsequent phases of research.
Phase 1: Needs Assessment
Survey. A total of 29 nursing administrators and educators from 14 LTC organizations responded to the survey. Key survey results related to learning needs and preferred modes of educational delivery are summarized in Table 2 and Table 3.
Participant Responses to Identified Leadership Skill Set Needs (N = 29)
Participants' Perceived Effectiveness of Education Methods (N = 29)
Perceived Learning Needs. Table 2 summarizes responses to priority leadership skills. Top ranking education needs included: conflict resolution, employee supervision, regulatory compliance, and communication skills.
Preferred Methods of Education Delivery. Table 3 summarizes the responses to the methods of educational delivery that participants believed would be most effective and acceptable. Most respondents indicated preference for an external educator delivering content within their organizations with in-house mentorship. Point of care, one-on-one training was perceived as being most effective.
Focus Groups. Two focus groups were conducted with 22 administrators and educators from 14 regional LTC centers. Six focus groups were conducted with 40 nurses at three separate LTC homes, which varied in size, location (urban, rural, and suburban), and language (English- and French-speaking).
Several concepts emerged from these discussions, which provided further insight on perceived learning needs for clinical leadership in the LTC context. The first of these pertained to the nature of clinical leadership. Emphasis was placed on the importance of good teamwork and being role models who are readily available to provide support. Participants believed that clinical leaders are skilled clinicians that promote and perform resident-centered care through tasks such as teaching, delegation, and providing constructive feedback. Although participants could describe a vision of clinical leadership, many shared they had little formal education on leadership. Clinical leadership skills had been developed through informal mentorship, guidance, and support from nursing colleagues.
Another key concept identified through focus group data was multiple demands in the LTC setting. These demands made certain skills related to conflict resolution, communication, and time management especially important. For participants, it was important that leadership education mirror the challenges inherent in the LTC environment (e.g., working with unregulated care providers, complex resident and family needs, time pressures). Participants described these demands in the context of a highly regulated setting, which added another level of stress. One participant claimed leadership training should address “how to meet regulatory standards without going crazy.”
The final concept that emerged from focus group data was a desire to learn through discussion and sharing. Nurses reported a preference for active and interactive learning strategies, such as discussions, responding to scenarios or videos, and self-reflection. Shorter, teleconference or online activities were acceptable, but face-to-face learning was preferred. Other delivery considerations included being away from the work setting for at least a full day so that nurses could focus on the educational opportunity. Ongoing mentorship was viewed by most participants as a key need of professional development.
Nursing administrators/educators revealed a stronger emphasis on knowledge of regulatory requirements, as well as clinical skill development. Clinical nurses focused on conflict resolution and empowering colleagues, indicating that they already felt comfortable with clinical skills. Preference for a full-day, face-to-face workshop as a mode of education delivery identified in Phase 1 was confirmed through focus groups.
Phase 2: Intervention and Initial Evaluation
Education Intervention. A 2-day workshop was developed by two nursing professors from a partner Community College (V.F. included). Content was informed by an empirical literature review and insights gained through Phase 1 data analysis. Participants included 13 RNs and 12 registered practical nurses with 2 to 30 years of experience. Eight administrators from corresponding institutions participated in the second day of the workshop to share in key learnings from the first workshop day, describe potential barriers to nurses' implementation of leadership practices, and identify strategies to address them.
Background information was provided prior to the first day of the workshop in an online format. The first day of the workshop addressed the different leadership styles with a focus on transformational leadership, along with competencies such as communication, conflict resolution, and delegation. The second day of the workshop began with a review of the first day's content and then focused on mentorship and the development of personal leadership learning objectives informed by self-assessment. Participants were encouraged to develop plans for seeking out a mentor. Assistance was offered to those who wanted a leadership mentor but could not identify one. Sessions on both days were conducted in a classroom setting using a variety of interactive learning strategies (e.g., case scenarios, role plays, discussions).
Initial Evaluation Survey. Surveys administered following each day of the workshop confirmed the desire of clinical staff to learn more in terms of conflict resolution. This topic received the highest scores in relation to the number of participants who were not at all confident and comfortable (n = 3/25), as well as the lowest scores for the percentage of those who were very confident and comfortable (n = 5/25).
Open-ended responses to survey questions revealed an evolving concept of leadership in response to the training as well as motivation to use the training to empower colleagues and staff, as one participant noted, “It has changed my understanding. Being a leader does not mean simply pushing people to do things. There are many ways, especially communication skills, that will help me to be a good leader.”
Following the workshop, 90% of respondents reported that they intended to develop a plan for mentorship and seek a mentor. Reasons for not doing so included a preference for other learning strategies or that mentorship was already in place. Open-ended survey responses suggested what was desired in a mentor as well as who constituted a mentor. One participant explained:
Having someone as a model whom I can emulate. Your mentor has to be caring, helpful, provide support when you are in need, tell you or encourage you to ask questions when in doubt, and not feel intimidated but relaxed when you are around your mentor.
Another participant added, “There is always someone who has a better idea or better way to do things…. A mentor does not have to be a more experienced nurse, it could also be anyone around you.”
The eight administrators who participated during the second day of the workshop identified a number of institutional-level challenges to clinical leadership in the LTC setting, including funding limitations and staffing issues (e.g., shortages, proportion of unregulated and regulated care providers, experience). The heavy focus on meeting regulatory requirements was perceived by some as a competing priority to the development of leadership skills. Six of eight administrators confirmed developing leadership and mentor-ship plans with their staff as part of their current roles. The remaining two administrators reported time constraints, high workloads, and no current leadership initiatives as barriers.
Phase 3: Follow-Up Evaluation Surveys
A total of seven nurses and three administrators responded to the 3-month follow-up survey. Quantitative data collected indicated that improvement in leadership skills were perceived by both nurses (self-assessment) as well administrators (observer assessment). Areas that received the highest improvement scores in terms of nurse self-assessment were conflict resolution, ability to give feedback, and supporting colleagues. The quantitative results collected from clinical nurses are summarized in Table A (available in the online version of this article). Although response rate to the follow-up survey was low (n = 7), most respondents indicated a positive level of agreement to improvement on all leadership items assessed.
Nursing self-assessment survey 3 months following the education intervention n=7 (%)
Qualitative responses to open-ended questions emphasized a sense of growing confidence, particularly in the area of communication. One participant commented, “I think [the clinical leadership program] instilled more confidence in my leadership skills. It is always a positive experience when you meet with peers from different facilities who are dealing with many of the same problems.”
This confidence was especially evident with respect to communication skills with colleagues and management. One participant explained, “I provide information to management regarding health and safety or any concerns and obtain feedback to further learn.” Open-ended responses provided further insight on how leadership education was implemented in the workplace and particular challenges that nurses faced. Although examples varied, they often emphasized the importance of conflict resolution and delegation, as one participant noted:
[We were] short staff[ed] on one working day…. Some staff members show concern and frustration to know we will be short staff[ed]. I was able to reassure staff and relocate resources to maximize productivity and ease stress staff [sic] and continue to provide quality of care.
Follow-up participants also shared ongoing challenges related to supervising unregulated staff often related to time and resource restrictions, with one participant claiming a challenge was “sharing the workload and asking for assistance when swamped. I just find it difficult to even find the time to ask.”
Participants were asked to reflect on how the leadership training could be modified to better meet clinical nurses' needs. Clinical nurses continued to reinforce the need for conflict resolution skills while administrators emphasized the need for knowledge of legislative requirements. Time and budget cutbacks were often mentioned in relation to factors that affected leadership plan goal attainment. An in-person, follow-up session was suggested to help consolidate the learning process along with more specific examples of conflict resolution strategies.
The current study provided a number of insights regarding perceived clinical leadership learning needs in the LTC setting and placed emphasis on communication and conflict resolution skills. The fact that these skills were prioritized by participants throughout the study's three phases deserves some attention. Data indicated that clinical nurses face multiple sources of conflict in managing family concerns or resident complaints. These conflicts occur in a time-pressured environment where staffing shortages often add an additional layer of stress. Siu, Spence Laschinger, and Finegan (2008) found a predictive relationship between positive professional practice environments and nurses' constructive conflict management skills in a study of 678 RNs working in community hospitals. The current study also highlights a relationship between practice setting and conflict resolution skills, which is an important consideration for clinical leadership training in LTC.
From a practice perspective, Harvath et al. (2008) argued that there is increasing evidence to support the link between the quality of care in LTC and the strengthening of nursing care in these settings. Although measurement of resident outcomes was not within the scope of the current study, it is important to recognize the link among developing nurses' leadership skills, improvements in team relationships, and subsequent improvements in resident care. It is essential to recognize that administrative supports for leadership skill development must be in place in LTC settings. This need for support from management is echoed in the study by Tourangeau, Laschinger, and Cranley (2009), who found an overall limited improvement assessment of participants' leadership skills despite leadership education. They relate these limited results to “the perceived lack of time, funding and administrative support to practice leadership behaviours that participants reported when returning to their LTC facilities” (Tourangeau et al., 2009, p. 6). It is essential to recognize that education and mentorship are only two components to clinical leadership role development, and that it is necessary to have institutional support for positive change to be realized.
Data from nursing administrators emphasized the additional dimension of regulatory compliance knowledge. In the study context, these regulations referred to Ontario's Long-Term Care Homes Act (2007), which was enacted with the goal that all residents receive safe, consistent, high-quality, resident-centered care. This Act sets detailed standards and procedures for all aspects of care. Paradoxically, the current study suggested that keeping up with regulatory compliance and other administrative duties was a perceived leadership development challenge for clinical nurses in LTC. An alternate point of view is that stronger clinical leadership would support a LTC home administrator's ability to meet regulatory requirements. This hypothesis warrants further exploration in future studies, particularly because few studies have addressed the impact of Ontario's Long-Term Care Homes Act.
In an age of growing support for online learning opportunities (Neuhauser, 2010), it was interesting that nurses indicated a preference for an in-person workshop. This preference may reflect clinical nurses' sentiment that they had to be removed enough from the unit to be able to engage with learning. Part of this preference came from a desire to share information, which many participants indicated they appreciated as part of the learning opportunity. Although the current study did not prescribe the optimal format, it suggested there was a strong preference for learning context-specific strategies, especially those related to conflict resolution skills.
Evaluation data indicated that a 2-day workshop was feasible and resulted in perceived leadership skill improvement, primarily in the domain of interpersonal leadership skills. Because follow-up evaluation participation was low (30% of workshop participants), the study is limited in what it can conclude about sustained benefits. As such, non-respondents in Phase 3 may not have experienced perceived improvement in leadership skills. However, the follow-up responses obtained supported ongoing perceived improvements in interpersonal leadership skills. More importantly, these responses provided context-specific examples of how these skills were used.
A notable limitation of the current study was that all data in Phases 2 and 3 were collected in English, meaning only bilingual Francophone individuals were able to participate. This limitation allowed consistency in the delivery of the education intervention and application of data collection tools, but may have limited participation from Francophone settings. This limitation also meant that a subgroup analysis comparing differences from linguistic groups could not be performed. Small follow-up numbers precluded subgroup analysis on other demographic factors, such as professional designation or years of experience. These constituted additional demographic factors that may be important to consider in future studies. Context-specific considerations for the transferability of these findings include legislated regulatory frameworks, availability and feasibility of onsite mentorship, past exposure to online learning opportunities, and feasibility of providing an off-unit–funded education intervention. The fact that nursing workshop attendance was funded but that minimal incentive was available at follow-up could have affected the difference in participation rates between Phases 2 and 3. A face-to-face follow-up “booster” workshop, like the one used by Tourangeau et al. (2009), may have improved follow-up responses.
Findings on perceived clinical leadership needs indicate that nurses in LTC support off-unit, face-to-face training with a focus on interpersonal leadership skills, including strategies for conflict resolution. The relationship between clinical leadership skills and context of regulatory frameworks deserves further study and must be considered in the development of clinical leadership training programs in the LTC setting.
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Overview of Research Sequence and Methods
|Phase of Research||Data Collection Methods|
|Phase 1 (pre-intervention): Needs assessment||Survey (nurse administrators and educators)|
|Focus groups (nurse administrators, educators, nurses)|
|Phase 2 (immediately post-intervention): Delivery of education intervention tailored using insights from Phase 1 (2-day workshop)||Survey (nurses)|
|Survey (nurse administrators)|
|Phase 3 (follow up, post-intervention): Mentorship and follow-up period (1 to 3 months)||Survey (nurses)|
|Survey (nurse administrators)|
Participant Responses to Identified Leadership Skill Set Needs (N = 29)
|Skill Set Need||n (%)|
| Communication||22 (76)a||7 (24)||0|
| Inspiration/motivation||16 (55)||11 (38)||2 (7)|
| Conflict resolution||23 (79)a||4 (14)||2 (7)|
| Relationship building||15 (52)||12 (41)||2 (7)|
| Self-awareness||16 (55)||11 (38)||2 (7)|
| Use of best practices||17 (59)||11 (38)||1 (3)|
| Research use||6 (21)||14 (48)||9 (31)|
| Gerontological nursing||17 (59)||11 (38)||1 (3)|
| Organizational/time management||19 (66)a||10 (34)||0|
| Person-centered care||18 (62)a||11 (38)||0|
|Related to Organization|
| Strategic planning/vision||5 (17)||18 (62)||6 (21)|
| Policy and program development||6 (21)||16 (55)||7 (24)|
| Team building||17 (59)||11 (38)||1 (3)|
| Change theory||12 (41)||15 (52)||2 (7)|
| Recruitment/retention||6 (21)||9 (31)||14 (48)|
| Human resources policies and procedures||7 (24)||14 (48)||8 (28)|
| Regulatory compliance||21 (72)||8 (28)||0|
| Financial/budgetary planning||3 (10)||12 (41)||14 (48)|
| Employee supervision/mentoring||23 (79)||5 (17)||1 (3)|
| Student supervision/mentoring||13 (45)||14 (48)||2 (7)|
| Quality improvement||20 (69)a||8 (28)||1 (3)|
Participants' Perceived Effectiveness of Education Methods (N = 29)
|Education Method||Effective||Not Effective||Not Applicable|
|1-day, in-house workshops||22 (76)a||4 (14)||3 (10)|
|1-day, external workshops||26 (90)a||3 (10)||—|
|45-minute sessions||22 (76)a||5 (17)||2 (7)|
|Handouts/readings||14 (48)||13 (45)||2 (7)|
|Online modules||16 (55)||6 (21)||7 (24)|
|Point of care training/one-on-one||28 (97)a||1 (3)||—|
|Mentorship/coaching by staff from within agency||20 (69)a||3 (10)||6 (21)|
|Mentorship/coaching by individuals external to agency||14 (48)||2 (7)||13 (45)|
|Inservices at shift change||16 (55)||9 (31)||4 (14)|
|Role play/simulations||10 (34)||6 (21)||13 (45)|
Nursing self-assessment survey 3 months following the education intervention n=7 (%)
|Clinical Nursing level of agreement||I have improved my conflict resolution skills||I have improved my communication skills||I have improved my interpersonal skills||I have improved my organizational and time management skills||I have improved my ability for person-centered care||I have improved my attributes of supporting and respecting my colleagues|
|7||2 (29 %)||1 (14%)||1 (14%)||1 (14%)||1 (14%)||2 (29%)|
|6||1 (14%)||4 (57%)||3 (43%)||4 (57%)||4 (57%)||3 (43%)|
|5||2 (29%)||1 (14%)|
|No response||2 (29%)||2 (29%)||2 (29%)||2 (29%)||2 (29%)||2 (29%)|
|Clinical Nursing level of agreement||I have improved my self-awareness and personal insight||I have improved my employee supervision and mentoring skills||I have improved my ability to give feedback to others||I have improved my accountability||I have improved my self confidence||I have improved my teaching and coaching skills||I am clear on my role and expectations in my current position|
|7||1 (14%)||1 (14%)||2 (29%)||1 (14%)||1 (14%)||1 (14%)||2 (29%)|
|6||3 (43%)||4 (57%)||2 (29%)||3 (43%)||4 (57%)||4 (57%)||3 (43%)|
|5||1 (14%)||1 (14%)||1 (14%)|
|No response||2 (29%)||2 (29%)||2 (29%)||2 (29%)||2 (29%)||2 (29%)||2 (29%)|