NURSE LEADER DEVELOPMENT1
Nurse Leader Development: A Review of Literature
Corinne Bradley
Ferris State University
Nurse Leader Development: A Review of Literature
Healthcare is ever evolving, requiring continual change and adaptability. With recent healthcare changes the nursing profession is being sought out to assist with the growing patient population. The Institute of Medicine (IOM) (2010) reported this need when identifying the high number of nursing professionals and the level of expertise they offer. The need for leaders in nursing is evident and in order to meet this need, leadership development is necessary.
Nursing leadership is centered on advanced and continual education as well as utilization of theoretical practices. The need for advanced degree nurses is present; however there are not enough nurse leaders to assist in mentoring those seeking higher degrees, again demonstrating the need for more advanced degree nurses (Oehrtman, Smolen, Hoblet, & Phillips, 2010). Theoretical practice is an expectation of the nursing profession and critical for those seeking high degrees and leadership positions. Many theories exist and two have been identified to support this literature review on nurse leader development including Donabedian’s Theory based around quality improvement, and Jean Watsons Theory of Transpersonal Caring (Jesse, 2010; Johnson, 2012).
When conducting a review of literature pertaining to nursing leadership, many common themes were discovered. The most common theme defined was the quality of care provided and how nursing leadership directly impacts this. Other common themes noted were patient satisfaction, employee engagement, and financial considerations. Quality patient care directly relates to all of the other common themes noted again emphasizing the importance of nursing leadership’s involvement with care practices. The purpose of this literature review is to focus on common themes identified in the development of a leader in nursing,and how these themes relate to theoretical practice.
Quality of Care
The quality of care provided to the patient is a large focus in healthcare and leading changes in the way that care is provided. Some of these changes are directly related to financial reimbursement based on the patient’s perception of the quality of care they receive, which is provided through patient satisfaction surveys (Mazza & Fazzi, 2009). Healthcare agencies are focusing on quality improvement continuously to ensure best practices are in place and that patients are receiving the desired level of care (Al-Abria & Al-Balushi, 2013). The focus on quality is also impacting who is hired into healthcare agencies at all levels of care to ensure quality care is of importance (Barry, 2012). It is essential that nurse leaders focus on the quality of care that is being provided by staff to patients (Kobayashi, Takemura, & Kanda, 2010). There are two main focuses of care quality that will be discussed in this literature review including evidence based practice and process improvement.
Evidence Based Practice
EBP uses current evidence and expertise of the clinician while also focusing on the individual needs and values of the patient (Tracy & Barnsteiner, 2012). Evidence based practice (EBP) is critical in ensuring that best care practices are being performed, improving patient outcomes and patient satisfaction. Tracy and Barnsteiner (2012) discuss how the focus on EBP stems from IOM reports on improving healthcare and patient outcomes with an alarming 15 percent of care processes actually being based on evidence.
EBP requires a systemic standardized approach to improving care processes. Melnyk, Gallagher-Ford, Long, and Fineout-Overholt (2014) discuss seven steps that assist in developing EBP care processes. The steps include cultivating a spirit of questioning among all care staff, asking questions, seeking answers using evidence, appraising the evidence with a critical eye, integrating the evidence into practice, evaluating the outcomes from the EBP changes, and ensuring that education of the outcomes is disseminated across the system (Melnyk et al., 2014).
There are many identified barriers to EBP. Melnyk, Gallagher-Ford, Long, and Fineout-Overholt (2014) identify the barriers of misconceptions of time constraints on EBP, lack of knowledge and skill to obtain adequate evidence, the difference between extensive research and EBP care processes, the lack of organization support, lack of mentorship on how to conduct and provide EBP, and the resistance of peers, leaders and executives. Tracy and Barnsteiner (2012) also have identified barriers including the lack of knowledge and skill to implement the evidence based findings into practice, and the lack of support from managers.
Nurse leaders must support EBP in care processes and mentor staff to assist them in successfully implementing process changes and collecting data of subsequent outcomes. This support begins with creating a culture that supports staff seeking out evidence based answers to their questions/concerns regarding patient care processes (Melynk,Gallagher-Ford, Long, Fineout-Overholt, 2014). Nurse leaders need to encourage this type of practice and provides the necessary tools and mentors to ensure successful change and improved patient outcomes.
Process Improvement
In order to improve the quality of care provided, there must be continuous process improvement. Lemak, Cohen, and Erb (2013) discuss how quality care and process improvement not only impact patient outcomes but also the level and amount of reimbursement for services that healthcare organizations receive. Blue Cross Blue Shield of Michigan (BCBSM) a large insurance payer source in the state of Michigan sought out ways to improve patient outcomes by holding care providers accountable and by providing additional quality improvement resources (Lemak et al., 2013). This is not exclusive to Michigan as many payer sources are looking at ways to pay for patient outcomes and not just services rendered. The nurse leader must recognize opportunities for process improvement to ensure quality care is provided to all patients.
There are many types of process improvement including root cause analysis (RCA). RCAs allow a team to take an incident and using a diagram such as a fishbone break down different elements to discover the root cause, allowing for process improvement to ensure the incident doesn’t occur again (Johnson, 2012). An example of a successful RCA is related to central line-associated bloodstream infections conducted by Inova Fairfax Medical Campus in Falls, Virginia (American Association of Critical-Care Nurse [AACN], 2014). Using a RCA there was a reduction of central line-associated bloodstream infections by 80 percent. Nurse leaders must recognize these opportunities and engage staff in the process improvement process assisting with ownership and accountability of the direct care team.
Staff Engagement
Staff engagement is critical in relation to the quality of care that is provided as they are the front line providers of care. The example of the RCA above demonstrates how when staff is engaged process improvements are successful. The critical care staff involved in decreasing central line-associated bloodstream infections felt the impact of their involvement as change agents, by seeing the dramatic reduction of these infections (AACN, 2014).
Job satisfaction is critical to fully engaging staff members. The National Database of Nursing Quality Indicators (NDNQI) demonstrates a direct correlation between nursing satisfaction and the quality of care that is provided to patients (Washington Nurse, 2013). With an increase of 29 percent in staffing and an increase of 25 percent in retention the quality of care provided to patients increased anywhere from 5-20 percent (Washington Nurse, 2013). Staff engagement not only improves the quality of care provided, but also patient outcomes and higher level of nursing continued education (Melnyk, Gallagher-Ford, Long, & Fineout-Overholt, 2014).
Nurse leaders must work diligently to engage staff by being transparent and visible, providing adequate support, and by sharing and demonstrating strong vision and values. Ways that transparency and visibility can be accomplished is through daily huddles, audits and rounding, setting consistent performance measures with clear expectations, and engaging staff in process flow improvements (Graban, 2012). Support can be provided and tracked through gemba boards, gemba walks, and providing resources for employees to reach out with questions and concerns (Graban, 2012). Vision and values of a nurse leader should align with not only the organization but with professionals standards set forth by accrediting bodies such as the American Nurses Association (ANA). The ANA provides standards and competencies for nurse leaders in multiple specialties to encourage nursing professionalism and advocacy for nursing oaths (ANA, 2009).
Patient Satisfaction
With current and future healthcare changes, patient satisfaction is of high importance to healthcare organizations. Patient satisfaction has become the most targeted outcome in healthcare (Kobayashi, Takemura, & Kanda, 2010). Even legislation is requiring hospitals to place a greater emphasis on patient satisfaction (Ashley, Mais, Abrams, Wong, and Morra, 2013). Patient satisfaction is defining the organizations overall performance in regards to quality, outcomes, and leading process improvement initiatives across the board (Al-Albri & Al-Balushi, 2014). Patient satisfaction is measured using surveys that are sent out to patients after their encounter with the healthcare organization and measured using national standards and benchmarks. There are many considerations when basing performance solely on patient satisfaction surveys including the timing of receiving the survey, the vendor of the survey, and whether the survey is quantified and standardized (Al-Albri & Al-Balushi, 2014). The most standardized method of performance currently is the consumer assessment of health plans (CAHPS). Nurse leaders must ensure that the results that they receive are using the most appropriate tools, use vendors that standardize and quantify the questions asked, and disseminate the information to staff for process improvement especially in consideration that a majority of the survey is service based. Patient satisfaction surveys not only impact care practices, but also financial considerations which will be discussed in the following section.
Financial Consideration
All of the themes that have been discussed in this literature review directly impact the financial stability and success of healthcare organizations. The largest impact is that of patient satisfaction survey results. Mazza and Fazzi (2009) discuss how Centers for Medicare and Medicaid Services (CMS) utilize CAHPS scores for reimbursement and reporting requirements. Reimbursement of services has changed drastically and does not entail the services provided as much as the outcomes, quality of care, and the satisfaction with services rendered. In a literature review by Cotterill-Walker (2012), it is supported that the higher level of education of nursing staff, the better the patient outcomes are. Nurse leaders must understand this concept as they look toward ensuring best care practices are in place using and encouraging EBP, process improvement, and by fully engaging staff.
Theoretical Practice
Theoretical practice is part of the nursing profession and critical in the development of a nurse leader. Kenney (2013) describes theoretical practice as “the application of various models, theories, and principles from nursing science and the biological, behavioral, medical and sociocultural disciples to clinical nursing practice” (p. 333). The two theories that will be tied to this literature review on nurse leader development are Jean Watsons Theory of Transpersonal Caring and Donabedian’s theory of structure-process-outcome approach to quality improvement (Jesse, 2010; Johnson, 2012).
Transpersonal Caring
Jean Watson is a well-respected and known nursing theorist. Watson’s theory of transpersonal caring is based on the knowledge, care, and respect of each individual uniquely (Jesse, 2010). The transpersonal caring theory is centered around ten carative factors including forming a humanistic altruistic system of values, instillation of faith and hope, cultivating sensitivity of self and others, developing a helping-trust relationship, promoting and accepting the expression of positive and negative feelings, use of scientific problem solving, promoting interpersonal teaching and learning, providing a supportive, protective, and corrective mental, physical, sociocultural, and spiritual environment, assisting with gratification of human needs, and allowing for existential-phenomenological forces (Jesse, 2012). When reviewing these factors they are all imperative to leadership development. In order to fully support patients, staff, peers, superiors, the organization, and oneself these factors must be considered. Nursing is based around a caring philosophy and being in leadership does not change that core standard it enhances it to involve a higher level of understanding. In order to ensure quality care, staff engagement, patient satisfaction, and fiscal stability the nurse leader must look toward the 10 carative factors in decision making, day to day interactions and operations, process improvement, problem solving, and providing care for all involved.
Donabedian’s Structure-Process-Outcome Theory
Quality of care is a major factor in healthcare today and Donabeian’s structure-process-outcome theory enhances the development of a nurse leader. The basis of Avedis Donabedian’s theory is that with the appropriate structure and correct processes, desired patient outcomes will result (Johnson, 2012). This was demonstrated through a study conducted by Kobayaski, Takemura, and Kanda (2010) regarding the perception of quality of service provided by nurses. Donabedian’s theory was supported by the authors of this article with its role in ensuring quality and performance improvement in healthcare organizations. Not only could this theory be used to improve performance such as decreasing patient falls, but also assist in multiple dimensions of communication, leadership, and organizational fiscal stability.
Conclusion
The development of a leader in the nursing profession is a dynamic process that requires theoretical application and use of evidence to guide practice. Healthcare is ever changing and requires adaptability of those leading these changes to meet the needs of the growing patient population. Mentorship of nurse leaders is an essential piece to the development of these professionals, requiring more advanced degree nurses. The higher level of education assists leaders in the nursing profession to critically evaluate the quality of care provided using evidence based practice and process improvement, fully engage and encourage staff, improve patient satisfaction, and be financially accountable and responsible to the organization served.
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