HISTÒRIA DE LA CUINA MOLECULAR

Extensive literature has been generated in relation to leadership development within nursing. Principles, frameworks, content and teaching methodologies regarding leadership development have been described in text books and journal articles. For the purpose of this research, a review of the literature on implemented leadership programs in nursing was undertaken. Key words used for the search were ‘nursing leadership programs, nursing leadership development programs, and nursing leadership training’. Databases included CINAHL 1990-2007, Pre-CINAHL, MEDLINE. Nine nursing leadership development programs that had been implemented fit the criteria for review and are discussed in the following section. A summary of these studies, including each of the program’s objectives, its design, its content and teaching methodologies, theoretical framework and the program’s evaluation methods are provided in Table 2.4 (Appendix B). Finally, the limitations of the existing leadership programs are identified.

2.7.1 Objectives and participants of the leadership programs

All nine programs sought to increase the leadership capability of its nurse participants (Wolf, 1996; Tourangeau, 2003; Cunningham & Kitson, 2000; Squires, 2001; Connelly et

al., 2003; Flowers et al., 2004; Maguire et al., 2004; Duffield, 2005; Wilson, 2005). Participants undertaking the leadership development programs included: baccalaureate- prepared registered nurses (Wolf, 1996), senior nurses and ward sisters (Cunningham & Kitson, 2000), newly appointed nurse managers (Squires, 2001), “established leaders” and “aspiring nurse leaders” (Tourangeau, 2003), senior nurses and modern matrons (Flowers et al., 2004), and front-line nurse managers in the other four studies (Connelly et al., 2003; Maguire et al., 2004; Duffield, 2005; Wilson, 2005).

Three studies examined other outcomes possibly associated with a change in leadership capability. Cunningham and Kitson (2000) measured changes in the quality of patient care. The focus of the small program described in Squires’ (2001) study was on the retention of newly appointed nurse managers, and anticipated turnover and work satisfaction were measured in another program (Wilson, 2005).

2.7.2 Content and teaching methodologies

The length of programs varied widely ranging from an 18 months program (Cunningham & Kitson, 2000) to a two day training program (Flowers et al, 2004). Programs in the main were conducted over a two to four week period. Nevertheless when this point is considered with the other facts, that the programs were conducted in four different countries (USA, UK, Canada, Australia) over a nine year period, numerous similarities were identified across the nine programs in both the program content, and teaching methodologies. All programs ‘taught leadership content’ through a range of learning methodologies. Five programs specifically nominated coaching and mentoring as being used to generate leadership learning (Wolf, 1996; Squires, 2001; Tourangeau, 2003; Flowers et al., 2004; Wilson, 2005). Coaching and mentoring were implied as part of the learning experience in three other studies (Cunningham & Kitson, 2000; Connelly et al., 2003; Duffield, 2005).

The role of the ‘expert facilitator’ in one of these programs took on the role of coach when she “helped all participants to construct their personal development plans” (Cunningham & Kitson, 2000). She also took on the role of a mentor for the four senior nurse participants in this program when she mentored and facilitated within their own action learning set (Cunningham & Kitson, 2000). Facilitators in another program played a coaching role due to the stated program requirement that facilitators must have leadership experience as, a charge nurse, head nurse, supervisor or subject matter expert (Connelly et

al., 2003). This experience was considered a requirement to facilitate effective leadership learning with participants throughout the program. The theoretical concepts underpinning a Master Class approach in Duffield’s (2005) program align with coaching and mentoring principles. It was identified that “the role of the facilitator is one of providing opportunities for individuals to analyse and understand their own behaviour” and leadership responses (Duffield, 2005).

Face to face sessions were used in all nine programs. Only one program nominated a self-paced learning process that would be facilitated by more senior nursing staff mentors (Squires, 2001). One study relied heavily upon a 360 degree appraisal system to inform learning experiences within the “two-day intensive leadership program” (Flowers et al., 2004). Three programs employed interactive exercises and scenario-based activities to assist the participants in developing in a wide range of leadership competencies (Connelly et al., 2003; Maguire et al., 2004; Duffield, 2005). Personal development plans, action learning, workshops, patient observations and listening to patient narratives were used by an expert facilitator to enhance effective clinical leadership development in one UK study (Cunningham & Kitson, 2000).

Program content which is presented in Table 2.4 clearly demonstrates a consistency within program designers’ selection of subjects that were considered necessary in the nine leadership development programs. An array of leadership content was included in all programs. Leadership relational skills of communication and problem solving were identified in seven programs (Wolf, 1996; Cunningham & Kitson, 2000; Connelly et al., 2003; Maguire et al., 2004; Flowers et al., 2004; Tourangeau, 2003; Wilson, 2005). Squires (2001) does not explicitly identify these subjects as part of the program. Duffield (2005) also does not expressly identify these two subjects, however from the list of topics that were addressed in the Master Class, for example, emotional intelligence, team building and dealing with difficult people, it appears sensible to conclude that these subjects would have been explored in some depth within that program. What was surprising was the fact that although financial management skills were identified in four of the six competencies studies reviewed, only six programs specified this subject as part of the program’s content (Wolf, 1996; Squires, 2001; Maguire et al., 2004; Tourangeau, 2003; Duffield, 2005; Wilson, 2005).

In the main all programs had a practical, experimental and work-based approach. Four programs specifically identified that the program’s emphasis was not just on knowledge and

skills acquisition, but on exploring attitudes, values and behaviours (Maguire, et al., 2004; Cunningham & Kitson, 2000; Tourangeau, 2003; Duffield, 2005). Cunningham and Kitson (2000) made an important point regarding the nexus between program content and teaching methodologies. They considered the program’s strength was the fact that it was an experiential work-based approach, where the content and the process of engaging in the learning process were equally important.

2.7.3 Theoretical framework

Seven of the nine programs reviewed utilised some form of a theoretical framework from which the program was designed (Wolf, 1996; Squires, 2001; Connelly et al., 2003; Maguire et al., 2004; Cunningham & Kitson, 2000; Tourangeau, 2003; Duffield, 2005). Squires (2001) and Connelly et al. (2003) designed, implemented and evaluated the program using adult learning principles. In Connelly et al’s (2003) program the framework was augmented with specific competencies that were previously identified in qualitative research, in which 42 participants who usually acted in the charge nurse role were asked to nominate the competencies required for the role. Participants in the study articulated 54 specific competencies (Connelly & Yoder, 1996). Maguire et al. (2004) used a learner centred framework in which instructors operated as facilitators rather than lecturers. The philosophy underpinning this framework was that participants were treated as full learning partners, making the learning process a democratic and collaborative endeavour (Maguire et al., 2004).

Only four of the programs used a leadership framework (Wolf, 1996; Cunningham & Kitson, 2000; Tourangeau, 2003; and Duffield (2005). The Situational Leadership model was utilised in Wolf’s (1996) study. Within this model, “leadership is defined as an attempt to influence individuals and groups” (Wolf, 1996). Cunningham and Kitson’s (2000) theoretical framework incorporated the theory of transformational leadership. Within the program this type of leadership was described by the authors as “moving away from control and command type leadership to one in which the leader promotes a more participatory, emancipatory style of leadership that emphases creative problem solving, flexibility and speed of response” (Cunningham & Kitson, 2000). Kouzes and Posner’s (1995) five leadership competencies model was used in the Canadian program examined by Tourangeau (2003). Learning opportunities at the Canadian institute were guided by this conceptual framework, asserting that nurse leaders required competencies in four domains: nursing practice, the business of healthcare, leadership practices, and use of self (Tourangeau, 2003).

Within this program the learning experiences were delivered by three experienced nurse leaders, over five days, who used didactic sessions, self-reflection, small group discussion and problem solving, coaching and networking opportunities to increase leader competencies aligning with the adopted leadership framework (Tourangeau, 2003). Duffield’s (2005) Australian program used an innovative theoretical paradigm of a Master Class. The learning experiences based on a Master Class framework were adapted for working with nurse unit managers to increase the effective leadership of this group. The basis of the program was that skills required of nurse unit managers are not easily taught and lend themselves to learning from and through experience and structured interaction with colleagues. Activities, games and exercises were used in the program that fostered creativity, flexibility and team building. These four programs which utilised a leadership framework also included content material related to the operational aspects of the front-line nurse manager role (Wolf, 1996; Cunningham & Kitson, 2000; Tourangeau, 2003; Duffield, 2005).

2.7.4 Program Evaluation Methods

Three programs evaluated changes in leadership following the program using a pre- test/post-test methodology (Wolf, 1996; Cunningham & Kitson, 2000; Tourangeau, 2003). Wolf (1996) measured changes in knowledge acquisition and application of Hersey and Blanchard’s model of leadership styles and leadership styles adaptability. Results from this study showed that participants undertaking the four-day management training program were able to obtain short-term changes in their primary leadership styles, with participants increasing their scores in leadership styles that were more participative (Wolf, 1996). There were no significant changes regarding participants’ leadership style adaptability scores (Wolf, 1996). A number of leadership dimensions significantly improved on the MLQ scoring tool in Cunningham and Kitson’s (2000) study. There was also evidence to show patient care had improved. This latter outcome was measured by examining the way nursing care was organised, and by patients’ account of the care they received. Weak internal consistency results within two of the five Kouzes and Posner’s leadership competencies meant that only three could be accurately measured in the Tourangeau (2003) study: challenging the process, inspiring a shared vision, and encouraging the heart. There were no statistically significant differences found in the self-reported leadership practices by institute participants, however supervisors reported significant increases in aspiring and established leaders, on two leadership practices: challenging the process and inspiring a shared vision (Tourangeau, 2003). Peers also observed improvements in participants’ leadership behaviours in all five leadership practices (Tourangeau, 2003)

Another program that used a pre-program and post-program evaluation measured anticipated turnover and work satisfaction (Wilson, 2005). This study had a strong focus on evaluating the outcomes of the program. Content subjects that were taught within the program are listed in the paper, however detailed teaching methodologies are not provided within the article. Individuals were not matched between the two data time periods; conclusions could therefore only be made for comparisons of the reported groups. In relation to work satisfaction there were no statistically significant changes between time one and time two, however there was a significant decrease in anticipated turnover (Wilson, 2005). This outcome challenges the association previously documented in the literature between work satisfaction and retention (Boyle et al., 1999).

All other programs used participants’ verbal and/or written feedback to evaluate the leadership program. Connelly et al., (2003) attempted to augmented participants’ feedback with head nurses’ assessment of the participants, however the response rate was too low to provide meaningful data. In Duffield’s (2005) study participants provided feedback using a 26 item evaluation tool. No program tested the effects of the programs using a randomised control trial.