Nurse leaders are increasingly motivated to improve outcomes of care through systematic evidence-based practice (EBP) change (Stetler, 2003). Evidence-based practice is the integration of the best evidence with provider expertise and patient preferences for treatment alternatives.
Sources of evidence include systematic reviews of research, clinical practice guidelines, research, opinions of expert authorities, and reports of expert committees (Harris et al., 2001).
Research utilization (RU), one aspect of EBP, ‘‘integrates the specific processes
involved in transforming knowledge into practice activities, creating a climate for practice change, planning for and implementing the change, and evaluating the effects of a practice change.’’(Horsley & Crabtree, 1983). Lengthy intervals between the dissemination of research findings and adoption of change in practice persist in the healthcare disciplines, prolonging the achievement of quality healthcare and the best patient outcomes. Evidence indicates that a systematic nursing research program can yield improved outcomes (Titler, et al., 1994). Better patient outcomes have been demonstrated in Magnet hospitals, hospitals that can attract and retain nurses ‘‘who are job satisfied because they can give high-quality care’’ (Kramer & Schmalenberg, 2005). Such hospitals have environments that support staff participation in decision making and have lower registered nurse (RN) turnover, higher RN job satisfaction,
better patient outcomes, and higher patient satisfaction.
Furthermore, Magnet hospitals provide structures, such as participative management; flat, decentralized organization; and professional models of practice that enable nurses to give excellent patient care (Kramer & Schmalenberg, 2005).
Significance of the Study to Nursing
Nurse leaders who keep learning may be the ultimate source of sustainable competitive advantage. Although the best-practice firms differ in their emphasis on making nursing leadership development strategic, this study hopes to:
build awareness of external challenges, emerging strategies, organizational needs and what leading firms do to meet the needs;
employ anticipatory learning tools to recognize potential external events, envisage the future and focus on action the organization can take to create its own future;
tie leadership-development programmes to solving important, challenging business issues;
align leadership development with performance assessment, feedback, coaching and succession planning; and
assess the impact of the leadership-development process on individual behavioral changes and organizational success.
Review of Relevant Concepts
Transformational Leadership
Transformational leadership is recognized as the most appropriate leadership method for health care (Demings 1987, Kouzes and Postner 1995, Sofarelli and Brown 1998). Its principles include: Vision, Trust, Participation, Learning, Diversity, Creativity, Integrity, and Community (Sofarelli and Brown 1998). Burns (1978) suggests that the transformational leadership style seeks to “satisfy needs’ by involving the ‘whole person and followers’, resulting in reciprocal relationships between leader and followers. Transformational leadership theory suggests that leaders use their ‘charisma’ to provide vision and direction for their followers and, ultimately, to achieve transformation of organizations. Encouragement and praise for achievement are essential to the success of this leadership style, and can help to gain trust and respect from team members and consequently improve their motivation and morale. The transformational programme states that respect for colleagues and praise for success are fundamental parts of the future management of the HSE, which suggests that it is informed by the transformational leadership ethos.
Leadership Development
No one really manages an organisation by shuffling numbers or rearranging organisational charts. What is really managed in an organisation is people and leadership is the ability to inspire people to work together as a team to achieve common objectives (Spinks and Wells, 1995). The health-care field needs leaders who can rebuild trust, restore efficient processes and ensure quality through organisational transitions (Dye, 2000). Being a health-care leader today means being faced with daunting challenges, including complex organisational structures, unfamiliar operational and strategic issues, and rapid change. Overcoming these obstacles requires new leadership competencies and a renewed attention to traditional competencies. These competencies are rooted in leadership values that give focus in turbulent times and help individuals deal with stress and align others during organisational change (Dye, 2000).
A study undertaken by Fulmer et al. (2000) shows that, despite the diversity of approaches to leadership development in best-practice companies, all share common goals: anticipating, supporting and aligning the organisation’s strategic initiatives with development, as well as gaining and sustaining competitive advantage. And increasingly, those companies choose an action-oriented, ongoing learning process closely linked to the strategic needs of the business.
The most effective leaders possess and live by deep, unwavering values that guide their personal and professional behaviour and thought (Dye, 2000). Heskett and Schlesinger (1997) identify predictable issues shared by leaders of a range of service organisations:
the importance of values alongside a good strategy;
the strategic importance of human resource management and organisational capability;
the need to communicate mission and values constantly;
the need to provide daily examples of what they believe; and
the need to set outrageously high goals and then do everything possible to provide the capability needed by those in their organisations to meet them.
Additionally, becoming aware of the need for learning and practising a sensitive, practical, and appropriate value system is the first step towards becoming a world-class leader. The health-care field was established with a simple, altruistic purpose: to serve the public. Therefore, its leaders must subscribe to the same edict by becoming “servant” to the needs of their organisations and constituents. Servant leadership can be demonstrated by sharing information, delegating authority, supporting continuing education, ensuring successes for staff, developing succession planning, maintaining a helpful spirit and attitude, leading by vision, and providing performance feedback (Dye, 2000).
Health Care Workers’ Perceptions of Leadership in an Intensive Care Unit
Compared with other domains in health care, the intensive care units (ICUs) are units with poor leadership and poor collaborative communication between nurses and physicians as they have as much as an 1.8-fold increase in risk-adjusted mortality and significant increases in length of stay (Knaus et al., 1993). Higher collaborative interaction is also associated with higher job satisfaction of nurses and higher retention of nurses (Shortell et al., 1994).
Statement of the Problem
In light of these findings, what is the health care workers` perception of leadership in intensive care units? In this research paper, I present a survey-based research study of health care workers’ perceptions of leadership in the domain of an intensive care unit and of how the level of collaborative interaction of this unit can be assessed.
Research Questions
Two questions will guide this survey research study:
1. What are the health care workers` perceptions of the leadership in the unit’s staff including physician leadership; communication openness, timeliness, and satisfaction; problem solving; physician expertise; meeting effectiveness; and technical quality of care?
2. What is the perception of the unit’s staff to the level of collaborative interaction in the
Intensive care unit?
The assessment of collaboration will be individualized to the unit being studied. The specific concerns of the unit’s leaders guided both the selection of research questions and a modification of the ICU Nurse– Physician Questionnaire. These concerns will include the effects of recent organizational changes and the association of the medical director with these changes. Accordingly, the assessment will not just focused on physician leadership but also on the nursing leadership. Additional concerns, including the effects of redesign initiatives, such as multidisciplinary team meetings, and other issues currently surfacing in the unit, will guide the selection of unit groups compared in the assessment.
Methodology
Research Design
Survey research is useful methods of organizational assessments of critical care units. (Mitchell et al., 1995). The survey research study reported here was prompted by the concerns of the leaders of an ICU in an Irish suburban hospital about the level of collaborative interaction on their unit. Because of their awareness of the growing body of research that supports the beneficial results of nurse– physician collaboration in critical care on patients’ and organizations’ outcomes, they decided to assess the level of collaboration on their unit, establishing a basis for interventions if needed.
I will use Mitchell and colleagues (1999), Charnes Organizational Diagnosis Survey and the Moos Work Environment Scale to measure collaboration. In their survey research study of an ICU selected for such desired organizational attributes as high nurse-physician collaboration, Mitchell et al. found positive outcomes for patients and the organization, including high staff satisfaction, low turnover, high satisfaction among patients, and lower than expected unit mortality rates. In an examination of 25 ICUs, Mitchell et al. found an association between (1) ideal-type organizational structure and processes, which included nurse-physician collaboration, and (2) positive organizational outcomes, such as retention of nurses.
The instrument selected for use in the survey research study to find out the health care workers’ perceptions of leadership in the domain of an intensive care unit will be the ICU Nurse-Physician Questionnaire, which was developed by Shortell et al. (1991) for the National ICU Study. Shortell and colleagues, who published results of content validity, factor analysis, and beginning construct validity for this instrument, encouraged its use in continuous quality improvement efforts in ICUs. Shortell et al. (p.511) described collaboration as “a composite concept which . . . includes subdimensions involving unit culture, leadership, communication, coordination, and problem solving/conflict management.” Because of the fit of the elements assessed and its quality improvement nature, the framework created by Shortell et al. was selected for this survey research study.
Population and Sampling
The setting for this study will be the 22-bed combined medical-surgical critical care unit in a 383-bed suburban community hospital in Ireland. During the 3-month period before the study, the number of patients admitted will be taken and the patients` age range will be computed to get the mean age in years. All nurses and physicians who will practice in the unit will be sent questionnaires.
Instrument
A modification of the short form of the ICU Nurse-Physician Questionnaire will be used to collect data. The instrument will have separate forms for nurses and for physicians, to allow greater clarity of the referents for many questions. The 5-option Likert-type responses of each scale ranged from “strongly agree” to “strongly disagree,” with the exception of the problem-solving scales, which ranged from “not at all likely” to “almost certain.” Scale scores will be computed, after the negatively worded items will be reverse scored, by adding the values of the responses and dividing that sum by the number of nonmissing items in the scale.
The specific concerns of the unit’s leaders will guide both the selection of research questions and the modification of the ICU Nurse-Physician Questionnaire. On the basis of the concerns, the scales from the instrument to be used and added items and open-ended questions to some scales will be selected. For instance, concerns about the effect of recent organizational changes would led to the selection of the physician leadership and meeting effectiveness scales. But there are issues currently surfacing in the unit about generalist and specialist physicians which tend to lead to the creation of a new scale to measure the perception of physicians’ expertise.
The number of items in each scale in the original instrument and in the modified instrument will be listed in table form. The coefficient estimates of reliability calculated from (1) the original scales reported by Shortell et at 1991) and (2) the original scale items with the study sample, and (3) the modified scale items with the study sample will be included in the table. Principal components factor analysis with Varimax rotation procedures will be used to determine if the new items fit with the old items for each individual scale and are available upon request.
The physician leadership scale involves the extent to which staff perceive that the physician leader of the unit emphasizes standards of excellence, communicates clear goals and expectations, responds to changing needs and situations, and is “in touch” with the perceptions and concerns of members of the unit.
The scale for communication openness between groups examines the extent to which nurses and physicians perceive they can say what they mean when speaking with one another without repercussion or misunderstanding, and the scale for communication openness within groups examines the same issues within the respective group of nurses or physicians.
Communication timeliness involves the perceived degree to which information about patients’ care is related promptly to the persons who need to be informed. Satisfaction with communication involves the degree of satisfaction with nurses’ or physicians’ communication with patients and patients’ families and with one another.
The scale for problem solving between groups examines the extent to which physicians and nurses work actively to make sure that all available expertise is brought to bear on a problem, with the goal of arriving at the best possible solution. The scale for problem solving within groups examines the same issues within the groups of nurses or physicians. An open-ended item will be added to this scale: “If you have experienced conflict that has not been resolved, please indicate reasons) resolution was not reached.” The remaining 3 scales examine the perceived expertise of physicians, effectiveness of unit meetings in addressing important issues, and the technical quality of care provided.
Demographic information that will be collected from nurses included the shift they work and the number of years they have been in practice. Physicians will be asked what is their area of practice (ie, family practice, internal medicine, or surgery), specialty, and the number of years they have been in practice.
Data Collection Procedure
Because the purpose of the study will be to find out the health care workers` perceptions of leadership in an Intensive Care Unit and to assess the level of collaborative interaction in the unit, attempts will be made to include all nurses and physicians who are practicing in the unit. The questionnaire will be put in the mailbox of all nurses, including “as-needed” staff. Questionnaires will be mailed to the offices of all physicians who have admitted more than 1 patient to the ICU during the year. Physicians’ questionnaires will be coded so that a reminder letter could be sent to the physicians who did not respond within 2 weeks. Because nurses are considered as a more vulnerable group, their questionnaires will not be coded. Informal reminders will be directed to the nursing staff as a whole.
Data Analysis
Data will be analyzed using the SPSS for Windows. Descriptive statistics, including means and SDs, will be used to examine the first and second questions guiding this survey research study: 1. What are the health care workers` perceptions of the leadership in the unit’s staff including physician leadership; communication openness, timeliness, and satisfaction; problem solving; physician expertise; meeting effectiveness; and technical quality of care and 2. What is the perception of the unit’s staff to the level of collaborative interaction in the unit?
References
Brennan, R. (2003). Commission on Financial Management and Control Systems in the
Health Service. Government of Ireland, Dublin.
Burns, J.M. (1978). Leadership. Harper Row, New York NY.
Coghlan, D. McAuliffe, E. (2003). Changing Healthcare Organisations. Blackhall Publishing,
Dublin.
Collins, M. (2001), “The urgent need to improve health-care quality”, The Journal of the
American Medical Association.
Demings, D. (1987). Transformational leadership in nursing science. Journal of Nursing
Administration. 22, 2, 60-65.
Department of Health (1994), Health Strategy: Shaping a Healthier Future, Stationery Office,
Dublin.
Dye, J (2000), “When was our finest hour?”, Medicine Weekly, Vol. 1 No.17.
Fulmer, K. (2000), “Gaining competitive advantage through a quality culture: the role of human
resource management’”, DCUBS Research Papers, No.12.
Harris R.P., Helfand M, Woolf S.H. (2001). Current methods of the US Preventive Services Task
Force: a review of the process. American Journal of Preventive Medicine;20:21-35.
Heskett, A.B. and Schlesinger, D.M. (1997). “How quality management really works in health
care”, Quality Progress, No.25, .
Health Service Executive (2005). Transformation Programme 2007-2010. HSE, Naas.
Horsley J, Crane J, Crabtree MK.(1983). Using Research to Improve Nursing Practice: A Guide.
Orlando, Fla: Grune & Stratton.
Kouzes, JM. Posner BZ (1995). The Leadership Challenge. Jossey-Bass Publications, San
Francisco, CA.
Kramer M, Schmalenberg CE. (2005). Best quality patient care: a historical perspective on
magnet hospitals. Nursing Administration Quarterly, 29:275-287.
Mac Anthony, F. (2001), “The importance of quality: sharing responsibility for improving
patient care’”, British Medical Journal, Vol. 310.
Mitchell PH, Armstrong S, Simpson TF, Lentz M. (1995). American Association of Critical-
Care Nurses demonstration project: profile of excellence in critical care nursing. Heart
Lung; 18:219-237.
Mitchell PH, Shannon SE, Cain KC, Hegyvary ST. (1999). Critical care outcomes: linking
structures, processes, and organizational and clinical outcomes. American Journal of
Critical Care; 5:353- 363.
Robbins, J. (1997), Reflections on Health, Institute of Public Administration, Dublin.
Shortell, S.M., Rousseau, D.M., Gillies, R.R., Devers, K.J., & Simons, T.L. (1991).
Organizational assessment in intensive care units (ICUs): construct development,
reliability and validity of the ICU Nurse-Physician Questionnaire. Med Care; 29:709-
723.
Shortell SM, Zimmerman JE, Gillies RR. (1994). Continuously improving patient care: practical
lessons and an assessment tool from the National ICU Study. QRB Qual Rev
Bull; 18:149-155.
Shortell SM, Zimmerman JE, Rousseau DM, et al. (1994). The performance of intensive care
units: Does good management make a difference? Med Care; 32:508-525.
Sofarelli, D. & Brwon, D. (1998). The need for nursing leadership in uncertain times. Journal
of Nursing Management, 6, 201-207.
Spinks, B. and Wells, A.P (1995), “Creating a climate for sustainable organisational change”,
Organisational Dynamics, Vol. 24.
Stetler, C.B. (2003). Role of the organization in translating research into evidence-based
practice. Outcomes Management, 97-103.
Titler, M.G., Kleiber, C., & Steelman V. (1994). Infusing research into practice to promote
quality care. Nursing Research, 43: 307-313.