A nursing leadership evidence-based practice project explored the impact of nurse manager leadership practices on organizational outcomes. A literature review found that structured leadership development programs using the Five Practices of Exemplary Leadership model improved transformational leadership behaviors, nurse satisfaction, and nurse retention compared to no leadership program. The project recommends developing a structured transformational leadership program for nurse managers at York Hospital to improve outcomes.

1. Development of exemplary
leadership in nurse managers:
An Evidence Based Practice Project
Paula F. Coe MSN, RN, NEA-BC
York College of Pennsylvania
1

2. Objectives
 Discuss the factors that contribute to the need for a nursing leadership
evidence based project
 Explore the impact of nurse manager leadership practices on organizational
outcomes
 Describe search strategies and evaluation of the literature
 Illustrate the evidence regarding TL, exemplary leadership practice, RN
satisfaction and retention
 Summarize the evidence and recommendations for translation of practice 2

3. “It is impossible in a book to teach a person
in charge of the sick how to manage, as it is
to teach her how to nurse.”
Florence Nightingale, 1860
3

4. John Hopkins Model –Project Management
 Practice Question (Steps 1-5)
• Recruit team
• Develop and refine the question*
• Define the scope of the EBP
question and identify
stakeholders*
• Determine responsibility for
project leadership*
• Schedule team meetings
 Evidence (Steps 6-10)
• Conduct internal and external
search for evidence*
• Appraise the level and quality
of each piece of evidence*
• Summarize the evidence*
• Synthesize overall strength
and quality of evidence*
• Develop recommendations
based upon strength of
evidence*
(Dearholt & Dang, 2012)
4

5. Why focus on nursing leadership?
The transformational leader must lead people to where they
need to be in order to meet the demands of the future (ANCC,
2013)
Nurse Managers (NM) have a direct impact on both clinical
and organizational outcomes (Zori, Nosek,& Musil, 2010)
Leadership ability, lack of support, guidance and
engagement issues with the NM impact RN satisfaction.
(Fenimore & Wolf, 2011)
5

6. Responding to the call for action
Institute of Medicine-Future of Nursing Report (IOM, 2010)
 Imperative to prepare nurses for leadership
 Future of nursing depends upon educating and supporting all
levels of nurse leaders
 Recommendation for nurse residency program
 Could include a nurse leader residency?
6

7. The reality of the nursing shortage…
 Lack of good management and leadership
contributes to nurses leaving their positions.
National Sample Survey of Registered Nurses
(NSSRN, 2008).
 Less than 48.2 % of hospitals have developed
strategies to ensure a formal mechanism to
prevent or reduce turnover and retain RNs.
(NSI, 2013 )
13
11.2
10.00
10.50
11.00
11.50
12.00
12.50
13.00
13.50
RN turnover
Bedside RN Turnover in
the US
2013 2012
(NSI, 2013 )
7

8. Transformational Leadership
Transformational leadership (Casida & Parker, 2011)
Vision
Risk taking
Aptitude for motivating others
Role model
Mentor
Investing in capable and effective leaders are paramount to
contributing to the mission and bottom line of a hospital (Casida
& Parker, 2011)
8

9. Nurse Manager Development…
Nurse’s don’t often assume the role of NM by choice
Few receive structured development beyond initial
orientation (Sherman, Bishop, Eggenberger, & Karden, 2007)
Continuing education is usually the route NM take to
increase knowledge and skills (Sherman, Bishop, Eggenberger, & Karden, 2007)
The NM have the responsibility for leading unit activities
which empower and engage clinicians accountable for care
and patient outcomes (Carthart, Greenspan, & Quin, 2010)
9

10. Nurse Manager development continued…
Many nurses become leaders without formal education or on
the job education needed to succeed in their role (Kerfoot, 2008)
Trial and error development often equates to failure for
nurse leaders/managers (Swearingen, 2003)
Many nursing leadership programs lack connection to
leadership development theories and conceptual
frameworks (Galuska, 2013)
10

11. Influence of the Nurse Manager
 Role of NM is critical and pivotal to engaging employees and sustaining
healthy work environments (Bowles & Candela, 2005)
 NM leadership behaviors influence nurses to impact outcomes and
performance (Germain & Cummings, 2010)
 Skills and competencies of the NM can influence:
 Support
 Feedback
 Engagement
 Fostering quality improvement for the NM is imperative in uncertain
and volatile healthcare environment (Marshall, 2011)
11

12. YH- RN satisfaction with NM
 Internal Goal:
• Outperform the NDNQI
Teaching benchmark the
majority of the time
• Job Satisfaction Scale- RN
Survey used 2007-2012
• RN satisfaction with NM has
not been above benchmark
for the past three years
(2011, 2012, 2013) despite
focused attention with action
plans
12

13. 2014 NDNQI RN Survey (PES)
Nurse Manager Ability, Leadership, and Support of
Nurses: York Hospital
2.99
2.95
2.94
2.92
3.02
2.99
2.98 2.98
2.81
3.03
3.02 3.02
2.96
2.70
2.75
2.80
2.85
2.90
2.95
3.00
3.05
Avg. All Units YH Magnet PG Mean All Hospital PG
Mean
Teaching Status PG
Mean
Bed Size Mean
2011 2012 2013
No
Data
No
Data
13

14. 2013 YH RN Satisfaction with NM
14

15. Reason to invest in NM transformational
leadership development
Impacts
 Organizational costs
 Quality of patient care
 Staff nurse satisfaction
 Retention and turnover
Executive leaders are responsible for developing
capacity and providing active involvement in the
NM
(Cummings et al, 2008; Cowden, Cummings,& Profetto-McGrath, 2011; Jones & Gates, 2007; Fenimore & Wolf, 2011)
15

16. Exemplary Leadership Model® and
Learning Practice Inventory (LPI)
 Kouzes and Posner originally published the Five Practices of Exemplary
Leadership ® in 1985.
 The LPI approaches leadership as a measurable, learnable and teachable
set of behaviors
 The LPI measures the frequency of specific leadership behaviors(LPI-Self;
LPI-Others)
 Five core practices emerged from “personal best” leadership stories
 Model the Way
 Inspire a Shared Vision
 Challenge the Process
 Enable Others to Act
 Encourage the Heart
16

17. “To be "in charge" is certainly not only to carry out the proper measures
yourself but to see that every one else does so too; to see that no one either
willfully or ignorantly thwarts or prevents such measures. It is neither to do
everything yourself nor to appoint a number of people to each duty, but to
ensure that each does that duty to which he is appointed.”
Florence Nightingale
17

18. PICO Question
Does a structured leadership development program for acute
care nurse managers (NM) using the five practices of exemplary
leadership model® improve transformational leadership (TL)
behaviors, RN satisfaction and RN retention compared to no
participation in a structured leadership development program?
18

19. Narrowing the scope…
P
Population
• Acute Care Nurse
Managers
I
Intervention
• Five practices of exemplary
leadership model®
C
Comparison
• No program
O
Outcome
•  TL Leadership
•  RN Satisfaction
•  Retention
19

20. Search Strategy
 Databases used:
 CINAHL
 MEDLINE
 PsychInfo
 OVID
 PubMed
 Google Scholar
 Cochrane Collaborative
 Dates of evidence review included
 2000-present
20

21. Keywords
 Nurse Manager
 Nurse leader
 Nursing leadership
 Transformational
leadership*
 Nurs* leader
 Leadership Practices
 Outcomes
 Satisfaction
 Nurs* satisfaction
 Work environment
 Retention
 Management
2
1

22. Inclusion and Exclusion Criteria
 Inclusion
• Acute care NM
• Hospitals in the United
States
• Leadership development
• Educational programs
• Organizational outcomes
• Work environments
 Exclusion
• Nurse Managers from long
term care
• Other NL positions:
Directors,
Vice Presidents
Chief Nursing Officers
• Leadership competencies
• Educational programs not
focused on NM
2
2

23. Findings
Level of
evidence
Number
of
research
articles
Quality of the evidence
A B C
Level I 0
Level II 2 2
Level III 23 11 4 8
Level IV 0
Level V 7 4 1 2
Totals 32 16 5 10 23

24. Types of research/literature reviewed…
 Quantitative (18)
• Systematic Reviews (6)
• Systematic Literature Review (1)
• Descriptive
Cross Sectional (4)
Quasi Experimental (1)
Pre-Post Survey (3)
Exploratory Correlational (1)
• Action Research (1)
• Non experimental predictive design (1)
 Qualitative (14)
• Metasynthesis (1)
• Descriptive (2)
• Grounded Theory (2)
• Interpretive Phenomenology (2)
 Non Research (7)
2
4

25. Exemplary Leadership Model® and LPI
 The LPI was developed through
qualitative and quantitative
research methods and studies.
• 3million surveys have been analyzed
 1.1million observers
 200,000 leaders
 Reliability routinely tested through
analysis of internal reliability all 5
practices have demonstrated strong
internal reliability co-efficients
 Results have high face and
predictive validity
 Evidence to support use of this
tool and educational program
• 9 studies reviewed illustrated
the use of the LPI and/or the
exemplary leadership model
with positive outcomes
• 4 of the systematic reviews
discussed use with positive
results.
• LPI-Self and Observer were used
by researchers to measure
leadership behavior 2
5

26. Transformational Leadership
Twenty eight of the thirty two articles reviewed involved
discussion and positive findings of TL related to:
Positive organizational outcomes (Wong, Cummings & Ducharme, 2013)
Impacted a shared vision and challenge the process (LPI)
Improved with leadership development programs (Cummings et. al,
2008; Curtis, Sheerin & deVries, 2011; Heuston & Wolf, 2011; Kleinman, 2004)
Achieving effectiveness and leadership outcomes in NM
Relationship between TL nursing leadership and patient
outcomes (Wong & Cummings, 2007)
26

27. Registered Nurse Satisfaction
 RN’s are influenced by the leadership of their NM
 Empowered NM empower their staff who in turn are more satisfied (MacPhee,
Skelton-Green, Bouthillette,& Suryaprakash, 2011)
 Behaviors utilized by NM can make a difference in employee outcomes
 Effective TL in NM is essential to creation of work and practice environment
(RN Satisfaction) (Pearson et al, 2007)
 Investment in NM TL style of informing and encouraging staff will enable
outcomes of positive work environment and patient care (Germain & Cummings, 2010)
27

28. Registered Nurse Retention
An effective frontline NM is key to retention of staff (Heuston &
Wolf, 2011)
NM has a direct impact on retention and recruitment
(Swearingen, 2009)
NM TL practices influence staff nurse retention and builds
on the intent of the RN to stay (Cowden, Cummings, & Profetto-McGrath, 2011)
Empowered nurses are committed to their organizations
(MacPhee, Skelton-Green, Bouthillette, & Suryaprakash, 2011) 28

29. Summary of findings
 High quality Level II A evidence- 2 systematic reviews:
 High-Good quality Level III A evidence
 High-Good quality Level V evidence
 Positive outcomes related to TL development programs and outcomes related
to patients and staff
 Moderate outcomes describing the relationship of using the Exemplary
Leadership model ®
 The LPI –Self and LPI-Observer tool has demonstrated high reliability and
validity over years of testing
29

30. Recommendations
 TL behaviors and practices can influence organizational
achievement of outcomes for bedside RN’s and for patients
 Effective NL by nurse managers and development of TL is
essential in the current complex healthcare environment
 Nurse managers who practice TL ensure a quality workplace and
are likely to retain staff (Cowden, Cummings, & Profetto-McGrath, 2011)
 Develop a structured TL development program for acute care NM at
York Hospital to improve TL behaviors, RN satisfaction and RN
retention.
30

31. “Unless we are making progress in our nursing
every year, every month, every week, take my
word for it we are going back”
Florence Nightingale
31

32. Questions
32

33. References
American Nurses Credentialing Center (2013) 2014 Magnet © Application Manual. Retrieved from
http://www.nursecredentialing.org/MagnetApplicationHighlightManual
Bowles, C., & Candela, L. (2005) First job experiences of recent RN graduates. Journal of Nursing Administration. 35(3) 130-137.
Casida, J., & Parker, J. (2011). Staff nurse perceptions of nurse manager leadership styles and outcomes.
Journal of Nursing Management, 19, 478-486. . doi: 10.1111/j.1265-2834.2011.01252.x
Cathcart, E. B., & Greenspan, M. (2012). A new window into nurse manager development. Journal of Nursing Administration, 42(12), 557-561.
doi: 10.1097/NNA.0b013e18274b52d
Cathcart, E. B., Greenspan, M., & Quin, M. (2010). The making of a nurse manager: the role of experiential learning in leadership development.
Journal of Nursing Management, 18, 440-447. doi:10.1111/j.1365-2834.2010.01082.x.
Curtis, E. A., Sheerin, F. K., & DeVries, J. (2011). Developing leadership in nursing: the impact of education and training. British Journal of
Nursing, 20(6), 344-352.
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Cummings, G., Lee, H., MacGregor, T., Davey, M., Wong, C., Paul, L., & Stafford, E. (2008). Factors contributing to nursing leadership: A
systematic review. Journal of Health Services Research and Policy, 13(4), 240-248. doi:10.1258/jhsrp.2008.007154
33

34. References
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35. References
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35

36. References
Wong, C. A., & Cummings, G. G. (2007). The relationship between nursing leadership and patient outcomes: A systematic review. Journal of
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