Testing the effects of an empowerment-based leadership development programme: part 2 - staff outcomes

An authentic leadership training programme to increase nurse empowerment and patient safety: A quasi-experimental study

BACKGROUND

Authentic leadership and empowered nurses are necessary if a healthy work environment is to be created and patient safety maintained; however, few studies have examined the impact of authentic leadership, on nurse empowerment and the patient safety climate.

PURPOSE

The aim of the study was to investigate the impact of an educational intervention delivered through a multi-faceted training programme on nurses' perceptions of authentic leadership, nurse empowerment (both structural and psychological) and the patient safety climate.

DESIGN

A quasi-experimental study using a one-group pretest-posttest design consistent with TREND guidelines.

METHODS

The study was conducted in a university hospital between December 2018 and January 2020. Participants were followed for 6 months. The programme involved 36 head nurses (leaders) and 153 nurses (followers). The effectiveness of the programme was evaluated using repeated measures of analysis of variance, dependent sample t-tests and hierarchical regression analysis.

RESULTS

Following the intervention, safety climate and authentic leadership scores increased among both leaders and followers. Structural and psychological empowerment scores also increased among followers. We found that authentic leadership and structural empowerment were predictors of safety climate.

CONCLUSION

The implementation of the education programme resulted in positive changes in participants' perceptions of authentic leadership and empowerment, which can enhance patient safety.

IMPLICATIONS

Healthcare organizations can implement similar multi-faceted training programmes focused on authentic leadership, and nurse empowerment to increase patient safety. Achieving effective results in such programmes can be facilitated by motivating participants with the support of the top management.

PATIENT OR PUBLIC CONTRIBUTION

The study included nurses in the intervention and the data collection processes.

IMPACT

Patient safety is a global concern, and improving patient safety culture/climate is a key strategy in preventing harm. Authentic leadership and nurse empowerment are essential in creating healthy work environments and delivering safe, high-quality care. Training programmes addressing these issues can help bring about improvements in healthcare organizations.

Impact of empowering leadership on emotional exhaustion: A controlled interventional study in a large French university hospital complex

AIM

The aim of this study is to assess the effect of a systemic intervention on the evolution of empowering leadership and emotional exhaustion in a university hospital sub-centre compared to a control sub-centre, both being part of a large French university hospital complex.

BACKGROUND

Empowering leadership is a promising strategy for developing hospital team engagement and performance. However, the bureaucratic functioning of large hospitals, characterized by a managerial culture of control and a stratified organization, can be a barrier to empowering leadership.

METHODS

The intervention included empowering leadership training, direct field experimentation of empowering leadership and coaching, involving all the sub-centre hierarchical levels for 12 months. Data were collected before and after the intervention. A total of 441 and 310 participants were, respectively, included in the intervention and control sub-centres.

RESULTS

Empowering leadership was decreased, and emotional exhaustion was increased in the control sub-centre, while the scores remained stable in the intervention sub-centre. The increased emotional exhaustion in the control sub-centre could partially be explained by the change in empowering leadership.

CONCLUSION

In a context of decreased empowering leadership and increased emotional exhaustion, the intervention had a protective effect. Implications for the design of future interventions were discussed.

IMPLICATIONS FOR NURSING MANAGEMENT

This study unequivocally showed the benefit of transforming hospital management towards empowering leadership, to prevent increased emotional exhaustion.

REGISTRATION NUMBER

This study is registered on ClinicalTrials.gov on 4 July 2019 (NCT04010773).

Leadership Styles and Psychological Empowerment: A Meta-Analysis

Psychological empowerment has become a popular construct in organizational research and practice. Leadership ranks high among the best predictors of employees’ psychological empowerment, yet little is known about which leadership styles prove more effective than others. This meta-analysis investigates the effects of four leadership styles on psychological empowerment. More specifically, we test whether empowering leadership evokes more psychological empowerment than transformational leadership, servant leadership, or transactional leadership. We found that empowering, transformational and servant leadership contribute almost equally to psychological empowerment. No relationship was found with transactional leadership. In an explorative manner, we tested the effects on the different dimensions of psychological empowerment. We found that the leadership styles had a weaker influence on the competence dimension of psychological empowerment. We also investigated the effects of several moderators on the relationships with psychological empowerment: country culture (power balanced freedom (PBF)), study design (cross-sectional vs. multi-wave studies) and publication status (published vs. unpublished). We found no moderating effects of culture, which indicates the universally empowering effects of the leadership styles. The relationships between leadership and empowerment were somewhat weaker when data were collected at different measurement points, and publication bias does not seem to be an issue in this research field.

Developing an instrument to assess empowering nurse leader communication behaviours

AIM

The overall purpose of the study was to develop an instrument to assess empowering nurse leader communication behaviours.

BACKGROUND

Effective communication by nurse leaders promotes empowerment, yet communication assessments are often broad in nature without specifying precise behaviours.

METHODS

An instrument development process was used to identify empowering nurse leader communication behaviours. Nurses working in United States military health care facilities (n = 240) provided responses to 47 pilot items, along with a 12-item psychological empowerment instrument to test for concurrent criterion validity.

RESULTS

After review of item performance, 12 items were deleted. An exploratory factor analysis supported either a 2- or 3-factor model, with confirmatory factor analyses conducted to validate the underlying latent variables of empowering and limiting behaviours. The final nurse leader communication assessment consists of 2 factors consisting of 20 positive items (empowering subscale) and 15 negative items (limiting subscale).

CONCLUSION

The final 2-factor assessment supports the theoretical premise of the empowering and limiting behaviours. Further testing may provide further dimensional clarity.

IMPLICATIONS FOR NURSING MANAGEMENT

Use of the assessment can provide a basis for the development of training for individual nurse leaders or for facility nurse leaders as a collective.

The effect of self-scheduling on organizational justice and work attitudes through leader-member exchange: A cross-sectional study using propensity scores

BACKGROUND

Nurses have a very stressful and demanding job, which probably affects their health and well-being. This has resulted in a search for an optimal nurse schedule. Self-scheduling is one method to enhance flexibility and give more control to the employee. Literature on self-scheduling is scarce and mainly focused on the implementation process. So far, little is known about the long-term effects of self-scheduling.

OBJECTIVE

The comparison of effects of self-scheduling versus fixed scheduling on three dimensions of organizational justice (distributive, procedural, interactional justice) and three work attitudes (job satisfaction, affective commitment, global empowerment). This total effect is decomposed into direct and indirect effects via hypothesised mediators (leader-member exchange and organizational justice).

DESIGN

A cross-sectional multisite-matched study.

SETTING

A questionnaire was distributed to nurses and nurse assistants of twelve nursing homes in Flanders (Belgium). Six matched pairs of nursing homes were formed, each containing a nursing home that uses self-scheduling (for at least one year) and one that uses fixed scheduling.

PARTICIPANTS

The study sample included 308 nurses and nurse assistants, of which 160 surveys were from nursing homes using fixed scheduling, versus 148 surveys from nursing homes using self-scheduling.

METHODS

Using a double robust fixed effects regression model adjusted for the propensity score, the total effect of self-scheduling compared to fixed scheduling was analysed on the proposed outcomes. Subsequently, a (multiple) mediation analysis was performed.

RESULTS

If all people would have used self-scheduling instead of fixed scheduling, on average a significant decrease in the mean procedural justice score (estimated mean difference = -0.20, 95% CI -0.36 to -0.05) would be found. There is a significant negative direct effect (estimated mean difference = -0.12, 95% CI -0.21 to -0.03) and indirect effect via the mediator leader-member-exchange (estimated mean difference = -0.08, 95% CI -0.15 to -0.01) on procedural justice. In addition, significant negative indirect effects of self-scheduling were found via the mediator leader-member exchange on all the investigated outcomes.

CONCLUSION

Drawing up the work schedule is perceived as less fair in the case of self-scheduling. Furthermore, self-scheduling has a negative indirect effect on several work attitudes as a result of the changed relationship between the head nurse and the employees. The increase in task variety and decision-making autonomy for the employees and the altered leadership role of the head nurse can have a major impact on the dynamics of the entire team.

The essentials of nursing leadership: A systematic review of factors and educational interventions influencing nursing leadership

BACKGROUND

Nursing leadership plays a vital role in shaping outcomes for healthcare organizations, personnel and patients. With much of the leadership workforce set to retire in the near future, identifying factors that positively contribute to the development of leadership in nurses is of utmost importance.

OBJECTIVES

To identify determining factors of nursing leadership, and the effectiveness of interventions to enhance leadership in nurses.

DESIGN

We conducted a systematic review, including a total of nine electronic databases.

DATA SOURCES

Databases included: Medline, Academic Search Premier, Embase, PsychInfo, Sociological Abstracts, ABI, CINAHL, ERIC, and Cochrane.

REVIEW METHODS

Studies were included if they quantitatively examined factors contributing to nursing leadership or educational interventions implemented with the intention of developing leadership practices in nurses. Two research team members independently reviewed each article to determine inclusion. All included studies underwent quality assessment, data extraction and content analysis.

RESULTS

49,502 titles/abstracts were screened resulting in 100 included manuscripts reporting on 93 studies (n=44 correlational studies and n=49 intervention studies). One hundred and five factors examined in correlational studies were categorized into 5 groups experience and education, individuals' traits and characteristics, relationship with work, role in the practice setting, and organizational context. Correlational studies revealed mixed results with some studies finding positive correlations and other non-significant relationships with leadership. Participation in leadership interventions had a positive impact on the development of a variety of leadership styles in 44 of 49 intervention studies, with relational leadership styles being the most common target of interventions.

CONCLUSIONS

The findings of this review make it clear that targeted educational interventions are an effective method of leadership development in nurses. However, due to equivocal results reported in many included studies and heterogeneity of leadership measurement tools, few conclusions can be drawn regarding which specific nurse characteristics and organizational factors most effectively contribute to the development of nursing leadership. Contextual and confounding factors that may mediate the relationships between nursing characteristics, development of leadership and enhancement of leadership development programs also require further examination. Targeted development of nursing leadership will help ensure that nurses of the future are well equipped to tackle the challenges of a burdened health-care system.

Impact at two years of an intervention on empowerment among medical care teams: study protocol of a randomised controlled trial in a large French university hospital

BACKGROUND

Empowerment of hospital workers is known as a key factor of organizational performance and occupational health. Nevertheless, empowering workers remains a real challenge. As in many traditional organizations, hospitals follow a bureaucratic model defined by a managerial culture of control and a stratified organization, which at once weaken professionals' mastery of their work and hinder their commitment and performance. Based on the existing literature this protocol describes a new managerial and organizational transformation program as well as the study design of its effect on worker empowerment in a large French public hospital. The project is funded by the French Ministry of Health for a total of 498,180 €.

METHODS

This study is a randomized controlled trial conducted in a French university hospital complex (CHU). The CHU comprises 12 sub-centers (SC) with about 20 care units and 1000 employees each. Randomization is performed at SC level. The intervention lasts 12 months and combines accompaniment of healthcare teams, frontline managers and SC directors to empower first-line professionals in the experimental SC. Quantitative outcome measurements are collected over 2 years during mandatory check-ups in the occupational medicine department. The primary outcomes are structural and psychological empowerment, motivational processes, managerial practices, working conditions, health and performance. Mixed linear modeling is the primary data analysis strategy.

DISCUSSION

The protocol was approved by the CHU health ethics committee. The results of the analysis of the intervention effects will be reported in a series of scientific articles. The results will contribute to reflection on prevention and management policies, and to the development of Workplace Quality-of-Life. If the intervention is a success, the system will warrant replication in other SCs and in other health facilities.

TRIAL REGISTRATION

The study was retrospectively registered at ClinicalTrials.gov on July 4, 2019 (NCT04010773).

Human resource management training of supervisors for improving health and well-being of employees

BACKGROUND

Many workers suffer from work-related stress and are at increased risk of work-related cardiovascular, musculoskeletal, or mental disorders. In the European Union the prevalence of work-related stress was estimated at about 22%. There is consensus that stress, absenteeism, and well-being of employees can be influenced by leadership behaviour. Existing reviews predominantly included cross-sectional and non-experimental studies, which have limited informative value in deducing causal relationships between leadership interventions and health outcomes.

OBJECTIVES

To assess the effect of four types of human resource management (HRM) training for supervisors on employees' psychomental stress, absenteeism, and well-being. We included training aimed at improving supervisor-employee interaction, either off-the-job or on-the-job training, and training aimed at improving supervisors' capability of designing the work environment, either off-the-job or on-the-job training.

SEARCH METHODS

In May 2019 we searched CENTRAL, MEDLINE, four other databases, and most relevant trials registers (ICTRP, TroPHI, ClinicalTrials.gov). We did not impose any language restrictions on the searches.

SELECTION CRITERIA

We included randomised controlled trials (RCT), cluster-randomised controlled trials (cRCT), and controlled before-after studies (CBA) with at least two intervention and control sites, which examined the effects of supervisor training on psychomental stress, absenteeism, and well-being of employees within natural settings of organisations by means of validated measures.

DATA COLLECTION AND ANALYSIS

At least two authors independently screened abstracts and full texts, extracted data and assessed the risk of bias of included studies. We analysed study data from intervention and control groups with respect to different comparisons, outcomes, follow-up time, study designs, and intervention types. We pooled study results by use of standardised mean differences (SMD) with 95% confidence intervals when possible. We assessed the quality of evidence for each outcome using the GRADE approach.

MAIN RESULTS

We included 25 studies of which 4 are awaiting assessment. The 21 studies that could be analysed were 1 RCT, 14 cRCTs and 6 CBAs with a total of at least 3479 employees in intervention and control groups. We judged 12 studies to have an unclear risk of bias and the remaining nine studies to have a high risk of bias. Sixteen studies focused on improving supervisor-employee interaction, whereas five studies aimed at improving the design of working environments by means of supervisor training.Training versus no interventionWe found very low-quality evidence that supervisor training does not reduce employees' stress levels (6 studies) or absenteeism (1 study) when compared to no intervention, regardless of intervention type or follow-up. We found inconsistent, very low-quality evidence that supervisor training aimed at employee interaction may (2 studies) or may not (7 studies) improve employees' well-being when compared to no intervention. Effects from two studies were not estimable due to missing data.Training versus placeboWe found moderate-quality evidence (2 studies) that supervisor training off the job aimed at employee interaction does not reduce employees' stress levels more than a placebo training at mid-term follow-up. We found low-quality evidence in one study that supervisor training on the job aimed at employee interaction does not reduce employees' absenteeism more than placebo training at long-term follow-up. Effects from one study were not estimable due to insufficient data.Training versus other trainingOne study compared the effects of supervisor training off the job aimed at employee interaction on employees' stress levels to training off the job aimed at working conditions at long-term follow-up but due to insufficient data, effects were not estimable.

AUTHORS' CONCLUSIONS

Based on a small and heterogeneous sample of controlled intervention studies and in contrast to prevailing consensus that supervisor behaviour influences employees' health and well-being, we found inconsistent evidence that supervisor training may or may not improve employees' well-being when compared to no intervention. For all other types of interventions and outcomes, there was no evidence of a considerable effect. However, due to the very low- to moderate-quality of the evidence base, clear conclusions are currently unwarranted. Well-designed studies are needed to clarify effects of supervisor training on employees' stress, absenteeism, and well-being.

The making and sustaining of leaders in health care

PURPOSE

Many nations are focussing on health care's Triple Aim (quality, overall community health and reduced cost) with only moderate success. Traditional leadership learning programmes have been based on a taught curriculum, but the purpose of this paper is to demonstrate more modern approaches through procedures and tools.

DESIGN/METHODOLOGY/APPROACH

This study evolved from grounded and activity theory foundations (using semi-structured interviews with ten senior healthcare executives and qualitative analysis) which describe obstructions to progress. The study began with the premise that quality and affordable health care are dependent upon collaborative innovation. The growth of new leaders goes from skills to procedures and tools, and from training to development.

FINDINGS

This paper makes "frugal innovation" recommendations which while not costly in a financial sense, do have practical and social implications relating to the Triple Aim. The research also revealed largely externally driven health care systems under duress suffering from leadership shortages.

RESEARCH LIMITATIONS/IMPLICATIONS

The study centred primarily on one Canadian community health care services' organisation. Since healthcare provision is place-based (contextual), the findings may not be universally applicable, maybe not even to an adjacent community.

PRACTICAL IMPLICATIONS

The paper dismisses outdated views of the synonymity of leadership and management, while encouraging clinicians to assume leadership roles.

ORIGINALITY/VALUE

This paper demonstrates how health care leadership can be developed and sustained.

Leadership styles and outcome patterns for the nursing workforce and work environment: A systematic review

BACKGROUND

Leadership is critical in building quality work environments, implementing new models of care, and bringing health and wellbeing to a strained nursing workforce. However, the nature of leadership style, how leadership should be enacted, and its associated outcomes requires further research and understanding. We aimed to examine the relationships between various styles of leadership and outcomes for the nursing workforce and their work environments.

METHODS

The search strategy of this systematic review included 10 electronic databases. Published, quantitative studies that examined the correlations between leadership behaviours and nursing outcomes were included. Quality assessments, data extractions and analysis were completed on all included studies by independent reviewers.

RESULTS

A total of 50,941 titles and abstracts were screened resulting in 129 included studies. Using content analysis, 121 outcomes were grouped into six categories: 1) staff satisfaction with job factors, 2) staff relationships with work, 3) staff health & wellbeing, 4) relations among staff, 5) organizational environment factors and 6) productivity & effectiveness. Our analysis illuminated patterns between relational and task focused leadership styles and their outcomes for nurses and nursing work environments. For example, 52 studies reported that relational leadership styles were associated with higher nurse job satisfaction, whereas 16 studies found that task-focused leadership styles were associated with lower nurse job satisfaction. Similar trends were found for each category of outcomes.

CONCLUSIONS

The findings of this systematic review provide strong support for the employment of relational leadership styles to promote positive nursing workforce outcomes and related organizational outcomes. Leadership focused solely on task completion is insufficient to achieve optimum outcomes for the nursing workforce. Relational leadership practices need to be encouraged and supported by individuals and organizations to enhance nursing job satisfaction, retention, work environment factors and individual productivity within healthcare settings.

The effect of nurses' empowerment perceptions on job safety behaviours: a research study in Turkey

Objective. This study aimed to investigate the effect of nurses' empowerment perceptions on job safety behaviours. Methods. A survey of 377 nurses working in five hospitals in Turkey was conducted using the conditions of work effectiveness questionnaire, psychological empowerment instrument, universal precautions compliance scale and occupational health and safety obligations compliance scale. Relations between variables were tested using Pearson's correlation and path analysis. Results. There was a moderate and statistically significant relationship between psychological and structural empowerment and complying with universal safety measures and meeting occupational health and safety obligations. Also, an increase of 1 unit on the level of psychological empowerment was found to correspond to an increase of 0.37 units on the level of universal precautions compliance and to an increase of 0.46 units on the level of occupational health and safety obligations compliance. As such, an increase of 1 unit in structural empowerment corresponds to an increase of 0.53 units on the level of universal precautions compliance and to an increase of 0.36 units (total effect) on the level of occupational health and safety obligations compliance. Conclusions. The findings reveal that empowerment is a valuable tool for nurses' positive job safety behaviours.

Employee Responses to Empowering Leadership: A Meta-Analysis

A recent and growing number of studies examined how empowering leadership influences employee outcomes. At the individual level, we meta-analyzed 55 independent samples to determine the association between empowering leader behaviors and subordinates’ responses. Results confirmed the positive links of empowering leadership with evaluations of the leader as well as with employee motivation and resources, attitudes, and performance; the strongest correlation was between empowering leadership and attitudes toward the leader (ρ = .59), whereas the weakest correlation was for empowering leadership with behavioral and performance outcomes (ρ = .31). However, the relationship of empowering leadership with subordinates’ emotions was not significant. Examination of potential moderators, including rating sources, nationality of sample, gender, and industry, did not explain much of the heterogeneity in the results. In sum, findings highlight the potential benefit of empowering leadership for individual and organizational outcomes. Thus, more knowledge about what causes empowering leadership could be useful.

Disentangling the relationships between staff nurses' workplace empowerment and job satisfaction

AIM

The primary aim of this study was to examine the relationships between structural empowerment, psychological empowerment and job satisfaction among staff nurses, after controlling for their leaders' use of empowering behaviours.

BACKGROUND

Nurses' job satisfaction is a critical factor in health-care organisations because of its association with nurse turnover and quality of patient care. Nurses continue to report high levels of job dissatisfaction.

METHODS

Cross-sectional data for 1007 Canadian staff nurses were analysed using hierarchical multiple regression.

RESULTS

Structural empowerment was the strongest independent predictor of job satisfaction, followed by leader empowering behaviours and psychological empowerment. After accounting for the effects of structural empowerment and leader empowering behaviours, the four dimensions of psychological empowerment showed only small independent effects on job satisfaction. Psychological empowerment did not mediate the effects of structural empowerment on job satisfaction.

CONCLUSION

Nurses' job satisfaction is most influenced by their access to organisational empowerment structures. Leader empowering behaviours, structural empowerment, and psychological empowerment, operating together, enhance nurses' job satisfaction.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurse leaders should use a variety of empowerment strategies that are important to nurses' job satisfaction and potentially to the quality of patient care and nurse turnover.

Psychometric evaluation of the McCloskey/Mueller Satisfaction Scale

AIM

The aim of the study was to evaluate and refine the eight-factor structure of the 31 item McCloskey/Mueller Satisfaction Scale, which is one of the most widely used scales for measuring job satisfaction among nurses. However, this scale was developed in 1990 for the American nursing context and its psychometric validity and utility for use with non-American nurse populations have been questioned by various researchers.

BACKGROUND

The eight-factor, 31-item McCloskey/Mueller Satisfaction Scale is one of the most widely used scales for measuring job satisfaction among nurses. However, this scale was developed in 1990 for the American nursing context, and its psychometric validity and utility for use with non-American nurse populations have been questioned by various researchers.

METHODS

Data from a sample of 1007 Canadian nurses who were working in hospital and community settings were analyzed by using an exploratory factor analysis with varimax rotation.

RESULTS

The original factor structure of the McCloskey/Mueller Satisfaction Scale was unable to be replicated. The best-fitting model that was obtained was a five-factor model with 25 items. The Cronbach's alphas for the new McCloskey/Mueller Satisfaction Scale subscales ranged from 0.71 to 0.87, which indicated stronger internal consistency than the original subscales (α = 0.52-0.84).

CONCLUSION

The reliability and structural validity of the revised 25 item instrument suggest that it is a potentially sound tool for measuring nurses' job satisfaction. As a result of its sound dimensionality, it could be particularly useful when investigating individual and work factors that impact nurse job satisfaction or when evaluating the outcomes of organizational interventions that are aimed at increasing job satisfaction.

Exploring the Needs for Support of Pediatric Nurses Caring for Children with a Mental Health Disorder Hospitalized in Non-Psychiatric Units

This qualitative study explored the experience and the needs for support of pediatric nurses caring for children with a mental health disorder hospitalized in non-psychiatric units in a health organization in Canada. Semi-structured interviews were conducted with 17 nurses. Content analysis revealed two main themes: (a) nurses are challenged by the lack of knowledge, the gap between access to mental health resources and the basic role of only ensuring safety. Amidst these barriers, nurses revealed their feelings of helplessness, frustration and injustice. (b) All participants voiced their willingness to break this powerlessness loop. They identified several strategies to support them: more training in mental health, better collaboration with the mental health team, etc. Further research is needed to evaluate the efficiency of these strategies to improve the delivery of care for children with a mental health disorder hospitalized in non-psychiatric units.

The Nursing Leadership Institute program evaluation: a critique

A theory-driven program evaluation was conducted for a nursing leadership program, as a collaborative project between university faculty, the nurses’ union, the provincial Ministry of Health, and its chief nursing officers. A collaborative logic model process was used to engage stakeholders, and mixed methods approaches were used to answer evaluation questions. Despite demonstrated, successful outcomes, the leadership program was not supported with continued funding. This paper examines what happened during the evaluation process: What factors failed to sustain this program?