Doctor of Philosophy / Hospitality Management and Dietetics / Kevin Sauer / There has been a historic and consistent call for Registered Dietitian Nutritionists (RDN) to develop and practice leadership skills regardless of roles and responsibilities. The majority of RDNs practice as clinicians in the health care environment, however, there is no clear description of what leadership entails in that setting. Very little published research exists regarding leadership in dietetics, and there are no known studies about clinical leadership in the profession. The purpose of this exploratory study was to develop an evidence and practice-based leadership behavior taxonomy for clinical RDNs. To do this, a comprehensive list of leadership behavior items was developed based on literature review and then validated by an expert panel of Clinical Nutrition Managers. A stratified random national sample of 4,700 clinical RDNs was invited to complete the survey instrument; participants rated the frequency of demonstrating each behavior item and the potential benefit to the patients or clients if they demonstrated it. Additional questions exploring clinical RDNs’ experiences and perspectives of clinical leadership and demographics were asked. There was a 14.6% response rate (N = 684). The frequency data were used to conduct exploratory (EFA) and confirmatory factor analyses. Five factors emerged from the EFA and a clinical leadership behavior taxonomy was developed based on those findings. Most clinical RDNs considered themselves clinical leaders (74.9%), felt that leadership was relevant to daily clinical nutrition practice (89.6%), and enjoyed their jobs more when practicing leadership at work (75.7%). One-way ANOVAs and independent t tests revealed no significant differences in composite mean leadership frequency scores across gender, level of education, years in practice, years in current position, type of current position, or having a specialty certification, however, there was a significant relationship between composite scores and levels of professional involvement Welch’s F (3, 674) = 13.79, p < .001. This research advances clinical dietetics practice by creating a common language to discuss leadership and its development and practice, the taxonomy should inform education standards, continuing education offerings, and employee development for clinical RDNs.

abstract: Nurses are ideally positioned to lead the transformation of healthcare delivery in the United States, however they must be prepared to do so. The Institute of Medicine has called for nurses to become change agents and assume leadership positions across all levels in order to become full partners with physicians and other health care providers. While clinical leadership is a responsibility for all nurses, expectations for new nurse clinical leadership have not been well studied. This study sought to determine the nursing leadership competencies clinical managers expect of new nurses in an acute care setting and to identify gaps between end-of-program nursing leadership competencies, as outlined in The Essentials of Baccalaureate Education for Professional Nursing Practice, with leadership competencies identified by clinical managers in an acute-care setting. A single, bounded case study approach was used to collect data from nurse managers and assistant nurse managers at one acute care hospital. Data from intensive interviews, focus groups, and archival records were analyzed. Seven major themes related to clinical leadership emerged, including intentional learning, communication, professional practice, advocacy, teamwork, influencing practice, and systems thinking. Traits, mentoring, and generational differences emerged as secondary themes. Data from this study revealed a developmental sequence for clinical leadership. Certain expectations identified as antecedent to clinical leadership emerged initially, whereas other aspects of clinical leadership, developed later in the career trajectory. It was clear that accomplishing nursing care tasks was a fundamental expectation for professional nursing practice. Communication, teamwork and advocacy are crucial leadership competencies which help the new nurse to effectively manage time and provide safe, high-quality nursing care. As the new nurse continues to develop, systems thinking and influencing nursing practice emerge as significant expectations. Nurse managers have clear expectations for how new nurses should be prepared for clinical leadership. The degree to which clinical practice partners employing new nurses and academic nursing programs educating future nurses collaborate to establish expected outcomes is variable; however, academic-practice collaborations are crucial in developing educational standards for entry to practice in complex healthcare delivery systems. / Dissertation/Thesis / Doctoral Dissertation Nursing and Healthcare Innovation 2018

Masters of Science - Msc (Physiotherapy) / The roles of doctors and nurses in clinical supervision and clinical education are well defined in literature. However, the role of the physiotherapist in clinical education has not been clearly defined. This could be because the understanding of a clinical supervisor varies from discipline to discipline.

Bakgrund: Inom psykiatrisk vård samverkar olika sorters team där sjuksköterskors ledarskap påverkas/påverkar olika grupprocesser. Specialistsjuksköterskor, inriktning psykiatrisk vård har ett ansvar medan sjuksköterskor på grundnivå utför ledarskapet utifrån deras vilja och förmåga. Kunskapsbrist råder vilka aspekter som påverkar sjuköterskors ledarskap inom psykiatrisk vård. Syfte: Syfte med föreliggande strukturerade litteraturöversikt är att beskriva aspekter som påverkar sjuksköterskors ledarskap som är verksamma inom psykiatrisk vård. Metod: Metoden systematisk litteraturöversikt med kvalitativ design användes och analysprocessen bestod av tematisk analys. Resultatartiklarna utgick från kvalitativa- och kvantitativa metoder. Resultat: Sex teman och sex kategorier framkom; Organisationsstruktur med dess inflytande av genomförandeprocess och kommunikation. Vårdande kultur, med stödjande ledarskap och chefers betydelse för sjuksköterskors ledarskap. Egna rollers förtydligande, konstaterade mandatets inverkan. Sammarbetsrelationer, blev synlig genom olika yrkesroller i teamet. Erfarenheter, framträdde i form av tolkning av vårdsituationer och moralisk stress och dess betydels för ledarskapet. Utbildningar påvisade bl.a. utbildningar och utbildningsnivåers inverkan. Diskussion: Den teoretiska utgångspunkten Caritativt ledarskap av Bondas (2003) synliggjorde sjuksköterskans ledarskap i betydelse av tesen människa. Caritativt ledarskap ställdes i relation till de fem teserna, människa, caritas motiv, värdighet, mätning och mening med hälso- och sjukvård, och relation till den vårdande kulturen vilket förtydligade hur sjuksköterskor ledarskap inom psykiatrisk vård kan stödjas inom vårdande organisationer. Resultatet indikerar ett outforskat fält avseende sjuksköterskors ledarskap och där flera aspekter kan få betydelse för framtida forskning inom ledarskap för sjuksköterskor som är verksamma inom psykiatrisk vård oavsett deras utbildningsgrad. / Background: In psychiatric care different kind of team interacts where nurses’ leadership affected / affects various group processes. Advanced nurses, targeting mental health services have a responsibility while nurses at undergraduate level performing leadership based on their willingness and ability. Lack of knowledge is what aspects affecting nurses’ leadership in psychiatric care. Aim: The purpose of this structured literature review is to describe aspects that influence nurses' leadership working in psychiatric care. Method: The method systematic literature review with a qualitative design was used and the analysis process consisted of thematic analysis. The result from the articles was based on qualitative and quantitative methods. Result: Six theme and six category emerged; Organizational structure and its influence of the implementation process and communication. Caring culture where supportive leadership and managers of importance for nursing leadership. Clarification of the own Health careers roles, stated mandate impact. Cooperative relationships became visible through different roles in the team. Experience, emerged in the form of interpretation of the care situations and moral stress and its importance for leadership. Education influenced further development and inter alia of the influence of various training and educational levels. Discussion: The theoretical point Caritative leadership of Bondas (2003) made ​​it visible se nursing leadership in the importance of the five theses. Caritative leadership was used in relation to the five theses, human, caritas motive, dignity, measurement and meaning in health care, and relationship to the caring culture which clarified how the leadership of psychiatric nurses in psychiatric care can be supported within caring organizations. The results indicate an unexplored field regarding nurses' leadership and where several aspects may be of importance for future research in leadership for nurses working in mental health care regardless of their education level.

I Sverige upplever sjuksköterskor höga nivåer av psykosociala arbetsmiljörelaterade besvär. Kliniskt ledarskap är ett relativt nytt, obeforskat begrepp som syftar till att identifiera ledarskapsbeteenden hos sjuksköterskor. Det saknas dock forskning om dess eventuella samband med psykosociala arbetsmiljöfaktorer. Föreliggande studies syfte är därför att undersöka hur upplevd stress, arbetskrav och work-family conflict predicerar kliniskt ledarskap hos sjuksköterskor i offentlig vård. För att undersöka detta svarade 239 sjuksköterskor på en webbenkät, där de skattade sin upplevda stress, arbetskrav, work-family conflict och kliniska ledarskap. Arbetsmiljövariablerna användes som prediktorer i en standard MRA med kliniskt ledarskap som utfallsvariabel. Resultaten visade att modellen förklarar 9,5 % av kliniskt ledarskap, där upplevd stress och känslomässiga krav är signifikanta enskilda prediktorer. Resultaten diskuteras bland annat utifrån tidigare forskning om stress, eget ledarskap och kliniskt ledarskap samt arbetskrav utifrån krav-kontroll modellen. / In Sweden, nurses experience high levels of troubles related to the psychosocial work environment. Clinical leadership is a new concept, which aims to identify leadership behaviors for nurses. However, there is a lack of studies about its possible relationship with psychosocial work environmental factors. Therefore, the purpose of this study was to investigate how perceived stress, work demands and work-family conflict predict clinical leadership in nurses in public sector health care. In this study, 239 nurses participated in a web-based questionnaire, where they rated perceived stress, work demands, work-family conflict and clinical leadership. The work environment variables were used as predictors in a standard MRA with clinical leadership as the dependent variable. Results showed that the model explained 9,5 % of clinical leadership, with perceived stress and emotional demands as significant predictors. Findings are discussed based on previous research on stress, self-leadership and clinical leadership, and job demands based on the Demand-Control model.

Le leadership clinique infirmier au point de dispensation des soins est important afin d’assurer des soins de qualité et sécuritaires dans les organisations de santé (ACN, 2015 ; RNAO, 2013). Des études mettent en évidence qu’un leadership exercé par l’ensemble des professionnels de la santé, qui prennent la responsabilité individuelle et collective d’offrir des soins efficaces et de haute qualité, serait plus adapté aux réalités contemporaines des milieux de soins (West et al., 2014 ; West et al., 2015). Or, le leadership clinique des infirmières est, jusqu’à ce jour, étudié selon des rôles spécifiques, ce qui ne permet pas de comprendre comment l’ensemble des infirmières d’une unité de soins exercent leur leadership au point de dispensation des soins. Le but de l’étude était de décrire l’exercice du leadership clinique infirmier dans des unités de soins hospitaliers, les facteurs qui le favorisent et ceux qui le contraignent, ainsi que la perception qu’ont les infirmières des résultats de cet exercice du leadership pour les patients, les infirmières, l’équipe interprofessionnelle et l’organisation. Pour soutenir cette étude, l’adaptation du modèle pour le développement et le maintien du leadership proposé par l’Association des infirmières et infirmiers autorisés de l’Ontario [RNAO] (2013) a été réalisée en y intégrant les pratiques de leadership clinique énoncées par Patrick et al. (2011). Une étude de cas multiple (Stake, 1995; 2016) a été réalisée auprès de trois équipes infirmières dans un centre hospitalier universitaire québécois. L’échantillon (N = 36) se composait de 22 infirmières soignantes, de 7 assistantes infirmières-chefs, de 4 infirmières en pratique avancée et de 3 infirmières-chefs d’unité. Trente-six entrevues, 120 heures d’observation ainsi qu’une analyse documentaire ont été effectuées. Une analyse pour chaque cas (Paillé et Mucchielli, 2016) et transversale (Stake, 2016) a permis la formulation de thèmes et une modélisation de l’exercice du leadership clinique infirmier. Nos résultats indiquent que le leadership clinique infirmier se manifeste sous cinq formes actives, quel que soit le rôle de l’infirmière sur l’unité : 1) prendre des initiatives de l’ordre de la pensée réflexive et de l’intervention ; 2) influencer l’atteinte des objectifs de soins du patient/famille et le développement professionnel des collègues en leur offrant du coaching ; 3) participer et mobiliser ses collègues à contribuer à des activités d’amélioration de la qualité des soins ; 4) s’impliquer afin de promouvoir une synergie et une cohésion d’équipe optimale ; 5) mobiliser des capacités personnelles et collaboratives. Des ressources multiniveaux, une organisation du travail qui prône l’autonomie professionnelle, le leadership clinique ainsi qu’un climat de travail positif seraient favorables à l’exercice du leadership. Finalement, les infirmières perçoivent de multiples résultats positifs (ex. : diminution des complications des patients, développement professionnel des infirmières). Cette étude propose une perspective collective du leadership clinique infirmier dans des unités de soins hospitaliers, met en évidence son effet de levier pour celui-ci ainsi que pour l’atteinte de résultats positifs. Elle propose aussi une modélisation pouvant servir d’outil pragmatique. Plusieurs pistes de réflexion et d’interventions sont présentées pour la gestion, la formation, la recherche et la pratique. / Clinical nursing leadership at the point of delivery of care is important to ensure safe, quality care in health care organizations (ACN, 2015; RNAO, 2013). Recent studies show that a leadership exercised by the entire team of health professionals, taking individual and collective responsibility for providing effective and high quality care, would be more suited to the contemporary realities of care settings (West et al., 2014; West et al., 2015). However, up until now, clinical leadership of nurses has only been studied according to specific roles. This does not allow us to understand how all the nurses working in a care unit exercise their leadership at the point of delivery of care. The aim of the study is to describe the exercise of clinical nursing leadership in the context of hospital care units, the factors that favor and those that constrain it, and how nurses perceive the effects of this exercise of leadership on patients, nurses, the interprofessional team and the organization. To support this study, the conceptual model for the development and maintenance of leadership proposed by the Registered Nurses Association of Ontario [RNAO] (2013) was adapted by incorporating clinical leadership practices identified by Patrick et al. (2011). A multiple case study (Stake, 1995; 2016) was conducted with three nursing teams in a Québec university hospital center. The sample (N = 36) was composed of 22 bedside nurses, 7 assistant unit nurse managers, 4 advanced practice nurses and 3 unit nurse managers. Thirty-six interviews, 120 hours of observation and a documentary analysis were conducted. For each case, an analysis (Paillé and Mucchielli, 2016) and a cross-case analysis (Stake, 2016) permitted to formulate themes and to offer a model of the exercise of clinical nursing leadership. Our results indicate that clinical nursing leadership manifests itself in five forms, regardless of the unit nurse’s role: 1) taking initiatives involving reflective thinking and intervention; 2) influencing the achievement of patient/family care goals and the professional development of colleagues by offering coaching; 3) participating and mobilizing colleagues to contribute to activities that improve the quality of care; 4) becoming involved in order to promote optimal synergy and team cohesion; and 5) mobilizing personal and collaborative capacities. Multilevel resources, a work organization that promotes professional autonomy, clinical leadership, as well as a positive work climate were found to be favorable to the exercise of leadership. Finally, nurses perceive multiple positive results (ex. a decrease in complications for the patients and professional development for the nurses). This study suggests a collective perspective of clinical nursing leadership in hospital care units, it highlights the leverage effect for itself and the achievement of positive outcomes. It also offers a model that could serve as a pragmatic tool. Finally, various suggestions for reflection and intervention are proposed for management, training, research and practice.

Thèse en administration des services-infirmiers subventionnée par "Formation et expertise en recherche administration des services infirmiers" (FERASI) / Cette étude a pour but de comprendre les processus de transformation de la pratique clinique chez les infirmières à la faveur des initiatives d’intégration des soins et services et d’examiner l’impact de ces processus sur le bien-être au travail des infirmières. De façon spécifique, l’étude vise: 1) à décrire les pratiques infirmières dans le contexte d’intégration des soins et services au Québec 2) à analyser la relation entre les processus de changement sous-jacents aux efforts d’intégration et le bien-être au travail des infirmières selon leurs perceptions et 3) à identifier les principaux leviers, sur les plans de la gestion et de la clinique, que peuvent mobiliser les organisations afin de soutenir la pratique infirmière dans un contexte d’intégration des soins. L’étude a été organisée en trois volets correspondant respectivement aux trois objectifs précédemment mentionnés. Le cadre de référence développé et utilisé pour cette étude est le « Modèle infirmier du développement de l’intégration des soins » (MIDIS). Il s’appuie sur les prémisses du modèle de Cazale, Touati et Fleury (2007), qui couvrent les interrelations entre les variables contextuelles (organisationnelles et structurelles), l’adoption et l’institutionnalisation des pratiques intégratives, et les effets qui y sont associés pour les infirmières en termes de bien-être au travail. Pour atteindre les objectifs de l’étude, un devis mixte a été utilisé, incluant : un devis quantitatif descriptif (volet 1), un devis quantitatif corrélationnel (volet 2) et un devis qualitatif d’étude de cas unique avec niveaux d’analyse imbriqués (volet 3). La collecte des données a été menée dans le cadre de quatre trajectoires de soins (TdeS) : Soutien à l’autonomie (SoAu), Palliatifs/oncologiques (PaOn), Santé mentale (SaMe) et Maladie pulmonaire obstructive chronique (Mpoc). L’étude a été effectuée auprès d’infirmières, de professionnels autres, et de gestionnaires. Pour les volets un et deux, 107 questionnaires ont été complétés et 37 entrevues semi-dirigées ont été effectuées pour le volet 3. Les résultats du premier volet ont démontré non seulement d’importantes variations dans le développement de l’intégration entre les TdeS mais également un décalage entre l’évolution de la pratique infirmière et l’introduction des changements visant une plus grande intégration des soins. Deux dimensions seulement de la pratique intégrative sur neuf (Qualité des soins et Équipe interprofessionnelle) prévalent dans l’ensemble des TdeS et seule la TdeS PaOn a atteint une étape plus avancée du processus d’intégration. Les résultats du deuxième volet démontrent que plus l’intégration se situe à un niveau avancé de développement, moins elle est associée à une perception de menace chez les infirmières et plus elle est associée à des réactions positives et un bien-être au travail. Le troisième volet a mis en lumière trois types de leviers qui doivent être mobilisés de manière complémentaire dans le but de favoriser l’intégration : les processus organisationnels, les processus cliniques, les investissements dans des ressources clés et dans le renouvellement de certaines structures organisationnelles. Ces résultats apportent des éclairages quant aux défis posés par les processus d’intégration des soins et montrent l’importance d’une pluralité d’interventions qui doivent être conduites à tous les paliers organisationnels afin de faciliter l’institutionnalisation des pratiques intégratives et obtenir les effets escomptés. / The aim of this study is to understand processes of transformation of clinical practice among nurses in the context of care and service integration initiatives, and to examine the impact of these processes on nurses’ well-being at work. Specifically, the study’s objectives are to: 1) describe nursing practices that underpin efforts to integrate care and services in Quebec; 2) analyze the relationship between the change processes underpinning integration efforts and nurses’ self-perceived well-being at work; and 3) identify the main levers that organizations can use at management and clinical levels to support nursing practices in an care integration context. The study was set up in three parts, corresponding respectively to the three objectives mentioned above. The reference framework developed for this study, is the Modèle infirmier du développement de l’intégration des soins (MIDIS – Development model for integrated care in nursing). It is based on the premises of the model of Cazale, Touati et Fleury, (2007) that cover the interrelationships between contextual variables (organizational and institutional), the adoption and institutionalization of integrative practices, and the associated effects on professionals with respect to well-being in the workplace. To achieve the study’s objectives, a mixed-method design was used, which included: a descriptive quantitative component (Part 1), a correlational quantitative component (Part 2), and a single case qualitative study with nested levels of analysis (Part 3). Data were collected within four care pathways (CPs): autonomy support for the elderly (ASE); palliative oncology services (POS); mental health services (MHS); and chronic obstructive pulmonary disease (CPOD). Data were collected from nurses, health professionals, and managers. For Parts 1 and 2, 107 questionnaires completed and 37 semi-structured interviews conducted for Part 3. The results of the first part of the study showed not only significant variations across CPs in the development of integration, but also a gap between the evolution of nursing practice and the introduction of changes aimed at greater integration of care. Only two out of nine dimensions of integrative practice (‘quality of care’ and ‘interprofessional teamwork’) were prevalent across all CPs and only one CP (POS) had reached a more advanced stage in the integration process. The results of the second part of the study showed that, as integration became more highly developed, it was associated less with a perception of threat by nurses and more with positive reactions and well-being at work. The third part of the study identified three types of levers that should be used in a complementary way to speed up the progress of integration: organizational processes; clinical-administrative processes; investment in key resources and in renovation of certain organizational structures. These results shed additional light on the challenges posed by the process of integration of care, and show the importance of leading multiple interventions at all organizational levels to facilitate institutionalization of integrative practices and achieve the intended effects.