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

Leadership style has been studied from various perspectives including transformational leadership and the components of leadership competencies needed to exhibit transformational styles. However, there was a gap in the literature on the influence of leadership style on nursing professional behaviors and overall professionalism. The purpose of this descriptive, phenomenological study was to understand and explore the beliefs, attitudes, and perceptions of staff nurses on leadership style and its influence on professional nursing behaviors working in an inpatient care unit at a tertiary care center. The theory of transformational leadership was the conceptual framework for the study. A phenomenological approach was used for the qualitative interview with data analysis using a descriptive method. A total of 8 nursing participants were interviewed revealing that nurses had similar thoughts on their perceptions of professional characteristics and leadership driving professional socialization. Nurses articulated a practical knowledge of professional activities with little to no connection to a larger sense of professional identity, theory in practice, and ethical obligations to the future of the profession of nursing. There is a noted lack of professionalism seen in the discipline of nursing. Professional registered nurses and heath care leaders in nursing can benefit from this study. Understanding how leadership style can influence nursing not only impacts positive social change and shapes the future of the discipline of nursing, but can also potentially impact patient care outcomes and patient.

The arrival of the modern matron into the NHS acute setting in 2001 was in response to increased public and political concern regarding standards of nursing care and the quality of patient care. As a politically motivated initiative, the modern matron role and its relationship with the concept of the traditional matron has been extensively debated. The aims of this study were to explore: 1. How far the modern matron represents continuity between the traditional matrons of the mid 20th century and the present day. 2. What socio-political forces led to the development and establishment of the modern matron? 3. From the perspective of health professionals, what impact has the modern matron had on the quality of patient care? Adopting a case study design underpinned by realistic evaluation, the study involved interviewing patients and a carer, a focus group and interviews with staff and national policy leads. Documentary analysis was undertaken on a set of traditional matron archives. A number of key themes emerged from the research, including: the importance of uniform and visibility, patient expectations, the impact of policy processes and the political rationale for national policy change. Conflict between ensuring nursing quality and operational demands, which acts as a barrier to the modern matron role, was also found. Long-held assumptions about the functions and the positioning of the traditional matron are explored, with continuity and divergence between the traditional and modern matron roles revealed. Using a realistic evaluation approach, the findings were framed whilst considering the structural and generative elements, which resulted in social interplay or visible phenomena and provided an explanation for the predicament of the modern matron. The key conclusions were that national policy decisions appeared to be diluted once locally implemented. Modern matrons in part did positively impact on care quality. The introduction of modern matrons and the quality agenda may have been the start of a national discussion about how to continually improve patient care in an arena where intermittent care quality challenges which give concern. The effect of previous national policies that impacted on senior nurses may have diverted them away from their core purpose – patient care. The modern matron guidance may have been limited before publication by the inference within it about limiting the authority of the new post-holders. There was limited evidence of the modern matrons’ visibility to patients and this was reflected by the traditional matron’s accounts. The expectation of modern matrons’ physical presence may have been drawn from assumptions embedded in nostalgia and media portrayal of the traditional matron. The thesis concludes with implications for strategic nurse leaders and national policy leads to consider how the organisational arrangements for secondary care can best support and secure the ultimate aim of consistent provision of good quality nursing care.

Background: More and more people in need of hospital care can today be cared for in their homes. This has led to that more and more people nowadays can be treated with an invasive mechanical ventilator in their homes. This fact has placed great demands on the nurse who is responsible for and leads nursing.  Aim: The aim was to describe nurses’ experiences of nursing leadership in community home care for people with invasive ventilator treatment. Method: The study had a qualitative approach. Eight nurses and two district nurses working in community home care in two different municipalities participated in the study. Data were collected through semi-structured interviews and analysed by qualitative content analysis. Results: Three categories and nine subcategories emerged. The first category; Equip oneself and the nursing staff for the task, with the subcategories; Creating a feeling of safety and Tutoring nursing staff. The second category; Lead the nursing in someone's home is a balance, with the subcategories; Not given access from the patient and Involving the patient and close associates. The third category; A complex challenge for the nurse, with the subcategories; Big responsibility to delegate, Lead nursing staff are time consuming, Lack in organizational conditions; Keep in mind all threads and Not feeling safe.  Conclusion: For the nurse it is a complex task to lead in nursing leadership in community home care for people with invasive ventilator treatment. Important requirements are placed on the nurse’s knowledge and skills. Lacks are found in organizational conditions. / Idag har allt fler personer som tidigare behövde sjukhusvård möjlighet att vårdas i sina hem, även då de är beroende av avancerad teknik. Detta ställer ökade krav på sjuksköterskors kompetens i hemsjukvård. I den här studien var avsikten att undersöka sjuksköterskors erfarenheter av att leda omvårdnad i kommunal hemsjukvård för personer med ventilatorvård via trakeostomi. Intervjuer gjordes med 10 sjuksköterskor vilka ansvarar för vården av personer med behov av andningshjälp via ventilator i hemmet. Vid intervjuerna efterfrågades sjuksköterskornas erfarenheter av att leda omvårdnad för dessa personer. Ur analys av intervjuerna framkom att sjuksköterskorna tyckte att det var en utmanande uppgift att leda omvårdnad för dessa personer. En stor och tidskrävande uppgift som sjuksköterskorna ansvarar för är att lära den övriga personalen som hjälper personen i hemmet att sköta omvårdnad och teknisk utrustning så som ventilator. Sjuksköterskorna upplevde att de fick för lite stöd från sjukhusets sida och från sin arbetsgivare. Många av sjuksköterskorna tyckte att de själva hade för lite praktisk erfarenhet av att sköta den tekniska utrustningen vilket försvårade i uppgiften att leda omvårdnad. Det skiljer sig mycket mellan vård på sjukhus och i hemmet. I hemmet var sjuksköterskorna ofta mer ensamma i sina beslut. Det fanns ingen annan i närheten att fråga. Många av sjuksköterskorna upplevde att det var roligt och utvecklande att leda omvårdnad för dessa personer med stora vårdbehov. De ansåg dock att denna typ av avancerad vård behöver organiseras bättre för att sjuksköterskorna ska kunna utföra sina arbetsuppgifter på ett tryggt och säkert sätt. Det som idag anses problematiskt behöver ses över. Detta eftersom det troligtvis kommer behövas ännu mer av denna typ av avancerad vård i hemmen i framtiden, då allt fler svårt sjuka har möjlighet att få vård i sina hem. Genom studien framkom viktig kunskap för att kunna fördela resurser och planera för en välfungerande organisation, god kompetens och säkerhet i vården. Kunskaper som chefer och politiker, vilka har beslutsfattande position skulle kunna ha användning av. Utifrån denna studies resultat kan förbättringsområden identifieras och motivera till förändringsarbete i verksamheter där denna typ av vård förekommer.

As the nation’s healthcare system moves through the 21st century, unprecedented changes are occurring on both a local and global stage. Healthcare organizations are faced with creating and implementing leadership strategies to enhance the overall patient experience. When coupled with the need to ensure increased nurse job satisfaction, improved cost-effectiveness and healthy organizational cultures with fiscally sound budgets, improvement work has led efforts to ensure effective leadership techniques are used across an agency. This task may be viewed as commonplace for some organizations, while others may perceive this process as a complete paradigm shift from historical practices related to leadership style, behaviors and performance. A successful transition during this time of unprecedented change may depend on an organization’s ability to accept and implement the tenets of transformational leadership. Empirical research illustrates that transformational leadership empowers staff, increases job satisfaction and facilitates cost-effectiveness while constructing an environment conducive to the development of a supportive organizational culture. In an effort to ascertain the current state of leadership at a southeastern Veterans Affair Medical Center, this research study explored the self-reporting leadership practices of all supervisory staff employed at the facility. As a means of measurement, the Leadership Practices Inventory (LPI) was coupled by demographic questionnaire developed by the researcher. Both measurement tools were used to collect the data.

Today, nurses represent many cultures and ethnic backgrounds. In their leadership style, nurse leaders must learn to embrace cultural intelligence or cultural quotient (CQ), that is, an extension of emotional intelligence that affords them the ability to manage a culturally diverse workforce. Historically, CQ has been relevant to business, locally and globally. But it is also important to explore the CQ of nurse leaders. Scholarly studies show that leaders with CQ are responsible for developing innovative employee behaviors, forward-thinking ideas, and creativeness in the workplace. CQ has a theoretical foundation in the 2003 research of Early and Ang who focused on CQ and the ability to lead in culturally diverse situations. This theoretical foundation will support the qualitative case study approach used to explore the CQ of nurse leaders. Ten participants were selected to answer semi structured interview questions, which were designed to produce data to answer research questions about the meaning of CQ to nurse leaders, the patient experience, self-awareness of CQ, and leadership practice. Thematic data analysis using the MAXQDA software program was the analysis tool. The results are expected to create positive social change by providing evidence-based results that can enhance the CQ of nurse leaders, their leadership style, and their practice in the United States. This study will add to the existing literature and its results may help the reader to reflect on the importance of CQ in their practice of leadership in the nursing profession.

<p></p><p>BAKGRUND: Antalet multisjuka äldre personer ökar och ett omfattande vårdbehov kan skönjas. Vårdens organisation och hur den fylls med innehåll påverkar relationen till patienten. Ledarskapsstilen påverkar upplevd arbetstillfredsställelse och den kultur som vårdpersonalen skapar tillsammans avgör livskvalitet och vårdandets kvalitet för patienten. SYFTE: Syftet med studien är att utifrån semistrukturerad observation beskriva arbetsinnehållet och ledarskap för en första linjens chef inom kommunal äldreomsorg. METOD: En fallstudie, a single case study, med semistrukturerad observation av en första linjens chef inom kommunal äldreomsorg. Studien hade en deskriptiv design med en kvalitativ ansats. Observatörens nedskrivna texter analyserades med latent innehållsanalys. RESULTAT: Utförande av arbetsuppgifter hade genomgående karaktär av ledarskap. Administration och organisering av arbete var en stor del av arbetsuppgifterna och övervägande var oplanerade. Ansvarstagande, problemlösning, bekräftelse, tjänstvillighet och organisering av arbete där personlighet, kunskap och yrkeserfarenhet påverkade ledarskapet och informantens upplevelse av utförandet av arbetsuppgifter. SLUTSATS: En första linjens chefs arbetsuppgifter är mångfacetterande och spänner sig över kvalificerat arbete där specifik utbildning krävs och till att serva boende och däremellan ge direktiv och organisera för att få arbetet utfört samt medverka vid möten med ledning och chefsgrupp. En dialog som exempelvis öppet informerar om förändringar och varför samt att medarbetare accepterar och samarbetar för att underlätta arbetet där perspektivet utgår från den boende vilket skulle påverka vårdkulturen i positiv riktning och öka möjligheten till en kreativ och livsbejakande miljö kring den boende.</p>

 BAKGRUND: Antalet multisjuka äldre personer ökar och ett omfattande vårdbehov kan skönjas. Vårdens organisation och hur den fylls med innehåll påverkar relationen till patienten. Ledarskapsstilen påverkar upplevd arbetstillfredsställelse och den kultur som vårdpersonalen skapar tillsammans avgör livskvalitet och vårdandets kvalitet för patienten. SYFTE: Syftet med studien är att utifrån semistrukturerad observation beskriva arbetsinnehållet och ledarskap för en första linjens chef inom kommunal äldreomsorg. METOD: En fallstudie, a single case study, med semistrukturerad observation av en första linjens chef inom kommunal äldreomsorg. Studien hade en deskriptiv design med en kvalitativ ansats. Observatörens nedskrivna texter analyserades med latent innehållsanalys. RESULTAT: Utförande av arbetsuppgifter hade genomgående karaktär av ledarskap. Administration och organisering av arbete var en stor del av arbetsuppgifterna och övervägande var oplanerade. Ansvarstagande, problemlösning, bekräftelse, tjänstvillighet och organisering av arbete där personlighet, kunskap och yrkeserfarenhet påverkade ledarskapet och informantens upplevelse av utförandet av arbetsuppgifter. SLUTSATS: En första linjens chefs arbetsuppgifter är mångfacetterande och spänner sig över kvalificerat arbete där specifik utbildning krävs och till att serva boende och däremellan ge direktiv och organisera för att få arbetet utfört samt medverka vid möten med ledning och chefsgrupp. En dialog som exempelvis öppet informerar om förändringar och varför samt att medarbetare accepterar och samarbetar för att underlätta arbetet där perspektivet utgår från den boende vilket skulle påverka vårdkulturen i positiv riktning och öka möjligheten till en kreativ och livsbejakande miljö kring den boende.

Societies in the developed world are becoming increasingly diverse as they experience growth in the number and size of minority groups, including visible minorities, immigrants, and, in some countries, Indigenous peoples. Societys institutions, including the health care system and its professional groups, are increasingly challenged to enhance their understanding of and respect for such societal diversity in providing services, and to work to reflect this diversity in the makeup of their membership. While many of the health care professions, including nursing, have acknowledged the importance of inclusion of individuals from diverse groups, their successes in meeting targeted increases have been limited. The purpose of this research was to elicit stories of nursing leadership that successfully promoted diversity and enhanced inclusiveness within the profession. The research problem was stated as follows: What were the experiences and stories of nurse leaders who successfully provided leadership to increase diversity and inclusion within the profession? The study used modified narrative inquiry research methods. The research was built on a conceptual framework consisting of three major concepts: diversity, critical leadership, and professional closure. The study focused on the stories of five Canadian nurse leaders who described and explained through their stories their leadership characteristics and challenges. Their stories of promoting diversity and inclusion were explored from a critical perspective, using literature found primarily in the fields of nursing and education to guide the exploration.<p> These leaders stories revealed their understanding that the nursing profession currently expected its members to represent the norm-- white middle class females. The stories showed that the participating nurse leaders generally had views of diversity that were broader than culture, ethnicity and race, the views that were most commonly addressed in the mainstream nursing literature. Their broad views of diversity included difference based on gender, sexual orientation, and ability. These views often arose from personal experiences of difference related to ethnicity, language, country of origin, gender, presence of an accent, or family circumstances. The leaders interviewed indicated that they saw a lack of tolerance for difference within the profession, but not simply in relation to cultural or physical difference. They described a lack of acceptance within the profession of different ways of thinking and beingreferred to in the study as diversity of thought. They reported that the profession expected and reinforced conformist thinking and tended to support the status quo.<p> The study findings contributed to an expanded understanding of the conceptual approach of critical leadership as a process to support diversity and promote inclusion in the profession. A conceptual framework for critical leadership, based on the work of Foster (1986; 1989) and Ryan (2006a; 2006b) was enhanced and expanded as a result of the study findings. Critical leadership involved critique, transformation, education, ethics, and inclusion. The study findings supported the view that the profession of nursing, perhaps inadvertently, limited access to the profession by marginalized groups. This process was called professional closure, and occurred as a result of increasing entrance requirements, inconsistent language requirements, and segmenting minority groups in lower paid practical nurse and front line positions, with little opportunity for advancement.<p> These findings about diversity and leadership, and about leadership for diversity, challenged the nursing profession to look beyond its day-to-day busyness, and to move beyond its current locked-down, controlled, risk-averse practices. The study findings challenged the profession to embrace the possibilities of increasing its diversity and inclusiveness, with the ultimate goal of building a better, stronger, more just profession and a better, stronger, more just society.<p> The study has significant implications for theory, practice, research and policy in the profession. From a theoretical perspective, the study pointed to the need for the nursing profession to contemplate its social obligations with respect to promoting social justice in society. The study findings suggest that the profession might engage in national level policy discussions committed to increasing the diversity of the profession in order to reflect the community it serves. This study suggests the need for additional qualitative and quantitative studies on critical leadership to further develop the conceptualizations that evolved in this study. Policy discussions are implicated to address approaches to difference, inclusion, culture, cultural competence, cultural safety, affirmative action and inclusive policy in nursing, nursing education and health care institutions.

Societies in the developed world are becoming increasingly diverse as they experience growth in the number and size of minority groups, including visible minorities, immigrants, and, in some countries, Indigenous peoples. Societys institutions, including the health care system and its professional groups, are increasingly challenged to enhance their understanding of and respect for such societal diversity in providing services, and to work to reflect this diversity in the makeup of their membership. While many of the health care professions, including nursing, have acknowledged the importance of inclusion of individuals from diverse groups, their successes in meeting targeted increases have been limited. The purpose of this research was to elicit stories of nursing leadership that successfully promoted diversity and enhanced inclusiveness within the profession. The research problem was stated as follows: What were the experiences and stories of nurse leaders who successfully provided leadership to increase diversity and inclusion within the profession? The study used modified narrative inquiry research methods. The research was built on a conceptual framework consisting of three major concepts: diversity, critical leadership, and professional closure. The study focused on the stories of five Canadian nurse leaders who described and explained through their stories their leadership characteristics and challenges. Their stories of promoting diversity and inclusion were explored from a critical perspective, using literature found primarily in the fields of nursing and education to guide the exploration.<p> These leaders stories revealed their understanding that the nursing profession currently expected its members to represent the norm-- white middle class females. The stories showed that the participating nurse leaders generally had views of diversity that were broader than culture, ethnicity and race, the views that were most commonly addressed in the mainstream nursing literature. Their broad views of diversity included difference based on gender, sexual orientation, and ability. These views often arose from personal experiences of difference related to ethnicity, language, country of origin, gender, presence of an accent, or family circumstances. The leaders interviewed indicated that they saw a lack of tolerance for difference within the profession, but not simply in relation to cultural or physical difference. They described a lack of acceptance within the profession of different ways of thinking and beingreferred to in the study as diversity of thought. They reported that the profession expected and reinforced conformist thinking and tended to support the status quo.<p> The study findings contributed to an expanded understanding of the conceptual approach of critical leadership as a process to support diversity and promote inclusion in the profession. A conceptual framework for critical leadership, based on the work of Foster (1986; 1989) and Ryan (2006a; 2006b) was enhanced and expanded as a result of the study findings. Critical leadership involved critique, transformation, education, ethics, and inclusion. The study findings supported the view that the profession of nursing, perhaps inadvertently, limited access to the profession by marginalized groups. This process was called professional closure, and occurred as a result of increasing entrance requirements, inconsistent language requirements, and segmenting minority groups in lower paid practical nurse and front line positions, with little opportunity for advancement.<p> These findings about diversity and leadership, and about leadership for diversity, challenged the nursing profession to look beyond its day-to-day busyness, and to move beyond its current locked-down, controlled, risk-averse practices. The study findings challenged the profession to embrace the possibilities of increasing its diversity and inclusiveness, with the ultimate goal of building a better, stronger, more just profession and a better, stronger, more just society.<p> The study has significant implications for theory, practice, research and policy in the profession. From a theoretical perspective, the study pointed to the need for the nursing profession to contemplate its social obligations with respect to promoting social justice in society. The study findings suggest that the profession might engage in national level policy discussions committed to increasing the diversity of the profession in order to reflect the community it serves. This study suggests the need for additional qualitative and quantitative studies on critical leadership to further develop the conceptualizations that evolved in this study. Policy discussions are implicated to address approaches to difference, inclusion, culture, cultural competence, cultural safety, affirmative action and inclusive policy in nursing, nursing education and health care institutions.