problem solving in nursing leadership

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

Affiliations.

• 1 Faculty of Nursing, Edmonton Clinic Health Academy, University of Alberta, 11405 87 Ave NW, Edmonton, AB T6G 1C9, Canada. Electronic address: [email protected].
• 2 Department of Nutrition, Dietetics and Food, School of Clinical Sciences at Monash Health, Monash University, Level 1, 264 Ferntree Gully Rd, Notting Hill, VIC 3168, Australia.
• 3 Faculty of Nursing, Edmonton Clinic Health Academy, University of Alberta, 11405 87 Ave NW, Edmonton, AB T6G 1C9, Canada.
• 4 Faculty of Nursing, Edmonton Clinic Health Academy, University of Alberta, 11405 87 Ave NW, Edmonton, AB T6G 1C9, Canada; Technical High School of Campinas, State University of Campinas (UNICAMP), Barão Geraldo, Campinas - São Paulo 13083-970, Brazil.
• PMID: 33383271
• DOI: 10.1016/j.ijnurstu.2020.103842

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.

Keywords: Interventions; Leadership; Nursing workforce; Systematic Review.

Copyright © 2020. Published by Elsevier Ltd.

Publication types

• Systematic Review
• Delivery of Health Care*
• Leadership*

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Institute of Medicine (US) Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington (DC): National Academies Press (US); 2011.

The Future of Nursing: Leading Change, Advancing Health.

• Hardcopy Version at National Academies Press

5 Transforming Leadership

Key Message #3 : Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States.

Strong leadership is critical if the vision of a transformed health care system is to be realized. Yet not all nurses begin their career with thoughts of becoming a leader. The nursing profession must produce leaders throughout the health care system, from the bedside to the boardroom, who can serve as full partners with other health profes sionals and be accountable for their own contributions to delivering high-quality care while working collaboratively with leaders from other health professions.

In addition to changes in nursing practice and education, discussed in Chapters 3 and 4 , respectively, strong leadership will be required to realize the vision of a transformed health care system. Although the public is not used to viewing nurses as leaders, and not all nurses begin their career with thoughts of becoming a leader, all nurses must be leaders in the design, implementation, and evaluation of, as well as advocacy for, the ongoing reforms to the system that will be needed. Additionally, nurses will need leadership skills and competencies to act as full partners with physicians and other health professionals in redesign and reform efforts across the health care system. Nursing research and practice must continue to identify and develop evidence-based improvements to care, and these improvements must be tested and adopted through policy changes across the health care system. Nursing leaders must translate new research findings to the practice environment and into nursing education and from nursing education into practice and policy.

Being a full partner transcends all levels of the nursing profession and requires leadership skills and competencies that must be applied both within the profession and in collaboration with other health professionals. In care environments, being a full partner involves taking responsibility for identifying problems and areas of waste, devising and implementing a plan for improvement, tracking improvement over time, and making necessary adjustments to realize established goals. Serving as strong patient advocates, nurses must be involved in decision making about how to improve the delivery of care.

Being a full partner translates more broadly to the health policy arena. To be effective in reconceptualized roles and to be seen and accepted as leaders, nurses must see policy as something they can shape and develop rather than something that happens to them, whether at the local organizational level or the national level. They must speak the language of policy and engage in the political process effectively, and work cohesively as a profession. Nurses should have a voice in health policy decision making, as well as being engaged in implementation efforts related to health care reform. Nurses also should serve actively on advisory committees, commissions, and boards where policy decisions are made to advance health systems to improve patient care. Nurses must build new partnerships with other clinicians, business owners, philanthropists, elected officials, and the public to help realize these improvements.

This chapter focuses on key message #3 set forth in Chapter 1 : Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States. The chapter begins by considering the new style of leadership that is needed. It then issues a call to nurses to respond to the challenge. The third section describes three avenues—leadership programs for nurses, mentorship, and involvement in the policy-making process—through which that call can be answered. The chapter then issues a call for new partnerships to tap the full potential of nurses to serve as leaders in the health care system. The final section presents the committee’s conclusions regarding the need to transform leadership in the nursing profession.

• A NEW STYLE OF LEADERSHIP

Those involved in the health care system—nurses, physicians, patients, and others—play increasingly interdependent roles. Problems arise every day that do not have easy or singular solutions. Leaders who merely give directions and expect them to be followed will not succeed in this environment. What is needed is a style of leadership that involves working with others as full partners in a context of mutual respect and collaboration. This leadership style has been associated with improved patient outcomes, a reduction in medical errors, and less staff turnover (Gardner, 2005; Joint Commission, 2008; Pearson et al., 2007). It may also reduce the amount of workplace bullying and disruptive behavior, which remains a problem in the health care field (Joint Commission, 2008; Olender-Russo, 2009; Rosenstein and O’Daniel, 2008). Yet while the benefits of collaboration among health professionals have repeatedly been documented with respect to improved patient outcomes, reduced lengths of hospital stay, cost savings, increased job satisfaction and retention among nurses, and improved teamwork, interprofessional collaboration frequently is not the norm in the health care field. Changing this culture will not be easy.

The new style of leadership that is needed flows in all directions at all levels. Everyone from the bedside to the boardroom must engage colleagues, subordinates, and executives so that together they can identify and achieve common goals (Bradford and Cohen, 1998). All members of the health care team must share in the collaborative management of their practice. Physicians, nurses, and other health professionals must work together to break down the walls of hierarchal silos and hold each other accountable for improving quality and decreasing preventable adverse events and medication errors. All must display the capacity to adapt to the continually evolving dynamics of the health care system.

Leadership Competencies

Nurses at all levels need strong leadership skills to contribute to patient safety and quality of care. Yet their history as a profession dominated by females can make it easier for policy makers, other health professionals, and the public to view nurses as “functional doers”—those who carry out the instructions of others—rather than “thoughtful strategists”—those who are informed decision makers and whose independent actions are based on education, evidence, and experience. A 2009 Gallup poll of more than 1,500 national opinion leaders, 1 “Nursing Leadership from Bedside to Boardroom: Opinion Leaders’ Perceptions,” identified nurses as “one of the most trusted sources of health information” (see Box 5-1 ) (RWJF, 2010a). The Gallup poll also identified nurses as the health professionals that should have greater influence than they currently do in the critical areas of quality of patient care and safety. The leaders surveyed believed that major obstacles prevent nurses from being more influential in health policy decision making. These findings have crucial implications for front-line nurses, who possess critical knowledge and awareness of the patient, family, and community but do not speak up as often as they should.

Results of Gallup Poll “Nursing Leadership from Bedside to Boardroom: Opinion Leaders’ Perceptions”. Opinion leaders rate doctors and nurses first and second among a list of options for trusted information about health and health (more...)

To be more effective leaders and full partners, nurses need to possess two critical sets of competencies: a common set that can serve as the foundation for any leadership opportunity and a more specific set tailored to a particular context, time, and place. The former set includes, among others, knowledge of the care delivery system, how to work in teams, how to collaborate effectively within and across disciplines, the basic tenets of ethical care, how to be an effective patient advocate, theories of innovation, and the foundations for quality and safety improvement. These competencies also are recommended by the American Association of Colleges of Nursing as essential for baccalaureate programs (AACN, 2008). Leadership competencies recommended by the National League for Nursing and National League for Nursing Accrediting Commission are being revised to reflect similar principles. More specific competencies might include learning how to be a full partner in a health team in which members from various professions hold each other accountable for improving quality and decreasing preventable adverse events and medication errors. Additionally, nurses who are interested in pursuing entrepreneurial and business development opportunities need competencies in such areas as economics and market forces, regulatory frameworks, and financing policy.

Leadership in a Collaborative Environment

As noted in Chapter 1 , a growing body of research has begun to highlight the potential for collaboration among teams of diverse individuals from different professions (Paulus and Nijstad, 2003; Pisano and Verganti, 2008; Singh and Fleming, 2010; Wuchty et al., 2007). Practitioners and organizational leaders alike have declared that collaboration is a key strategy for improving problem solving and achieving innovation in health care. Two nursing researchers who have studied collaboration among health professionals define it as

a communication process that fosters innovation and advanced problem solving among people who are of different disciplines, organizational ranks, or institutional settings [and who] band together for advanced problem solving [in order to] discern innovative solutions without regard to discipline, rank, or institutional affiliation [and to] enact change based on a higher standard of care or organizational outcomes. (Kinnaman and Bleich, 2004)

Much of what is called collaboration is more likely cooperation or coordination of care. Katzenbach and Smith (1993) argue that truly collaborative teams differ from high-functioning groups that have a defined leader and a set direction, but in which the dynamics of true teamwork are absent. The case study presented in Box 5-2 illustrates just how important it is for health professionals to work in teams to ensure that care is accessible and patient centered.

Case Study: Arkansas Aging Initiative. A Statewide Program Uses Interprofessional Teams to Improve Access to Care for Older Arkansans B onnie Sturgeon was an independent 80-year-old in 2005 when shortness of breath began to slow her down. She had been (more...)

Leadership at Every Level

Leadership from nurses is needed at every level and across all settings. Although collaboration is generally a laudable goal, there are many times when nurses, for the sake of delivering exceptional patient and family care, must step into an advocate role with a singular voice. At the same time, effective leadership also requires recognition of situations in which it is more important to mediate, collaborate, or follow others who are acting in leadership roles. Nurses must understand that their leadership is as important to providing quality care as is their technical ability to deliver care at the bedside in a safe and effective manner. They must lead in improving work processes on the front lines; creating new integrated practice models; working with others, from organizational policy makers to state legislators, to craft practice policy and legislation that allows nurses to work to their fullest capacity; leading curriculum changes to prepare the nursing workforce to meet community and patient needs; translating and applying research findings into practice and developing functional models of care; and serving on institutional and policy-making boards where critical decisions affecting patients are made.

Leadership in care delivery is particularly important in community and home settings where nurses work more autonomously with patients and families than they do in the acute care setting. In community and home settings, nurses provide a direct link connecting patients, their caregivers, and other members of the health care team. Other members of the health care team may not have the time, expertise, or first-hand experience with the patient’s home environment and circumstances to understand and respond to patient and family needs. For example, a neurologist may not be able to help a caregiver of an Alzheimer’s patient understand or curtail excessive spending habits, or a surgeon may not be able to offer advice to a caregiver on ostomy care—roles that nurses are perfectly positioned to assume. Leadership in these situations sometimes requires nurses to be assertive and to have a strong voice in advocating for patients and their families to ensure that their needs are communicated and adequately met.

Box 5-3 describes a nurse who evolved over the course of her career from thinking that being an effective nurse was all about honing her nursing skills and competencies to realize that becoming an agent of change was an equally important part of her job.

Nurse Profile: Connie Hill. A Nurse Leader Extends Acute Care Nursing Beyond the Hospital Walls I t was at a 2002 meeting at Children’s Memorial Hospital in Chicago that Connie Hill, MSN, RN, reviewed the chart of a child who had been on a ventilator (more...)

• A CALL FOR NURSES TO LEAD

Leadership does not occur in a social or political vacuum. As Bennis and Nanus (2003) note, the fast pace of change can be managed only if it is accompanied by leaders who can track the context of the “social architecture” to sustain and implement innovative ideas. Creating innovative care models at the bedside and in the community or taking the opportunity to fill a seat in a policy-making body or boardroom requires nurse leaders to develop ideas; approach management; and courageously make decisions within the political, economic, and social context that will make their solutions real and sustainable. A shift must take place in how nurses view their responsibility to those they care for; they must see themselves as full partners with other health professionals, and practice and education environments must socialize and educate them accordingly.

An important aspect of this socialization is mentoring others along the way. More experienced nurses must take the time to show those who are new and less experienced the most effective ways of being an exceptional nurse at the bedside, in the boardroom, and everywhere between. Technology such as chat rooms, Facebook, and even blogs can be used to support the mentoring role.

A crucial part of working within the social architecture is understanding how leadership and practice produce change over time. The nursing profession’s history includes many examples of the effect of nursing leadership on changes in systems and improvements in patient care. In the late 1940s and early 1950s, nurse Elizabeth Carnegie led the fight for the racial integration of nursing in Florida by example and through her extraordinary character and organizational skills. Her efforts to integrate the nursing profession were based in her sense of social justice not just for the profession, but also for the care of African American citizens who had little access to a workforce that was highly skilled or provided adequate access to health care services. Also in Florida, in the late 1950s, Dorothy Smith, the first dean of the new University of Florida College of Nursing, developed nursing practice models that brought nursing faculty into the hospital in a joint nursing service. Students thereby had role models in their learning experiences, and staff nurses had the authority to improve patient care. From this system came the patient kardex and the unit manager system that freed nurses from the constant search for supplies that took them away from the bedside. In the 1980s, nursing research by Neville Strumpf and Lois Evans highlighted the danger of using restraints on frail elders (Evans and Strumpf, 1989; Strumpf and Evans, 1988). Their efforts to translate their findings into practice revolutionized nursing practice in nursing homes, hospitals, and other facilities by focusing nursing care on preventing falls and other injuries related to restraint use, and led to state and federal legislation that resulted in reducing the use of restraints on frail elders.

Nurses also have also led efforts to improve health and access to care through entrepreneurial endeavors. For example, Ruth Lubic founded the first free-standing birth center in the country in 1975 in New York City. In 2000, she opened the Family Health and Birth Center in Washington, DC, which provides care to underserved communities (see Box 2-2 in Chapter 2 ). Her efforts have improved the care of thousands of women over the years. There are many other examples of nurse entrepreneurs, and a nurse entrepreneur network 2 exists that provides networking, education and training, and coaching for nurses seeking to enter the marketplace and business.

Will Student Nurses Hear the Call?

Leadership skills must be learned and mastered over time. Nonetheless, it is important to obtain a basic grasp of those skills as early as possible—starting in school (see Chapter 4 ). Nursing educators must give their students the most relevant knowledge and practice opportunities to equip them for their profession, while instilling in them a desire and expectation for new learning in the years to come. Regardless of the basic degree with which a nurse enters the profession, faculty should feel obligated to show students the way to their first or next career placement, as well as to their next degree and continuous learning opportunities.

Moreover, students should not wait for graduation to exercise their potential for leadership. In Georgia, for example, health students came together in 2001 under the banner “Lead or Be Led” to create a student-led, interprofessional nonprofit organization that “seeks to make being active in the health community a professional habit.” Named Health Students Taking Action Together (Health-STAT), the group continues to offer workshops in political advocacy, media training, networking, and fundraising. Its annual leadership symposium convenes medical, nursing, public health, and other students statewide to learn about health issues facing the state and work together on developing potential solutions (HealthSTAT, 2010). The National Student Nurses Association (NSNA), initiated in 1998, offers an online Leadership University that allows students to enhance their capacity for leadership through several avenues, such as earning academic credit for participating in the university’s leadership activities and discussing leadership issues with faculty. Students work in cooperative relationships with other students from various disciplines, faculty, community organizations, and the public (Janetti, 2003). Box 5-4 profiles two student leaders, one of whom eventu ally became NSNA president; both represent as well the growing diversity of the nursing profession, a crucial need if the profession is to rise to the challenge of helping to transform the health care system (see Chapter 4 ).

Nurse Profile: Kenya D. Haney and Billy A. Caceres. Building Diversity in Nursing, One Student at a Time D espite improvements to thedemographic make up of the nursing workforce in recent decades, the workforce remains predominantly white, female, and (more...)

Looking to the future, nurse leaders will need the skills and knowledge to understand and anticipate population trends. Formal preparation of student nurses may need to go beyond what has traditionally been considered nursing education. To this end, a growing number of schools offer dual undergraduate degrees in partnership with the university’s business or engineering school for nurses interested in starting their own business or developing more useful technology. Graduate programs offering dual degree programs with schools of business, public health, law, design, or communications take this idea one step further to equip students with an interest in administrative, philanthropic, regulatory, or policy-making positions with greater competencies in management, finance, communication, system design, or scope-of-practice regulations from the start of their careers.

Will Front-Line Nurses Hear the Call?

Given their direct and sustained contact with patients, front-line nurses, along with their unit or clinic managers, are uniquely positioned to design new models of care to improve quality, efficiency, and safety. Tapping that potential will require developing a new workplace culture that encourages and supports leaders at the point of care (whether a hospital or the community) and requires all members of a health care team to hold each other accountable for the team’s performance; nurses must also be equipped with the communication, conflict resolution, and negotiating skills necessary to succeed in leadership and partnership roles. For example, one new quality and safety strategy requires checklists to be completed before certain procedures, such as inserting a catheter, are begun. Nurses typically are asked to enforce adherence to the checklist. If another nurse or a physician does not wash his/her hands or contaminates a sterile field, nurses must possess the basic leadership skills to remind their colleague of the protocol and stop the procedure, if necessary, until the checklist is followed. And again, nurses must help and mentor each other in their roles as expert clinicians and patient advocates. No one can build the capabilities of an exceptional and effective nurse like another exceptional and effective nurse.

Will Community Nurses Hear the Call?

Nurses working in the community have long understood that to be effective in contributing to improvements in the entire community’s health, they must assume the role of social change agent. Among other things, community and public health nurses must promote immunization, good nutrition, and physical activity; detect emergency health threats; and prevent and respond to outbreaks of communicable diseases. In addition, they need to be prepared to assume roles in dealing with public health emergencies, including disaster preparedness, response, and recovery. Recent declines in the numbers of community and public health nurses, however, have made the leadership imperative for these nurses much more challenging.

Community and public health nurses learn to expect the unexpected. For example, a school nurse alerted health authorities to the arrival of the H1N1 influenza virus in New York City in 2009 (RWJF, 2010c). Likewise, an increasing number of nurses are being trained in incident command as part of preparedness for natural disasters and possible terrorist attacks. This entails understanding the roles of and working with community, state, and federal officials to assure the health and safety of the public. For example, when the town of Chehalis, south of Seattle, experienced a 100-year flood in 2007, a public health nurse called the secretary of Washington State’s Department of Health, Mary Selecky, to ask how to “deal with and dispose of dead cows, an unforeseen challenge [for] a public health nurse. The nurse knew she needed [to provide] tetanus shots and portable toilets but had not anticipated other, less common, aspects of the emergency” (IOM, 2010).

The profile in Box 5-5 illustrates how nurses lead efforts that provide critical services for communities. The profile also shows how nurses can also become leaders and social change agents in the broader community by serving on the boards of health-related institutions. The importance of this role is discussed in the next section.

Nurse Profile: Mary Ann Christopher. Cultivating Neighborhood Nursing at the Visiting Nurse Association of Central Jersey A t the Visiting Nurse Association of Central Jersey (VNACJ), president and chief executive officer Mary Ann Christopher, MSN, RN, (more...)

Will Chief Nursing Officers Hear the Call?

Although chief nursing officers (CNOs) typically are part of the hierarchical decision-making structure in that they have authority and responsibility for the nursing staff, they need to move up in the reporting structure of their organizations to increase their ability to contribute to key decisions. Not only is this not happening, however, but CNOs appear to be losing ground. A 2002 survey by the American Organization of Nurse Executives (AONE) showed that 55 percent of CNOs reported directly to their institution’s CEO, compared with 60 percent in 2000. More CNOs described a direct reporting relationship to the chief operating officer instead. Such changes in reporting structure can limit nurse leaders’ involvement in decision making about the most important product of hospitals—patient care. Additionally, the AONE survey showed that most CNOs (70 percent) have seen their responsibilities increase even as they have moved down in the reporting structure (Ballein Search Partners and AONE, 2003). CNOs face growing issues of contending not only with increased responsibilities, but also with budget pressures and difficulties with staffing, retention, and turnover levels during a nursing shortage (Jones et al., 2008).

Nurses also are underrepresented on institution and hospital boards, either their own or others. A biennial survey of hospitals and health systems conducted in 2007 by the Governance Institute found that only 0.8 percent of voting board members were CNOs, compared with 5.1 percent who were vice presidents for medical affairs (Governance Institute, 2007). More recently, a 2009 survey of community health systems found that nurses made up only 2.3 percent of their boards, compared with 22.6 percent who were physicians (Prybil et al., 2009). 3 While most boards focus mainly on finance and business, health care delivery, quality, and responsiveness to the public—areas in which the nature of their work gives nurses particular expertise—also are considered key (Center for Healthcare Governance, 2007). A 2007 survey found that 62 percent of boards included a quality committee (Governance Institute, 2007). A 2006 survey of hospital presidents and CEOs showed the impact of such committees. Those institutions with a quality committee were more likely to adopt various oversight practices; they also experienced lower mortality rates for six common medical conditions measured by the Agency for Healthcare Research and Quality’s (AHRQ’s) Inpatient Quality Indicators and the State Inpatient Databases (Jiang et al., 2008).

The growing attention of hospital boards to quality and safety issues reflects the increased visibility of these issues in recent years. Several states and the Centers for Medicare and Medicaid Services, for example, are increasing their oversight of specific preventable errors (“never events”), and new payment structures in health care reform may be based on patient outcomes and satisfaction (Hassmiller and Bolton, 2009; IOM, 2000; King, 2009; Wachter, 2009). Given their expertise in quality and safety improvement, nurses are more likely than many other board members to understand the issues involved and often can educate other members about these issues (Mastal et al., 2007). This is one area, then, in which nurse board members can have a significant impact. Recognizing this, the 2009 survey of community health systems mentioned above specifically recommended that community health system boards consider appointing expert nursing leaders as voting board members to strengthen clinical input in deliberations and decision-making processes (Prybil et al., 2009).

More CNOs need to prepare themselves and seek out opportunities to serve on the boards of health-related institutions. If decisions are taking place about patient care and a nurse is not at the decision-making table, important perspectives will be missed. CNOs should also promote leadership activities among their staff, encouraging them to secure important decision-making positions on committees and boards, both internal and external to the organization.

Will Nurse Researchers Hear the Call?

Nurse researchers must develop new models of quality care that are evidence based, patient centered, affordable, and accessible to diverse populations. Developing and imparting the science of nursing is also an important contribution to nurses’ ability to deliver high-quality, safe care. Additionally, nurses must serve as advocates and implementers for the program designs they develop. Academic–service partnerships that typically involve nursing schools and nearby, often low-income communities are a first step toward implementation. Given that a nursing school does not exist in every community, however, such partnerships cannot achieve change on the scale needed to transform the health care system. Nurse researchers must become active not only in studying important care deliv ery questions but also in translating research findings into practice and developing and setting the policy agendas. Their leadership is vital in ensuring that new state-and federal-level policies are based on evidence and will help increase quality and access while decreasing costs and health care disparities. The Affordable Care Act (ACA) provides opportunities for demonstration projects and pilot programs directed at various elements of nursing. If these projects and programs do not adequately track nursing inputs and intended/unintended outcomes, they cannot hope to achieve their potential.

Nurse researchers should seek funding from the National Institute for Nursing Research and other institutes of the National Institutes of Health, as do scientists from other disciplines, to help increase the evidence base for improved models of care. Funding might also be secured from other government entities, such as AHRQ and the Health Resources and Services Administration (HRSA) and local and national foundations, depending on the research topic. To be competitive in these efforts, nurses should hone their analytical skills with training in such areas as statistics and data analysis, econometrics, biometrics, and other qualitative and quantitative research methods that are appropriate to their research topics. Mark Pauly, codirector of the Robert Wood Johnson Foundation’s Interdisciplinary Nursing Quality Research Initiative, argues that, for nursing research to achieve parity with other health services research in terms of acceptability, it must be managed by interprofessional teams that include both nurse scholars and scholars from methodological and modeling disciplines. For nurse researchers to achieve parity with other health services researchers, they must develop the skills and initiative to take leadership roles in this research. 4

Will Nursing Organizations Hear the Call?

The Gallup poll of 1,500 opinion leaders referenced earlier in this chapter also highlighted fragmentation in the leadership of nursing organizations as a challenge. Responding opinion leaders predicted that nurses will have little influence on health care reform over the next 5–10 years (see Figure 5-1 ). By contrast, they believed that nurses should have more input and impact in areas such as planning, policy development, and management ( Figure 5-2 ) (RWJF, 2010a). No one expects all professional health organizations to coordinate their public agendas, actions, or messaging for every issue. But nursing organizations must continue to collaborate and work hard to develop common messages, including visions and missions, with regard to their ability to offer evidence-based solutions for improvements in patient care. Once common ground has been established, nursing organizations will need to activate their membership and constituents to work together to take action and support shared goals. When policy makers and other key decision makers know that the largest group of health professionals in the country is in agreement on important issues, they listen and often take action. Conversely, when nursing organizations and their members disagree with one another on important issues, decisions are not made, as the decision makers often are unsure of which side to take.

Opinion leaders’ predictions of the amount of influence nurses will have on health care reform. NOTE: Govt. = Government; Ins. Execs. = Insurance executives; Pharma. execs. = Pharmaceutical executives; HC execs. = Health care executives.

Opinion leaders’ views on the amount of influence nurses should have on various areas of health care. SOURCE: RWJF, 2010b. Reprinted with permission from Frederick Mann, RWJF.

Quality and safety are important areas in which professional nursing organizations have great potential to serve as leaders. The Nursing Alliance for Quality Care (NAQC) 5 is a Robert Wood Johnson Foundation–funded effort with the mission of advancing the quality, safety, and value of patient-centered health care for all individuals, including patients, their families, and the communities where patients live. Based at the George Washington University School of Nursing, the organization stresses the need for nurses to advocate actively for and be accountable to patients for high-quality and safe care. The establishment of the NAQC “is based on the assumption that only with a stronger, more unified ‘voice’ in nursing policy will dramatic and sustainable achievements in quality and safety be achieved for the American public” (George Washington University Medical Center, 2010).

• ANSWERING THE CALL

The call for nurses to assume leadership roles can be answered through leadership programs for nurses; mentorship; and involvement in the policy-making process, including political engagement.

Leadership Programs for Nurses

Leadership is not necessarily innate; many individuals develop into leaders. Sometimes that development comes through experience. For example, nurse leaders at the executive level historically earned their way to their position through their competence, rather than obtaining formal preparation through a business school. However, development as a leader can also be achieved through more formal education and training programs. The wide range of effective leadership programs now available for nurses is illustrated by the examples described below. The challenge is to better utilize these opportunities to develop a greater number of nursing leaders.

Integrated Nurse Leadership Program

The Integrated Nurse Leadership Program (INLP), 6 funded by the Gordon and Betty Moore Foundation, works with hospitals in the San Francisco Bay area that wish to remodel their professional culture and systems of care to improve care while dealing more effectively with continual change. The program develops hospital leaders, offers training and technical assistance, and provides grants to support the program’s implementation. INLP has found that the development of stable, effective leadership in nursing-related care is associated with better-than-expected patient care outcomes and improvements in nurse recruitment and retention. The impact of the program will be evaluated to produce models that can be replicated in other parts of the country.

Fellows Program in Management for Nurse Executives at Wharton 7

When the Johnson & Johnson Company and the Wharton School joined in 1983 to offer a senior nurse executive management fellowship, the program concentrated on helping senior nursing leaders manage their departments by providing them, for example, intense training in accounting (Shea, 2005). The Wharton Fellows program has changed in many ways since then in response to the evolving health care environment, according to a 2005 review (Shea, 2005). For example, the program has strengthened senior nursing executives’ ability to argue for quality improvement on the basis of solid evidence, including financial documentation and probabilistic decision making. The program also aims to improve such leadership competencies as systems thinking, negotiation, communications, strategy, analysis, and the development of learning communities. Its offerings will likely undergo yet more changes as hospital chief executive and chief operating officers increasingly come from the ranks of the nursing profession.

Robert Wood Johnson Foundation Executive Nurse Fellows Program

The Robert Wood Johnson Foundation Executive Nurse Fellows Program 8 is an advanced leadership program for nurses in senior executive roles who wish to lead improvements in health care from local to national levels. It provides a 3-year in-depth, comprehensive leadership development experience for nurses who are already serving in senior leadership positions. The program is designed to cultivate and expand fellows’ capacity to lead teams and organizations. The fellowship program includes curriculum and program activities that provide opportunities for executive coaching and mentoring, team-based and individual leadership projects, professional development that incorporates best practices in leadership, as well as access to online communities and leadership networks. Through the program, fellows master 20 leadership competencies that cover a broad range of knowledge and skills that can be used when “leading self, leading others, leading the organization and leading in health care” (RWJF Executive Nurse Fellows, 2010).

Best on Board

Best on Board 9 is an education, testing, and certification program that helps prepare current and prospective leaders to serve on the governing board of a health care organization. Its CEO, Connie Curran, is a registered nurse (RN) who chaired a hospital nursing department, was the dean of a medical college, and founded her own national management and consulting services firm. A 2010 review cites the growing recognition by blue ribbon panels and management researchers that nurses are an untapped resource for the governing bodies of health care organizations. The authors argue that while nurses have many qualities that make them natural assets to any health care board, they must also “understand the advantages of serving on boards and what it takes to get there” (Curran and Totten, 2010).

Robert Wood Johnson Foundation Health Policy Fellows and Investigator Awards Programs

While not limited to nurses, the Robert Wood Johnson Foundation Health Policy Fellows and Investigator Awards programs 10 offer nurses, other health professionals, and behavioral and social scientists “with an interest in health [the opportunity] to participate in health policy processes at the federal level” (RWJF Scholars, Fellows & Leadership Programs, 2010). Fellows work on Capitol Hill with elected officials and congressional staff. The goal is for fellows to use their academic and practice experience to inform the policy process and to improve the quality of policies enacted. Investigators are funded to complete innovative studies of topics relevant to current and future health policy. Participants in both programs receive intensive training to improve the content and delivery of messages intended to improve health policy and practice. This training is critical, as investigators are often called upon to testify to Congress about the issues they have explored. The health policy fellows bring their more detailed understanding of how policies are formed back to their home organizations. In this way, they are more effective leaders as they strive to bring about policy changes that lead to improvements in patient care.

American Nurses Credentialing Center Magnet Recognition Program

Although not an individual leadership program, the American Nurses Credentialing Center (ANCC) Magnet Recognition Program 11 recognizes health care organizations that advance nursing excellence and leadership. In this regard, achieving Magnet status indicates that the nursing workforce within the institution has attained a number of high standards relating to quality and standards of nursing practice. These standards, as designated by the Magnet process, are called “Forces of Magnetism.” According to ANCC, “the full expression of the Forces embodies a professional environment guided by a strong visionary nursing leader who advocates and supports development and excellence in nursing practice. As a natural outcome of this, the program elevates the reputation and standards of the nursing profession” (ANCC, 2010). Some of these Forces include quality of nursing leadership, management style, quality of care, autonomous nursing care, nurses as teachers, interprofessional relationships, and professional development.

Mentorship 12

Leadership is also fostered through effective mentorship opportunities with leaders in nursing, other health professions, policy, and business. All nurses have a responsibility to mentor those who come after them, whether by helping a new nurse become oriented or by taking on more formal responsibilities as a teacher of nursing students or a preceptor. Nursing organizations (membership associations) also have a responsibility to provide mentoring and leadership guidance, as well as opportunities to share expertise and best practices, for those who join.

Fortunately, a number of nursing associations have organized networks to support their membership and facilitate such opportunities:

• The American Association of Colleges of Nursing (AACN) conducts an expertise survey that is used to identify subject matter experts across topic areas within its membership; it also maintains a list of nursing education experts. Names of these experts are shared with members on request. These resources also are used to identify experts to serve on boards, respond to media requests, and serve in other capacities. In addition, AACN offers an annual executive leadership development program and a new deans mentoring program to further promote and foster leadership.
• The National League for Nursing (NLN) has established an Academy of Nurse Educators whose members are available to serve as mentors for NLN members. NLN engages these educators in a variety of mentoring programs, from a National Scholarly Writing Retreat to the Johnson & Johnson mentoring program for new faculty.
• While AONE does not have a formal mentoring program, it has developed online learning communities where members are encouraged to interact, post questions, and learn from each other. These online communities facilitate collaboration; encourage the sharing of knowledge, best practices, and resources; and help members discover solutions to day-to-day challenges in their work.
• The American Academy of Nursing keeps a detailed list of nurse “Edge Runners” 13 that describes the programs nursing leaders have developed and the outcomes of those programs. Edge Runner names and contact information are prominently displayed so that learning and mentoring can take place freely. 14
• The American Nurses Association just passed a resolution at its 2010 House of Delegates to develop a mentoring program for novice nurses. The program has yet to be developed.
• Over the years, the National Coalition of Ethnic Minority Nurse Associations (NCEMNA) has offered numerous workshops, webinars, and educational materials to develop its members’ competencies in leadership, policy, and communications. NCEMNA’s highly regarded Scholars program 15 promotes the academic and professional development of ethnic minority investigators, in part through a mentoring program. It serves as a model worth emulating throughout the nursing profession.

Involvement in Policy Making

Nurses may articulate what they want to happen in health care to make it more truly patient centered and to improve quality, access, and value. They may even have the evidence to support their conclusions. As with any worthy cause, however, they must engage in the policy-making process to ensure that the changes they believe in are realized. To this end, they must be able to envision themselves as leaders in that process and seek out new partners who share their goals.

The challenge now is to motivate all nurses to pursue leadership roles in the policy-making process. Political engagement is one avenue they can take to that end. As Bethany Hall-Long, a nurse who was elected to the Delaware State House of Representatives in 2002 and is now a state senator, writes, “political actions may be as simple as voting in local school board elections or sharing research findings with state officials, or as complex as running for elected office” (Hall-Long, 2009). For example, engaging school board candidates about the fundamental role of school nurses in the management of chronic conditions among students can make a difference at budget time. And if the goal is broader, perhaps to locate more community health clinics within schools, achieving buy-in from the local school board is absolutely vital. As Hall-Long writes, however, “since nurses do not regularly communicate with their elected officials, the elected officials listen to non-nursing individuals” (Hall-Long, 2009).

Political engagement can be a natural outgrowth of nursing experience. When Marilyn Tavenner first started working in an intensive care unit in Virginia, she thought, “If I were the head nurse or the nurse manager, I would make changes. I would try to influence that unit and that unit’s quality and staffing.” After she became a nurse manager, she thought, “I wouldn’t mind doing this for the entire hospital.” After succeeding for several years as a director of nursing, she was encouraged by a group of physicians to apply for the CEO position of her hospital when it became available. Eventually, Timothy Kaine, governor of Virginia from 2006 to 2010, recruited her to be the state’s secretary of health and human resources. In February 2010, Ms. Tavenner was named deputy administrator for the federal Centers for Medicare and Medicaid Services. Like many nurses, she had never envisioned working in government. But she realized that she wanted to have an impact on health care and health care reform. She wanted to help the uninsured find resources and access to care. For her, that meant building on relationships and finding opportunities to work in government. 16

Other notable nurses who have answered the call to serve in government include Sheila Burke, who served as chief of staff to former Senate Majority Leader Robert Dole, has been a member of the Medicare Payment Advisory Commission, and now teaches at Georgetown and Harvard Universities; and Mary Wakefield, who was named administrator of HRSA in 2009 and is the highest-ranking nurse in the Obama Administration. Speaker of the House Nancy Pelosi’s office has had back-to-back nurses from The Robert Wood Johnson Foundation Health Policy Fellows Program as staffers since 2007, providing a significant entry point for the development of new health policy leaders. Additionally, in 1989 Senator Daniel Inouye established the Military Nurse Detailee fellowship program. This 1-year fellowship provides an opportunity for a high-ranking military nurse, who holds a minimum of a master’s degree, to gain health policy leadership experience in Senator Inouye’s office. The fellowship rotates among three branches of service (Army, Navy, and Air Force) annually. 17 During the Clinton Administration, Beverly Malone served as deputy assistant secretary for health in the Department of Health and Human Services (HHS). In 2002, Richard Carmona, who began his education with an associate’s degree in nursing from the Bronx Community College in New York, was appointed surgeon general by President George W. Bush. Shirley Chater led the reorganization of the Social Security Administration in the 1990s. Carolyne Davis served as head of the Health Care Finance Administration (predecessor of the Centers for Medicare and Medicaid Services) in the 1980s during the implementation of a new coding system that classifies hospital cases into diagnosis-related groups. From 1979 to 1981, Rhetaugh Dumas was the first nurse, the first woman, and the first African American to serve as a deputy director of the National Institute of Mental Health (Sullivan, 2007). Nurses also have served as regional directors of HHS and as senior advisors on health policy to HHS.

As for elected office, there were three nurse members of the 111th Congress—Eddie Bernice Johnson (D-TX), Lois Capps (D-CA), and Carolyn McCarthy (D-NY)—all of whom had a hand in sponsoring and supporting health care–focused legislation, from AIDS research to gun control. Lois Capps organized and co-chairs the Congressional Nursing Caucus (which also includes members who are not nurses). The group focuses on mobilizing congressional support for health-related issues. Additionally, 105 nurses have served in state legislatures, including Paula Hollinger of Maryland, who sponsored one of the nation’s first stem cell research bills. None of these nurses waited to be asked; they pursued their positions, both elected and appointed, because they knew they had the expertise and experience to make changes in health care.

Very little in politics is accomplished without preparation or allies. Health professionals point with pride to multiple aspects of the Prescription for Pennsylvania initiative, a state health care reform initiative that preceded the ACA and is also described in Box 5-6 . As is clear from a detailed 2009 review, success was not achieved overnight; smaller legislative and regulatory victories set the stage starting in the late 1990s. Even some apparent legislative failures built the foundation for future successes because they caused nurses to spend more time meeting face to face with physicians who had organized opposition to various measures. As a result, nursing leaders developed a better sense of where they could achieve compromises with their opponents. They also found a new ally in the Chamber of Commerce to counter opposition from some sections of organized medicine (Hansen-Turton et al., 2009).

Case Study: Prescription for Pennsylvania. A Governor’s Leadership Improves Access to Care for Residents of a Rural State W hen Pennsylvania Governor Edward Rendell took office in 2003, one-twelfth of the state’s 12 million residents had (more...)

Hansen-Turton and colleagues draw three major lessons from this experience. First, nurses must build strong alliances within their own professional community, an important lesson alluded to earlier in this chapter. Pennsylvania’s nurses were able to speak with a unified voice because they first worked out among themselves which issues mattered most to them. Second, nurses must build relationships with key policy makers. Pennsylvania’s nurses developed strong relationships with several legislators from both major political parties and earned the support of two successive sitting governors: Thomas Ridge (Republican) and Edward Rendell (Democrat). Third, nurses must find allies outside the nursing profession, particularly in business and other influential communities. Pennsylvania’s nurses gained a strong ally in the Chamber of Commerce when they were able to demonstrate how expanding regulations to allow nurses to do all they were educated and demonstrably capable of doing would help lower health care costs (Hansen-Turton et al., 2009).

Perhaps the most important lesson to draw from the Pennsylvania experience lies in the way the campaign was framed. The focus of attention was on achieving quality care and cost reductions. A closer examination of the issues showed that achieving those goals required, among other things, expanding the roles and responsibilities of nurses. What drew the greatest amount of political support for the Prescription for Pennsylvania campaign was the shared goal of getting more value out of the health care system—quality care at a sustainable price. The fact that the campaign also expanded nursing practice was secondary. Those expansions are likely to continue as long as the emphasis is on quality care and cost reduction. Similarly, the committee believes that the goal in any transformation of the health care system should be achieving innovative, patient-centered, highvalue care. If all stakeholders—from legislators, to regulators, to hospital executives, to insurance companies—act from a patient-centered point of reference, they will see that many of the solutions they are seeking require a transformation of the nursing profession.

• A CALL FOR NEW PARTNERSHIPS

Having enough nurses and having nurses with the right skills and competencies to care for the population is an important societal issue. Having allies from outside the profession is important to achieving this goal. More nurses need to reach out to new partners in arenas ranging from business, government, and philanthropy to state and national medical associations to consumer groups. Additionally, nurses need to fortify alliances that are made through personal connections and relationships. Just as important, society needs to understand its stake in ensuring that nurses are effective full partners and leaders in the quest to deliver quality, high-value care that is accessible to diverse populations. The full potential of the nursing profession in care, leadership, and research must be tapped to deal with the wide range of health care challenges the nation will face in the coming years.

Eventually, to transform the way health care is delivered in the United States, nurses will have to move not just out of the hospital, but also out of health care organizations entirely. For example, nurses are underrepresented on the boards of private nonprofit and philanthropic organizations, which do not provide health care services but often have a large impact on health care decisions. The Commonwealth Fund and the Kaiser Family Foundation, for instance, have no nurses on their boards, although they do have physicians. Without nurses, vital ground-level perspectives on quality improvement, care coordination, and health promotion are likely missing. On the other hand, AARP provides a positive example. At least two nurses at AARP have served in the top leadership and governance roles (president and chair) in the past 3 years. Nurses serve on the health and long-term services policy committee, and the senior vice president of the Public Policy Institute is also a nurse. AARP’s commitment to nursing is clear through its sponsorship, along with the Robert Wood Johnson Foundation, of the Center to Champion Nursing.

Enactment of the ACA will provide unprecedented opportunities for change in the U.S. health care system for the foreseeable future. Strong leadership on the part of nurses, physicians, and others will be required to devise and implement the changes necessary to increase quality, access, and value and deliver patient-centered care. If these efforts are to be successful, all nurses, from students, to bedside and community nurses, to CNOs and members of nursing organizations, to researchers, must develop leadership competencies and serve as full partners with physicians and other health professionals in efforts to improve the health care system and the delivery of care. Nurses must exercise these competencies in a collaborative environment in all settings, including hospitals, communities, schools, boards, and political and business arenas. In doing so, they must not only mentor others along the way, but develop partnerships and gain allies both within and beyond the health care environment.

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Gallup research staff—Richard Blizzard, Christopher Khoury, and Coleen McMurray—conducted telephone surveys with 1,504 individuals, including university faculty, insurance executives, corporate executives, health services leaders, government leaders, and industry thought leaders.

See http://www ​.nurse-entrepreneur-network ​.com/public/main.cfm .

It should be noted that, while there are many more physicians than nurses on hospital boards, health care providers still are generally underrepresented.

Personal communication, Mark Pauly, Bendheim Professor, Professor of Health Care Management, Professor of Business and Public Policy, Professor of Insurance and Risk Management, and Professor of Economics, Wharton School of the University of Pennsylvania, and Codirector of the Robert Wood Johnson Foundation’s Interdisciplinary Nursing Quality Research Initiative, June 25, 2010.

See http://www ​.gwumc.edu ​/healthsci/departments/nursing/naqc/ .

See http://futurehealth ​.ucsf ​.edu/Public/Leadership-Programs ​/Home.aspx?pid=35 .

See http: ​//executiveeducation ​.wharton.upenn.edu ​/open-enrollment/health-care-programs ​/Fellows-Program-Management-Nurse-Executives.cfm .

See http://www ​.executivenursefellows.org .

See http://www ​.bestonboard.org .

See http://www ​.rwjfleaders ​.org/programs/robert-wood-johnson-foundation-health-policy-fellow .

See http://www ​.nursecredentialing ​.org/Magnet/ProgramOverview ​.aspx .

This section draws on personal communication in 2010 with Susan Gergely, Director of Operations, American Organization of Nurse Executives; Beverly Malone, CEO, National League for Nursing; Robert Rosseter, Chief Communications Officer, American Association of Colleges of Nursing; and Pat Ford Roegner, CEO, American Academy of Nursing.

The Edge Runner program is a component of the American Academy of Nursing’s Raise the Voice campaign, funded by the Robert Wood Johnson Foundation. The Edge Runner designation recognizes nurses who have developed innovative, successful models of care and interventions to address problems in the health care delivery system or unmet health needs in a population.

See AAN’s Edge Runner Directory, http://www ​.aannet.org ​/custom/edgeRunner/index ​.cfm?pageid=3303&showTitle ​=1 .

See http://www ​.ncemna.org/scholarships.asp .

This paragraph draws on personal communication with Marilyn Tavenner, principal deputy administrator and chief operating officer, Centers for Medicare and Medicaid Services, May 11, 2010.

Personal communication, Corina Barrow, Lieutenant Colonel, Army Nurse Corps, Nurse Corps Detailee, Office of Senator Daniel Inouye (D-HI), August 25, 2010.

• Cite this Page Institute of Medicine (US) Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington (DC): National Academies Press (US); 2011. 5, Transforming Leadership.
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The Value of Critical Thinking in Nursing

Gayle Morris

Contributing Writer

Learn about our editorial process .

Updated October 3, 2023

Are you ready to earn your online nursing degree?

Some experts describe a person's ability to question belief systems, test previously held assumptions, and recognize ambiguity as evidence of critical thinking. Others identify specific skills that demonstrate critical thinking, such as the ability to identify problems and biases, infer and draw conclusions, and determine the relevance of information to a situation.

Nicholas McGowan, BSN, RN, CCRN, has been a critical care nurse for 10 years in neurological trauma nursing and cardiovascular and surgical intensive care. He defines critical thinking as "necessary for problem-solving and decision-making by healthcare providers. It is a process where people use a logical process to gather information and take purposeful action based on their evaluation."

"This cognitive process is vital for excellent patient outcomes because it requires that nurses make clinical decisions utilizing a variety of different lenses, such as fairness, ethics, and evidence-based practice," he says.

How Do Nurses Use Critical Thinking?

Successful nurses think beyond their assigned tasks to deliver excellent care for their patients. For example, a nurse might be tasked with changing a wound dressing, delivering medications, and monitoring vital signs during a shift. However, it requires critical thinking skills to understand how a difference in the wound may affect blood pressure and temperature and when those changes may require immediate medical intervention.

Nurses care for many patients during their shifts. Strong critical thinking skills are crucial when juggling various tasks so patient safety and care are not compromised.

Jenna Liphart Rhoads, Ph.D., RN, is a nurse educator with a clinical background in surgical-trauma adult critical care, where critical thinking and action were essential to the safety of her patients. She talks about examples of critical thinking in a healthcare environment, saying:

"Nurses must also critically think to determine which patient to see first, which medications to pass first, and the order in which to organize their day caring for patients. Patient conditions and environments are continually in flux, therefore nurses must constantly be evaluating and re-evaluating information they gather (assess) to keep their patients safe."

The COVID-19 pandemic created hospital care situations where critical thinking was essential. It was expected of the nurses on the general floor and in intensive care units. Crystal Slaughter is an advanced practice nurse in the intensive care unit (ICU) and a nurse educator. She observed critical thinking throughout the pandemic as she watched intensive care nurses test the boundaries of previously held beliefs and master providing excellent care while preserving resources.

"Nurses are at the patient's bedside and are often the first ones to detect issues. Then, the nurse needs to gather the appropriate subjective and objective data from the patient in order to frame a concise problem statement or question for the physician or advanced practice provider," she explains.

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Top 5 ways nurses can improve critical thinking skills.

We asked our experts for the top five strategies nurses can use to purposefully improve their critical thinking skills.

Case-Based Approach

Slaughter is a fan of the case-based approach to learning critical thinking skills.

In much the same way a detective would approach a mystery, she mentors her students to ask questions about the situation that help determine the information they have and the information they need. "What is going on? What information am I missing? Can I get that information? What does that information mean for the patient? How quickly do I need to act?"

Consider forming a group and working with a mentor who can guide you through case studies. This provides you with a learner-centered environment in which you can analyze data to reach conclusions and develop communication, analytical, and collaborative skills with your colleagues.

Practice Self-Reflection

Rhoads is an advocate for self-reflection. "Nurses should reflect upon what went well or did not go well in their workday and identify areas of improvement or situations in which they should have reached out for help." Self-reflection is a form of personal analysis to observe and evaluate situations and how you responded.

This gives you the opportunity to discover mistakes you may have made and to establish new behavior patterns that may help you make better decisions. You likely already do this. For example, after a disagreement or contentious meeting, you may go over the conversation in your head and think about ways you could have responded.

It's important to go through the decisions you made during your day and determine if you should have gotten more information before acting or if you could have asked better questions.

During self-reflection, you may try thinking about the problem in reverse. This may not give you an immediate answer, but can help you see the situation with fresh eyes and a new perspective. How would the outcome of the day be different if you planned the dressing change in reverse with the assumption you would find a wound infection? How does this information change your plan for the next dressing change?

Develop a Questioning Mind

McGowan has learned that "critical thinking is a self-driven process. It isn't something that can simply be taught. Rather, it is something that you practice and cultivate with experience. To develop critical thinking skills, you have to be curious and inquisitive."

To gain critical thinking skills, you must undergo a purposeful process of learning strategies and using them consistently so they become a habit. One of those strategies is developing a questioning mind. Meaningful questions lead to useful answers and are at the core of critical thinking .

However, learning to ask insightful questions is a skill you must develop. Faced with staff and nursing shortages , declining patient conditions, and a rising number of tasks to be completed, it may be difficult to do more than finish the task in front of you. Yet, questions drive active learning and train your brain to see the world differently and take nothing for granted.

It is easier to practice questioning in a non-stressful, quiet environment until it becomes a habit. Then, in the moment when your patient's care depends on your ability to ask the right questions, you can be ready to rise to the occasion.

Practice Self-Awareness in the Moment

Critical thinking in nursing requires self-awareness and being present in the moment. During a hectic shift, it is easy to lose focus as you struggle to finish every task needed for your patients. Passing medication, changing dressings, and hanging intravenous lines all while trying to assess your patient's mental and emotional status can affect your focus and how you manage stress as a nurse .

Staying present helps you to be proactive in your thinking and anticipate what might happen, such as bringing extra lubricant for a catheterization or extra gloves for a dressing change.

By staying present, you are also better able to practice active listening. This raises your assessment skills and gives you more information as a basis for your interventions and decisions.

Use a Process

As you are developing critical thinking skills, it can be helpful to use a process. For example:

• Ask questions.
• Gather information.
• Implement a strategy.
• Evaluate the results.
• Consider another point of view.

These are the fundamental steps of the nursing process (assess, diagnose, plan, implement, evaluate). The last step will help you overcome one of the common problems of critical thinking in nursing — personal bias.

Common Critical Thinking Pitfalls in Nursing

Your brain uses a set of processes to make inferences about what's happening around you. In some cases, your unreliable biases can lead you down the wrong path. McGowan places personal biases at the top of his list of common pitfalls to critical thinking in nursing.

"We all form biases based on our own experiences. However, nurses have to learn to separate their own biases from each patient encounter to avoid making false assumptions that may interfere with their care," he says. Successful critical thinkers accept they have personal biases and learn to look out for them. Awareness of your biases is the first step to understanding if your personal bias is contributing to the wrong decision.

New nurses may be overwhelmed by the transition from academics to clinical practice, leading to a task-oriented mindset and a common new nurse mistake ; this conflicts with critical thinking skills.

"Consider a patient whose blood pressure is low but who also needs to take a blood pressure medication at a scheduled time. A task-oriented nurse may provide the medication without regard for the patient's blood pressure because medication administration is a task that must be completed," Slaughter says. "A nurse employing critical thinking skills would address the low blood pressure, review the patient's blood pressure history and trends, and potentially call the physician to discuss whether medication should be withheld."

Fear and pride may also stand in the way of developing critical thinking skills. Your belief system and worldview provide comfort and guidance, but this can impede your judgment when you are faced with an individual whose belief system or cultural practices are not the same as yours. Fear or pride may prevent you from pursuing a line of questioning that would benefit the patient. Nurses with strong critical thinking skills exhibit:

• Learn from their mistakes and the mistakes of other nurses
• Look forward to integrating changes that improve patient care
• Treat each patient interaction as a part of a whole
• Evaluate new events based on past knowledge and adjust decision-making as needed
• Solve problems with their colleagues
• Are self-confident
• Acknowledge biases and seek to ensure these do not impact patient care

An Essential Skill for All Nurses

Critical thinking in nursing protects patient health and contributes to professional development and career advancement. Administrative and clinical nursing leaders are required to have strong critical thinking skills to be successful in their positions.

By using the strategies in this guide during your daily life and in your nursing role, you can intentionally improve your critical thinking abilities and be rewarded with better patient outcomes and potential career advancement.

Frequently Asked Questions About Critical Thinking in Nursing

How are critical thinking skills utilized in nursing practice.

Nursing practice utilizes critical thinking skills to provide the best care for patients. Often, the patient's cause of pain or health issue is not immediately clear. Nursing professionals need to use their knowledge to determine what might be causing distress, collect vital information, and make quick decisions on how best to handle the situation.

How does nursing school develop critical thinking skills?

Nursing school gives students the knowledge professional nurses use to make important healthcare decisions for their patients. Students learn about diseases, anatomy, and physiology, and how to improve the patient's overall well-being. Learners also participate in supervised clinical experiences, where they practice using their critical thinking skills to make decisions in professional settings.

Do only nurse managers use critical thinking?

Nurse managers certainly use critical thinking skills in their daily duties. But when working in a health setting, anyone giving care to patients uses their critical thinking skills. Everyone — including licensed practical nurses, registered nurses, and advanced nurse practitioners —needs to flex their critical thinking skills to make potentially life-saving decisions.

Meet Our Contributors

Crystal Slaughter, DNP, APRN, ACNS-BC, CNE

Crystal Slaughter is a core faculty member in Walden University's RN-to-BSN program. She has worked as an advanced practice registered nurse with an intensivist/pulmonary service to provide care to hospitalized ICU patients and in inpatient palliative care. Slaughter's clinical interests lie in nursing education and evidence-based practice initiatives to promote improving patient care.

Jenna Liphart Rhoads, Ph.D., RN

Jenna Liphart Rhoads is a nurse educator and freelance author and editor. She earned a BSN from Saint Francis Medical Center College of Nursing and an MS in nursing education from Northern Illinois University. Rhoads earned a Ph.D. in education with a concentration in nursing education from Capella University where she researched the moderation effects of emotional intelligence on the relationship of stress and GPA in military veteran nursing students. Her clinical background includes surgical-trauma adult critical care, interventional radiology procedures, and conscious sedation in adult and pediatric populations.

Nicholas McGowan, BSN, RN, CCRN

Nicholas McGowan is a critical care nurse with 10 years of experience in cardiovascular, surgical intensive care, and neurological trauma nursing. McGowan also has a background in education, leadership, and public speaking. He is an online learner who builds on his foundation of critical care nursing, which he uses directly at the bedside where he still practices. In addition, McGowan hosts an online course at Critical Care Academy where he helps nurses achieve critical care (CCRN) certification.

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Inspiring Leadership in Nursing: Key Topics to Empower the Next Generation of Nurse Leaders

This article was written in collaboration with Christine T. and ChatGPT, our little helper developed by OpenAI.

Nursing leadership plays a crucial role in the healthcare industry, influencing the quality of patient care and the overall performance of healthcare organizations. As the nursing profession continues to evolve, aspiring nurse leaders must stay informed about the latest developments and best practices in nursing leadership. This comprehensive guide explores essential nursing leadership topics, offering valuable insights and strategies for success.

The Importance of Nursing Leadership

Impact on patient care.

Effective nursing leadership directly impacts patient care, ensuring that nurses provide safe, high-quality, and evidence-based care. Nurse leaders play a critical role in developing and implementing policies, protocols, and standards of practice that promote positive patient outcomes.

Topic Examples

• The role of nurse leaders in reducing hospital-acquired infections
• How nurse leaders can improve patient satisfaction
• The effect of nursing leadership on patient safety initiatives
• Combating health care-associated infections: a community-based approach
• Nurse leaders’ impact on the reduction of medication errors
• Promoting patient-centered care through nursing leadership
• The role of nurse leaders in implementing evidence-based practices to improve patient outcomes
• How transformational leadership can positively impact patient satisfaction
• The impact of nurse leaders on patient safety and error reduction initiatives

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Influence on Organizational Performance

Nurse leaders contribute to the overall performance of healthcare organizations by guiding and supporting nursing teams, managing resources, and participating in decision-making processes. Their leadership helps create a positive work environment, reduce staff turnover, and improve patient satisfaction.

• How nurse leaders can contribute to reducing staff turnover
• The role of nurse leaders in improving the hospital’s financial performance
• Nurse leaders as drivers of organizational culture
• The integral role of nurses in healthcare systems: the importance of education and experience
• The relationship between nurse leadership and hospital readmission rates
• How nurse leaders can contribute to reducing healthcare costs
• The role of nurse leaders in promoting interprofessional collaboration to improve organizational performance
• Strategies for nurse leaders to foster a positive work environment
• The impact of nursing leadership on employee engagement and satisfaction

Advancement of the Nursing Profession

Nurse leaders advocate for nursing, promoting professional development, innovation, and research. They also work to elevate the nursing profession’s status, fostering collaboration and interdisciplinary partnerships.

• The role of nurse leaders in shaping the future of nursing education
• How nurse leaders can advocate for the nursing profession
• The impact of nurse leaders on the development of nursing standards and policies
• Encouraging research and evidence-based practice among nursing teams
• The role of nurse leaders in promoting interprofessional collaboration
• Encouraging the pursuit of advanced nursing degrees and certifications among nursing staff
• The impact of nurse leaders on shaping healthcare policies and regulations
• How nurse leaders can advocate for improved working conditions and fair compensation for nursing staff

Essential Nursing Leadership Skills

Communication and interpersonal skills.

Effective communication and interpersonal skills are crucial for nursing leaders. They must listen actively, express themselves clearly, and demonstrate empathy and understanding when interacting with colleagues, patients, and families.

• Active listening skills for nurse leaders
• Developing emotional intelligence in nursing leadership
• The role of nonverbal communication in nursing leadership
• Strategies for nurse leaders to improve communication with their teams
• How nurse leaders can facilitate open and honest feedback
• The importance of emotional intelligence in nurse leadership
• Strategies for nurse leaders to improve their communication skills with diverse populations
• The role of nurse leaders in fostering effective communication within interdisciplinary healthcare teams

Decision-Making and Problem-Solving Abilities

Nurse leaders must be skilled in making informed decisions and solving complex problems. They should be able to analyze situations, weigh the pros and cons of various options, and choose the best course of action.

• Critical thinking skills for nurse leaders
• Ethical decision-making in nursing leadership
• The role of evidence-based practice in nursing leadership decisions
• Strategies for nurse leaders to develop effective problem-solving skills
• The importance of collaboration and teamwork in decision-making for nurse leaders
• The role of nurse leaders in crisis management and emergency preparedness
• How nurse leaders can develop effective problem-solving strategies to address complex healthcare challenges

Time Management and Organization

Managing time and resources effectively is essential for nurse leaders. They must be able to prioritize tasks, delegate responsibilities, and balance competing demands to ensure the smooth operation of their teams and organizations.

• Prioritization techniques for nurse leaders
• The role of delegation in effective time management for nursing managers
• Strategies for nurse leaders to manage workload and reduce stress
• Balancing clinical and administrative responsibilities as a nurse leader
• Time management tools and techniques for nurse leaders
• The importance of delegation in nurse leadership
• Strategies for nurse leaders to effectively manage their workload and prioritize tasks
• The role of nurse leaders in creating efficient workflows and processes within nursing teams

Embracing Diversity and Inclusivity in Nursing Leadership

The value of a diverse nursing workforce.

A diverse nursing workforce brings unique perspectives, experiences, and skills to the healthcare environment, benefiting patient care. By embracing diversity, nurse leaders can foster a more inclusive and supportive work environment that encourages collaboration and innovation.

• The benefits of diverse nursing teams for patient care
• The role of nurse leaders in recruiting and retaining diverse nursing staff
• Addressing health disparities through a diverse nursing workforce
• The impact of cultural competence on nursing practice and leadership
• Encouraging diverse perspectives and experiences in nursing teams
• Global health learning in nursing and health care disparities
• The benefits of having a diverse nursing workforce on patient outcomes and satisfaction
• Addressing health disparities through culturally competent nursing leadership

Strategies for Promoting Diversity and Inclusion

Nurse leaders can promote diversity and inclusion by implementing hiring and promotion practices that support equal opportunities, offering cultural competency training, and actively addressing discrimination and bias within their organizations.

• Overcoming unconscious bias in nursing leadership
• The role of nurse leaders in fostering an inclusive work environment
• Strategies for promoting diversity and inclusion in nursing education
• The impact of diversity and inclusion on nursing team performance
• Encouraging cultural competence and sensitivity among nursing staff
• Implementing diversity and inclusion training programs for nursing staff
• The role of nurse leaders in fostering a culture of respect and inclusivity within nursing teams
• Strategies for nurse leaders to address unconscious bias and promote equity in the workplace

Developing and Mentoring Future Nurse Leaders

Identifying and nurturing leadership potential.

Nurse leaders play an essential role in identifying and nurturing the leadership potential of their staff. By offering guidance, encouragement, and opportunities for growth, they can help prepare the next generation of nurse leaders.

• Recognizing leadership potential in nursing staff
• Strategies for nurse leaders to develop their team’s leadership skills
• The importance of succession planning in nursing leadership
• Encouraging a growth mindset among nursing teams
• The role of mentorship and coaching in nurturing future nurse leaders
• Strategies for nurse leaders to identify and develop emerging nurse leaders within their teams
• The role of nurse leaders in creating leadership development programs for nursing staff

Mentorship and Coaching

Mentorship and coaching are invaluable for aspiring nurse leaders. By sharing their knowledge, experience, and insights, experienced nurse leaders can help guide and support those looking to advance in nursing.

• The benefits of mentorship for both mentors and mentees in nursing
• Developing effective mentoring relationships in nursing
• The role of nurse leaders in fostering a mentoring culture
• Strategies for providing constructive feedback and coaching to nursing staff
• Encouraging professional growth and development through mentorship
• The benefits of mentorship relationships for both mentors and mentees in nursing
• Strategies for nurse leaders to establish effective mentorship programs within their organizations
• The role of nurse leaders in providing coaching and feedback to nursing staff for professional growth

Promoting Teamwork and Collaboration in Nursing

The importance of teamwork in healthcare.

Teamwork is crucial for delivering safe, high-quality patient care. Nurse leaders must foster a culture of collaboration, encouraging open communication, mutual support, and shared decision-making among their teams.

• The role of nurse leaders in promoting effective teamwork
• Strategies for building trust and collaboration among nursing teams
• The impact of teamwork on patient care and safety
• The benefits of interprofessional collaboration in healthcare
• The role of nurse leaders in fostering a positive team culture
• The role of nurse leaders in promoting collaboration and teamwork among nursing staff
• Strategies for nurse leaders to address and resolve conflicts within nursing teams
• The impact of effective teamwork on patient outcomes and staff satisfaction in healthcare settings

Strategies for Building Effective Nursing Teams

Nurse leaders can build effective nursing teams by promoting shared goals and values, providing clear expectations and feedback, and recognizing and celebrating team achievements. Additionally, they should facilitate team-building activities and opportunities for professional development, which can strengthen team cohesion and performance.

• The importance of clear communication and expectations in nursing teams
• Strategies for addressing and resolving conflicts within nursing teams
• The role of team-building activities in fostering collaboration and trust among nursing staff
• The impact of shared decision-making on nursing team performance
• Encouraging a culture of continuous improvement and learning within nursing teams
• The role of nurse leaders in selecting and retaining top nursing talent
• Strategies for nurse leaders to create a positive work environment that fosters teamwork and collaboration
• The importance of team-building activities and exercises for nursing staff

Advocating for Nursing and Improving Patient Care

Policy and advocacy.

Nurse leaders are responsible for advocating for policies and initiatives that support the nursing profession and improve patient care. They should be informed about healthcare legislation, engage in advocacy efforts, and encourage their teams to participate in policy-making.

• The role of nurse leaders in shaping healthcare policy
• Strategies for nurse leaders to advocate for the nursing profession at the local, state, and national levels
• The impact of nursing leadership on the development and implementation of healthcare policies and regulations
• Engaging nursing staff in policy discussions and advocacy efforts
• The importance of staying informed about current healthcare policy issues for nurse leaders
• The role of nurse leaders in advocating for policies that improve patient care and support the nursing profession
• Strategies for nurse leaders to effectively engage with policymakers and stakeholders
• The impact of nurse leaders on shaping healthcare policies at the local, state, and national levels

Driving Quality Improvement and Innovation

Nurse leaders must be committed to continuous quality improvement and innovation in patient care. By staying informed about evidence-based practices and encouraging their teams to adopt innovative approaches, they can drive positive change within their organizations and the healthcare industry.

• The role of nurse leaders in promoting a culture of continuous quality improvement
• Strategies for nurse leaders to identify and address areas for improvement in patient care
• The impact of nursing leadership on the implementation of evidence-based practices and innovations
• Encouraging a culture of creativity and innovation among nursing teams
• The role of nurse leaders in driving change and improvement in healthcare organizations
• The role of nurse leaders in leading quality improvement initiatives within their organizations
• Strategies for nurse leaders to foster a culture of continuous improvement and innovation among nursing staff
• The impact of nurse-led quality improvement projects on patient care and organizational performance

Fostering a Positive Work Environment

Creating a supportive and respectful culture.

A positive work environment is essential for nursing staff satisfaction, retention, and performance. Nurse leaders should foster a culture of support and respect where staff feels valued, empowered, and motivated to provide the best possible care.

• The role of nurse leaders in fostering a positive work environment
• Strategies for nurse leaders to promote a culture of support and respect among nursing staff
• The importance of addressing and preventing workplace bullying and incivility in nursing
• Encouraging open and honest communication within nursing teams
• The role of nurse leaders in promoting work-life balance and well-being among nursing staff

Addressing Workplace Challenges and Conflicts

Nurse leaders must be proactive in addressing workplace challenges and conflicts. They can maintain a healthy and productive work environment by developing and implementing strategies to manage issues such as workload, burnout, and interpersonal conflicts.

• The role of nurse leaders in conflict resolution within nursing teams
• Strategies for nurse leaders to address common workplace challenges, such as staffing shortages and burnout
• The importance of developing a proactive approach to addressing conflicts and challenges in nursing
• Promoting a culture of accountability and responsibility among nursing staff
• The role of nurse leaders in providing support and resources for nursing staff facing challenges and conflicts
• Conflict resolution strategies for nurse leaders
• The role of nurse leaders in mediating and resolving interprofessional conflicts within healthcare teams
• Strategies for nurse leaders to prevent and address workplace burnout among nursing staff

Lifelong Learning and Professional Development

Commitment to continuing education.

Lifelong learning is essential for nurse leaders to stay current with healthcare and nursing practice advances. They should pursue continuing education opportunities, research, and stay informed about industry trends and best practices.

• The importance of lifelong learning for nurse leaders and nursing staff
• Strategies for nurse leaders to promote a culture of continuous education and professional development within their teams
• The impact of continuing education on nursing practice and leadership
• Encouraging nursing staff to engage in professional development opportunities
• Transforming advanced nursing practice: embracing IOM recommendations and higher education
• The role of nurse leaders in staying informed about current nursing research and best practices
• The impact of continuing education on nursing practice and patient outcomes
• Strategies for nurse leaders to support and encourage continuing education among their nursing staff
• The role of nurse leaders in staying up-to-date with the latest nursing research, guidelines, and best practices

Encouraging Professional Development in Nursing Teams

Nurse leaders should support and encourage the professional development of their nursing teams. By providing resources, opportunities, and encouragement, they can help their staff grow professionally and contribute to advancing the nursing profession.

• The role of nurse leaders in identifying professional development opportunities for nursing staff
• Strategies for nurse leaders to create individualized professional development plans for their team members
• The importance of fostering a growth mindset among nursing staff
• Encouraging nursing staff to participate in conferences, workshops, and other professional development activities
• The role of nurse leaders in providing mentorship and guidance for nursing staff seeking career advancement
• The benefits of ongoing professional development for nursing staff and healthcare organizations
• Strategies for nurse leaders to create professional development opportunities within their organizations
• The role of nurse leaders in developing and implementing career advancement pathways for nursing staff

The Power of Inspiring Leadership in Nursing

Nursing leadership is a critical component of the healthcare industry, impacting patient care, organizational performance, and the advancement of the nursing profession. By mastering essential leadership skills, embracing diversity, promoting teamwork, and fostering a positive work environment, aspiring nurse leaders can make a meaningful difference in the lives of their patients, colleagues, and organizations. Committing to lifelong learning and professional development will ensure that nurse leaders remain at the forefront of their field, inspiring and empowering the next generation of nursing professionals.

Table of content

Crafted with Care:

Nursing Essays!

Precision, Passion, & Professionalism in Every Page.

• Research article
• Open access
• Published: 07 October 2020

Impact of social problem-solving training on critical thinking and decision making of nursing students

• Soleiman Ahmady 1 &
• Sara Shahbazi   ORCID: orcid.org/0000-0001-8397-6233 2 , 3  

BMC Nursing volume  19 , Article number:  94 ( 2020 ) Cite this article

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The complex health system and challenging patient care environment require experienced nurses, especially those with high cognitive skills such as problem-solving, decision- making and critical thinking. Therefore, this study investigated the impact of social problem-solving training on nursing students’ critical thinking and decision-making.

This study was quasi-experimental research and pre-test and post-test design and performed on 40 undergraduate/four-year students of nursing in Borujen Nursing School/Iran that was randomly divided into 2 groups; experimental ( n  = 20) and control (n = 20). Then, a social problem-solving course was held for the experimental group. A demographic questionnaire, social problem-solving inventory-revised, California critical thinking test, and decision-making questionnaire was used to collect the information. The reliability and validity of all of them were confirmed. Data analysis was performed using SPSS software and independent sampled T-test, paired T-test, square chi, and Pearson correlation coefficient.

The finding indicated that the social problem-solving course positively affected the student’ social problem-solving and decision-making and critical thinking skills after the instructional course in the experimental group ( P  < 0.05), but this result was not observed in the control group ( P  > 0.05).

Conclusions

The results showed that structured social problem-solving training could improve cognitive problem-solving, critical thinking, and decision-making skills. Considering this result, nursing education should be presented using new strategies and creative and different ways from traditional education methods. Cognitive skills training should be integrated in the nursing curriculum. Therefore, training cognitive skills such as problem- solving to nursing students is recommended.

Peer Review reports

Continuous monitoring and providing high-quality care to patients is one of the main tasks of nurses. Nurses’ roles are diverse and include care, educational, supportive, and interventional roles when dealing with patients’ clinical problems [ 1 , 2 ].

Providing professional nursing services requires the cognitive skills such as problem-solving, decision-making and critical thinking, and information synthesis [ 3 ].

Problem-solving is an essential skill in nursing. Improving this skill is very important for nurses because it is an intellectual process which requires the reflection and creative thinking [ 4 ].

Problem-solving skill means acquiring knowledge to reach a solution, and a person’s ability to use this knowledge to find a solution requires critical thinking. The promotion of these skills is considered a necessary condition for nurses’ performance in the nursing profession [ 5 , 6 ].

Managing the complexities and challenges of health systems requires competent nurses with high levels of critical thinking skills. A nurse’s critical thinking skills can affect patient safety because it enables nurses to correctly diagnose the patient’s initial problem and take the right action for the right reason [ 4 , 7 , 8 ].

Problem-solving and decision-making are complex and difficult processes for nurses, because they have to care for multiple patients with different problems in complex and unpredictable treatment environments [ 9 , 10 ].

Clinical decision making is an important element of professional nursing care; nurses’ ability to form effective clinical decisions is the most significant issue affecting the care standard. Nurses build 2 kinds of choices associated with the practice: patient care decisions that affect direct patient care and occupational decisions that affect the work context or teams [ 11 , 12 , 13 , 14 , 15 , 16 ].

The utilization of nursing process guarantees the provision of professional and effective care. The nursing process provides nurses with the chance to learn problem-solving skills through teamwork, health management, and patient care. Problem-solving is at the heart of nursing process which is why this skill underlies all nursing practices. Therefore, proper training of this skill in an undergraduate nursing program is essential [ 17 ].

Nursing students face unique problems which are specific to the clinical and therapeutic environment, causing a lot of stresses during clinical education. This stress can affect their problem- solving skills [ 18 , 19 , 20 , 21 ]. They need to promote their problem-solving and critical thinking skills to meet the complex needs of current healthcare settings and should be able to respond to changing circumstances and apply knowledge and skills in different clinical situations [ 22 ]. Institutions should provide this important opportunity for them.

Despite, the results of studies in nursing students show the weakness of their problem-solving skills, while in complex health environments and exposure to emerging diseases, nurses need to diagnose problems and solve them rapidly accurately. The teaching of these skills should begin in college and continue in health care environments [ 5 , 23 , 24 ].

It should not be forgotten that in addition to the problems caused by the patients’ disease, a large proportion of the problems facing nurses are related to the procedures of the natural life of their patients and their families, the majority of nurses with the rest of health team and the various roles defined for nurses [ 25 ].

Therefore, in addition to above- mentioned issues, other ability is required to deal with common problems in the working environment for nurses, the skill is “social problem solving”, because the term social problem-solving includes a method of problem-solving in the “natural context” or the “real world” [ 26 , 27 ]. In reviewing the existing research literature on the competencies and skills required by nursing students, what attracts a lot of attention is the weakness of basic skills and the lack of formal and systematic training of these skills in the nursing curriculum, it indicates a gap in this area [ 5 , 24 , 25 ]. In this regard, the researchers tried to reduce this significant gap by holding a formal problem-solving skills training course, emphasizing the common social issues in the real world of work. Therefore, this study was conducted to investigate the impact of social problem-solving skills training on nursing students’ critical thinking and decision-making.

Setting and sample

This quasi-experimental study with pretest and post-test design was performed on 40 undergraduate/four-year nursing students in Borujen nursing school in Shahrekord University of Medical Sciences. The periods of data collection were 4 months.

According to the fact that senior students of nursing have passed clinical training and internship programs, they have more familiarity with wards and treatment areas, patients and issues in treatment areas and also they have faced the problems which the nurses have with other health team personnel and patients and their families, they have been chosen for this study. Therefore, this study’s sampling method was based on the purpose, and the sample size was equal to the total population. The whole of four-year nursing students participated in this study and the sample size was 40 members. Participants was randomly divided in 2 groups; experimental ( n  = 20) and control (n = 20).

The inclusion criteria to take part in the present research were students’ willingness to take part, studying in the four-year nursing, not having the record of psychological sickness or using the related drugs (all based on their self-utterance).

Intervention

At the beginning of study, all students completed the demographic information’ questionnaire. The study’s intervening variables were controlled between the two groups [such as age, marital status, work experience, training courses, psychological illness, psychiatric medication use and improving cognitive skills courses (critical thinking, problem- solving, and decision making in the last 6 months)]. Both groups were homogeneous in terms of demographic variables ( P  > 0.05). Decision making and critical thinking skills and social problem solving of participants in 2 groups was evaluated before and 1 month after the intervention.

All questionnaires were anonymous and had an identification code which carefully distributed by the researcher.

To control the transfer of information among the students of two groups, the classification list of students for internships, provided by the head of nursing department at the beginning of semester, was used.

Furthermore, the groups with the odd number of experimental group and the groups with the even number formed the control group and thus were less in contact with each other.

The importance of not transferring information among groups was fully described to the experimental group. They were asked not to provide any information about the course to the students of the control group.

Then, training a course of social problem-solving skills for the experimental group, given in a separate course and the period from the nursing curriculum and was held in 8 sessions during 2 months, using small group discussion, brainstorming, case-based discussion, and reaching the solution in small 4 member groups, taking results of the social problem-solving model as mentioned by D-zurilla and gold fried [ 26 ]. The instructor was an assistant professor of university and had a history of teaching problem-solving courses. This model’ stages are explained in Table  1 .

All training sessions were performed due to the model, and one step of the model was implemented in each session. In each session, the teacher stated the educational objectives and asked the students to share their experiences in dealing to various workplace problems, home and community due to the topic of session. Besides, in each session, a case-based scenario was presented and thoroughly analyzed, and students discussed it.

Instruments

In this study, the data were collected using demographic variables questionnaire and social problem- solving inventory – revised (SPSI-R) developed by D’zurilla and Nezu (2002) [ 26 ], California critical thinking skills test- form B (CCTST; 1994) [ 27 , 28 ] and decision-making questionnaire.

SPSI-R is a self - reporting tool with 52 questions ranging from a Likert scale (1: Absolutely not – 5: very much).

The minimum score maybe 25 and at a maximum of 125, therefore:

The score 25 and 50: weak social problem-solving skills.

The score 50–75: moderate social problem-solving skills.

The score higher of 75: strong social problem-solving skills.

The reliability assessed by repeated tests is between 0.68 and 0.91, and its alpha coefficient between 0.69 and 0.95 was reported [ 26 ]. The structural validity of questionnaire has also been confirmed. All validity analyses have confirmed SPSI as a social problem - solving scale.

In Iran, the alpha coefficient of 0.85 is measured for five factors, and the retest reliability coefficient was obtained 0.88. All of the narratives analyzes confirmed SPSI as a social problem- solving scale [ 29 ].

California critical thinking skills test- form B(CCTST; 1994): This test is a standard tool for assessing the basic skills of critical thinking at the high school and higher education levels (Facione & Facione, 1992, 1998) [ 27 ].

This tool has 34 multiple-choice questions which assessed analysis, inference, and argument evaluation. Facione and Facione (1993) reported that a KR-20 range of 0.65 to 0.75 for this tool is acceptable [ 27 ].

In Iran, the KR-20 for the total scale was 0.62. This coefficient is acceptable for questionnaires that measure the level of thinking ability of individuals.

After changing the English names of this questionnaire to Persian, its content validity was approved by the Board of Experts.

The subscale analysis of Persian version of CCTST showed a positive high level of correlation between total test score and the components (analysis, r = 0.61; evaluation, r = 0.71; inference, r = 0.88; inductive reasoning, r = 0.73; and deductive reasoning, r = 0.74) [ 28 ].

A decision-making questionnaire with 20 questions was used to measure decision-making skills. This questionnaire was made by a researcher and was prepared under the supervision of a professor with psychometric expertise. Five professors confirmed the face and content validity of this questionnaire. The reliability was obtained at 0.87 which confirmed for 30 students using the test-retest method at a time interval of 2 weeks. Each question had four levels and a score from 0.25 to 1. The minimum score of this questionnaire was 5, and the maximum score was 20 [ 30 ].

Statistical analysis

For analyzing the applied data, the SPSS Version 16, and descriptive statistics tests, independent sample T-test, paired T-test, Pearson correlation coefficient, and square chi were used. The significant level was taken P  < 0.05.

The average age of students was 21.7 ± 1.34, and the academic average total score was 16.32 ± 2.83. Other demographic characteristics are presented in Table  2 .

None of the students had a history of psychiatric illness or psychiatric drug use. Findings obtained from the chi-square test showed that there is not any significant difference between the two groups statistically in terms of demographic variables.

The mean scores in social decision making, critical thinking, and decision-making in whole samples before intervention showed no significant difference between the two groups statistically ( P  > 0.05), but showed a significant difference after the intervention ( P  < 0.05) (Table  3 ).

Scores in Table  4 showed a significant positive difference before and after intervention in the “experimental” group ( P  < 0.05), but this difference was not seen in the control group ( P  > 0.05).

Among the demographic variables, only a positive relationship was seen between marital status and decision-making skills (r = 0.72, P  < 0.05).

Also, the scores of critical thinking skill’ subgroups and social problem solving’ subgroups are presented in Tables  5 and 6 which showed a significant positive difference before and after intervention in the “experimental” group (P < 0.05), but this difference was not seen in the control group ( P  > 0.05).

In the present study conducted by some studies, problem-solving and critical thinking and decision-making scores of nursing students are moderate [ 5 , 24 , 31 ].

The results showed that problem-solving skills, critical thinking, and decision-making in nursing students were promoted through a social problem-solving training course. Unfortunately, no study has examined the effect of teaching social problem-solving skills on nursing students’ critical thinking and decision-making skills.

Altun (2018) believes that if the values of truth and human dignity are promoted in students, it will help them acquire problem-solving skills. Free discussion between students and faculty on value topics can lead to the development of students’ information processing in values. Developing self-awareness increases students’ impartiality and problem-solving ability [ 5 ]. The results of this study are consistent to the results of present study.

Erozkan (2017), in his study, reported there is a significant relationship between social problem solving and social self-efficacy and the sub-dimensions of social problem solving [ 32 ]. In the present study, social problem -solving skills training has improved problem -solving skills and its subdivisions.

The results of study by Moshirabadi (2015) showed that the mean score of total problem-solving skills was 89.52 ± 21.58 and this average was lower in fourth-year students than other students. He explained that education should improve students’ problem-solving skills. Because nursing students with advanced problem-solving skills are vital to today’s evolving society [ 22 ]. In the present study, the results showed students’ weakness in the skills in question, and holding a social problem-solving skills training course could increase the level of these skills.

Çinar (2010) reported midwives and nurses are expected to use problem-solving strategies and effective decision-making in their work, using rich basic knowledge.

These skills should be developed throughout one’s profession. The results of this study showed that academic education could increase problem-solving skills of nursing and midwifery students, and final year students have higher skill levels [ 23 ].

Bayani (2012) reported that the ability to solve social problems has a determining role in mental health. Problem-solving training can lead to a level upgrade of mental health and quality of life [ 33 ]; These results agree with the results obtained in our study.

Conducted by this study, Kocoglu (2016) reported nurses’ understanding of their problem-solving skills is moderate. Receiving advice and support from qualified nursing managers and educators can enhance this skill and positively impact their behavior [ 31 ].

Kashaninia (2015), in her study, reported teaching critical thinking skills can promote critical thinking and the application of rational decision-making styles by nurses.

One of the main components of sound performance in nursing is nurses’ ability to process information and make good decisions; these abilities themselves require critical thinking. Therefore, universities should envisage educational and supportive programs emphasizing critical thinking to cultivate their students’ professional competencies, decision-making, problem-solving, and self-efficacy [ 34 ].

The study results of Kirmizi (2015) also showed a moderate positive relationship between critical thinking and problem-solving skills [ 35 ].

Hong (2015) reported that using continuing PBL training promotes reflection and critical thinking in clinical nurses. Applying brainstorming in PBL increases the motivation to participate collaboratively and encourages teamwork. Learners become familiar with different perspectives on patients’ problems and gain a more comprehensive understanding. Achieving these competencies is the basis of clinical decision-making in nursing. The dynamic and ongoing involvement of clinical staff can bridge the gap between theory and practice [ 36 ].

Ancel (2016) emphasizes that structured and managed problem-solving training can increase students’ confidence in applying problem-solving skills and help them achieve self-confidence. He reported that nursing students want to be taught in more innovative ways than traditional teaching methods which cognitive skills training should be included in their curriculum. To this end, university faculties and lecturers should believe in the importance of strategies used in teaching and the richness of educational content offered to students [ 17 ].

The results of these recent studies are adjusted with the finding of recent research and emphasize the importance of structured teaching cognitive skills to nurses and nursing students.

Based on the results of this study on improving critical thinking and decision-making skills in the intervention group, researchers guess the reasons to achieve the results of study in the following cases:

In nursing internationally, problem-solving skills (PS) have been introduced as a key strategy for better patient care [ 17 ]. Problem-solving can be defined as a self-oriented cognitive-behavioral process used to identify or discover effective solutions to a special problem in everyday life. In particular, the application of this cognitive-behavioral methodology identifies a wide range of possible effective solutions to a particular problem and enhancement the likelihood of selecting the most effective solution from among the various options [ 27 ].

In social problem-solving theory, there is a difference among the concepts of problem-solving and solution implementation, because the concepts of these two processes are different, and in practice, they require different skills.

In the problem-solving process, we seek to find solutions to specific problems, while in the implementation of solution, the process of implementing those solutions in the real problematic situation is considered [ 25 , 26 ].

The use of D’zurilla and Goldfride’s social problem-solving model was effective in achieving the study results because of its theoretical foundations and the usage of the principles of cognitive reinforcement skills. Social problem solving is considered an intellectual, logical, effort-based, and deliberate activity [ 26 , 32 ]; therefore, using this model can also affect other skills that need recognition.

In this study, problem-solving training from case studies and group discussion methods, brainstorming, and activity in small groups, was used.

There are significant educational achievements in using small- group learning strategies. The limited number of learners in each group increases the interaction between learners, instructors, and content. In this way, the teacher will be able to predict activities and apply techniques that will lead students to achieve high cognitive taxonomy levels. That is, confront students with assignments and activities that force them to use cognitive processes such as analysis, reasoning, evaluation, and criticism.

In small groups, students are given the opportunity to the enquiry, discuss differences of opinion, and come up with solutions. This method creates a comprehensive understanding of the subject for the student [ 36 ].

According to the results, social problem solving increases the nurses’ decision-making ability and critical thinking regarding identifying the patient’s needs and choosing the best nursing procedures. According to what was discussed, the implementation of this intervention in larger groups and in different levels of education by teaching other cognitive skills and examining their impact on other cognitive skills of nursing students, in the future, is recommended.

Social problem- solving training by affecting critical thinking skills and decision-making of nursing students increases patient safety. It improves the quality of care because patients’ needs are better identified and analyzed, and the best solutions are adopted to solve the problem.

In the end, the implementation of this intervention in larger groups in different levels of education by teaching other cognitive skills and examining their impact on other cognitive skills of nursing students in the future is recommended.

Study limitations

This study was performed on fourth-year nursing students, but the students of other levels should be studied during a cohort from the beginning to the end of course to monitor the cognitive skills improvement.

The promotion of high-level cognitive skills is one of the main goals of higher education. It is very necessary to adopt appropriate approaches to improve the level of thinking. According to this study results, the teachers and planners are expected to use effective approaches and models such as D’zurilla and Goldfride social problem solving to improve problem-solving, critical thinking, and decision-making skills. What has been confirmed in this study is that the routine training in the control group should, as it should, has not been able to improve the students’ critical thinking skills, and the traditional educational system needs to be transformed and reviewed to achieve this goal.

Availability of data and materials

The datasets used and analyzed during the present study are available from the corresponding author on reasonable request.

Abbreviations

California critical thinking skills test

Social problem-solving inventory – revised

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Acknowledgments

This article results from research project No. 980 approved by the Research and Technology Department of Shahrekord University of Medical Sciences. We would like to appreciate to all personnel and students of the Borujen Nursing School. The efforts of all those who assisted us throughout this research.

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SA and SSH conceptualized the study, developed the proposal, coordinated the project, completed initial data entry and analysis, and wrote the report. SSH conducted the statistical analyses. SA and SSH assisted in writing and editing the final report. All authors read and approved the final manuscript.

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Ahmady, S., Shahbazi, S. Impact of social problem-solving training on critical thinking and decision making of nursing students. BMC Nurs 19 , 94 (2020). https://doi.org/10.1186/s12912-020-00487-x

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Leadership in Nursing: Qualities of a Good Nurse Leader

Effective nursing leadership is essential for quality outcomes in healthcare. Outstanding leadership is demonstrated every day when nurses rise to challenges and accept opportunities to make a meaningful difference in the health care of our population. The importance of leadership in nursing cannot be overstated. 

Qualities of a good nurse leader include:

• Commitment to patients and families
• Perseverance and a humble mindset
• Aptitude for conflict resolution
• Empathy and professional communication
• Strong clinical skills
• Dedication to evidence-based practice

From an educational perspective, graduate nursing programs are available to train nursing educators and clinical nurse leaders (CNLs). With a Master of Science in Nursing (MSN) degree , a world of possibilities for specialization and increased practice autonomy becomes available to registered nurses (RNs) who aspire to formalize their leadership roles.

These are two distinct pathways that aspiring nurse leaders can take to develop their professional skills and gain additional experience for vital leadership roles in the community and within our nation’s existing healthcare systems. 

Qualities of a Good Nurse Leader

Are you a registered nurse with a desire to develop your leadership skills in nursing beyond the bedside? You are well-positioned to pursue additional training that can set you apart in the job market and grow your confidence to take on new challenges. 

Nursing leadership qualities can be encouraged through faculty mentorship and further developed through nursing experience and graduate education. 

Let’s look at some of the best qualities of a good nurse leader. 

Empathy and Compassion

Empathy is the ability to understand a situation from another person’s perspective, including the emotions experienced and potential motivations for decisions. Good nurses can empathize with others and express compassion in how they communicate, both verbally and nonverbally. When a nurse is empathetic it enables meaningful connection with another person on a human-to-human level.

In nursing leadership, empathy promotes ethical and professional conduct. Good leaders can see problems from multiple angles and consider how various potential solutions may impact several different stakeholders. The ability to empathize also helps a nurse leader implement sensible decisions when there are multiple approaches that can make the best decision more difficult to discern.

Nurse leaders are also advocates for patients and other nurses, and advocacy allows a good nurse leader to:

• Suggest processes, policies and interventions that are in the best interest of patients and staff
• Connect patients and staff with helpful community resources
• Encourage self-care and participation in programs designed to reduce nurse burnout
• Help patients and families articulate their needs for quality health care

Closely linked to the skills of empathy and compassion are excellent communication skills. Effective communication is a hallmark of quality nursing care and quality leadership.

Communication Skills

Nurses communicate daily with many different people and through different modalities. A good nurse can communicate with other clinicians about patient status clearly and accurately and also relay this information to their patients in ways they can understand, all while empowering and educating them in their health care. 

Written communication is also critical for leadership in nursing as documentation of the nursing plan of care is recorded in medical records where nurses need to be thorough yet succinct. 

Nursing leaders mentor other nurses to promote professional development and continuity of care through shift changes and between visits (depending on the area of nursing practice). Strong leaders maintain open lines of discussion and work to resolve interpersonal conflict in ways that encourage teamwork and mutual understanding. Communication-savvy nurses can motivate, inspire and urge collaboration for a positive work environment.

Adaptability and Resilience

Nursing is a profession where adaptability to change and flexibility in daily activities are essential qualities. Good nurses can prioritize urgent actions and important details of their schedules as drawbacks occur. This can include:

• Declines or improvements in the health status of patients
• New patient admissions and discharges
• Nurse staffing and regular shift changes
• Assessment initiatives for quality improvement
• Accreditation audits and other regulatory reviews

Each of these instances would require a nurse to reevaluate priorities and adapt to the changing needs of patients and families within the healthcare facility. A good nurse can critically think about the urgency and importance of tasks to achieve quality patient care within the changing environment. 

Nurse leaders must be adept in strategic thinking, as well. As there are changes in staffing or new needs for facility accreditation, nursing leadership needs to proactively plan unit-based and organizational strategies for successfully navigating change.

Decision-Making and Problem-Solving Abilities

Within a team of healthcare personnel, there are many valuable viewpoints to consider when making decisions. A nurse leader will observe and request input from the departments and disciplines involved when working to solve problems effectively. 

Problem-solving is as much about the problem itself as it is about the professional relationships and collaboration that may be required. Skills for nursing leaders that can aid in effective problem-solving include:

• Active listening to understand what others are communicating and why
• Willingness to consider differing viewpoints on a situation
• Self-awareness to understand personal motives and potential bias
• Emotional regulation and a propensity toward conflict resolution

Nurses who make good leaders are also those who give attention to detail. Many times, the details are often where the root cause of a problem can be identified and solutions can be proposed. Good leaders are willing to try potential solutions and honestly evaluate when a different route may be better. Proposing data-driven solutions, admitting faults and learning from mistakes are critical abilities for nursing leadership to possess.

Importance of Continuing Education for Nurse Leaders

Another quality of a good nurse leader is the expertise and knowledge gained through continuing education. Skills in health informatics allow nursing leadership to access and analyze available data to report measurable progress and identify areas for improvement in health care delivery. 

The desire to enhance knowledge and skills is a motivational factor for continued development and growth in any career. It is especially important for nurse leaders to pursue and model this growth mindset as mentors for other nurses and to exemplify standards for professionalism. 

Areas for continuing education include:

• Organizational leadership strategies
• Teaching methods in patient care and academics
• Soft skills for team building and working effectively with others
• Clinical knowledge and advancements for managing specific conditions
• Emerging technology with health care application

Research evidence for best practices continues to be published as discoveries are made and real-world interventions are implemented and evaluated. The ability to provide timely, evidence-based care is rooted in the practice of continuing education and willingness to learn. 

Next, let’s take an in-depth look at two pathways for becoming a nurse leader: Nursing Educator and Clinical Nurse Leader (CNL). 

Nursing Educator vs. Clinical Nurse Leader

If you are interested in a nursing career with ample opportunity for teaching, mentorship and leading individuals and teams toward improved health outcomes, both the nursing educator and clinical nurse leader roles will provide this. 

A CNL and a nurse educator are similar in that they both work to educate and train healthcare personnel through professional development opportunities and continuing education. 

A nursing educator may work in a clinical facility, such as a hospital or public health agency, or they may be found working in academic roles teaching student nurses. A clinical nurse leader is generally responsible for overseeing direct patient care and improving patient outcomes in a leadership position. 

Both roles are prepared through graduate education and require a master’s degree in nursing. 

Roles and Responsibilities of Nursing Educators

As a nursing educator , you may be responsible for conducting activities such as:

• Designing coursework and curriculum for students and nurses
• Researching best practices in teaching
• Planning professional development activities
• Teaching clinical skills for direct patient care
• Process-outcome evaluations of learning in the classroom and clinical setting

The specific activities of a nursing educator's role are somewhat dependent on the setting in which they are employed. Academic settings carry additional responsibilities of student mentorship, grading assignments and regular communication with other faculty to ensure alignment of the educational content with academic accreditation standards. 

Within the hospital or clinical setting, a nursing educator may work with students. However, when nursing educators are positioned within clinical employment positions, they are also frequently responsible for ensuring opportunities for growth and development for a particular unit or nursing specialty. 

Summary of Nursing Education Role

Roles and responsibilities of clinical nurse leaders.

The CNL role is known for leadership commitment with the primary goal of improved patient outcomes through quality improvement, education and other methods for enhancing care delivery within healthcare systems. 

Some of the responsibilities of a CNL include:

• Coordinating care and communication within interdisciplinary teams
• Designing evidence-based care plans for patients and families
• Identifying areas for quality improvement through data analysis and evaluation
• Promoting patient safety through risk assessments
• Facilitating transitions of care from one discipline or facility to another

In times of crisis, CNLs are on the front lines of nursing leadership as they stay abreast of current news and the latest recommendations for implementation. A CNL may be the person to suggest process changes for patient treatment plans and nursing care delivery based on an emerging technology or available community resource.

Summary of Clinical Nurse Leader Role

Leadership styles in nursing.

Many of the qualities of a good nurse and leader are important when implementing distinct styles of leadership in nursing. Depending on your personality or the unique dynamics of your workplace, different nursing leadership styles may be more effective than others. 

Leadership styles that are good for nursing leadership include:

• Transformational - the leader focuses on mentorship to bring the best out of a team
• Servant - the leader prioritizes meeting the needs of others and leads by example
• Laissez-faire - the leader entrusts decision-making responsibilities to those they oversee
• Democratic - the leader builds concensus and makes decisions by creating strong team dynamics

Transformational leadership is especially useful when visionary leaders are working to develop a strong nursing team for the future. Compassion and empathy are valuable qualities in many situations, especially when applying the servant leadership style. The laissez-faire style of leadership promotes a hands-off approach that is especially effective in situations with experienced and self-directed nurses. However, this style may provide too much autonomy for newer nurses who would benefit from greater direction and presence from a leader. 

Nursing leaders who can effectively apply a combination of styles can lead with the benefits of several styles while minimizing the shortcomings a particular style may have. 

If you are ready to embark on your journey to become a dynamic nurse leader, Cleveland State University (CSU) offers high-quality graduate nursing programs to help you reach your goals.

Cleveland State University’s Online MSN - Nursing Education 

The Online Master of Science in Nursing - Nursing Education program at CSU prepares nurses to become educators in academic and clinical settings. This program prepares graduates to design and implement innovative teaching strategies, mentor future nurses and contribute to curriculum development. 

Program features include: 

• Completion in two years on a part-time schedule
• Experiential hands-on learning in your community
• Accredited by the Commission on Collegiate Nursing Education (CCNE)
• Prepares you for the National League for Nursing’s (NLN) Certification for Nurse Educators (CNE) exam

With an MSN degree, you may begin working in academia as a clinical instructor. If you are interested in a future role in academic faculty, an MSN degree is the next step to furthering your education toward a doctorate that will allow you to achieve professorial roles in colleges and universities. 

Cleveland State University’s Online MSN - Clinical Nurse Leader

The Online Master of Science in Nursing - Clinical Nurse Leader program at CSU prepares nurses for leadership roles in health care delivery by developing advanced clinical skills and interdisciplinary collaboration. Graduates of the CNL program are prepared to improve patient outcomes through evidence-based practice in complex health delivery situations. 

Program features include:

• Completion in one year and seven months on a part-time schedule
• Accredited by the Commission on Collegiate Education (CCNE)
• Prepares you for the Commission on Nurse Certification’s (CNC) Clinical Nurse Leader (CNL) certification exam

Cleveland State University’s online MSN programs prepare you with the essential qualities of a nursing leader. For more information and details on how to apply, visit the Online MSN-NE and Online MSN-CNL program pages.

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• http://orcid.org/0000-0001-8401-4976 Majd T Mrayyan 1 ,
• http://orcid.org/0000-0002-6393-3022 Abdullah Algunmeeyn 2 ,
• http://orcid.org/0000-0002-2639-9991 Hamzeh Y Abunab 3 ,
• Ola A Kutah 2 ,
• Imad Alfayoumi 3 ,
• Abdallah Abu Khait 1
• 1 Department of Community and Mental Health Nursing, Faculty of Nursing , The Hashemite University , Zarqa , Jordan
• 2 Advanced Nursing Department, Faculty of Nursing , Isra University , Amman , Jordan
• 3 Basic Nursing Department, Faculty of Nursing , Isra University , Amman , Jordan
• Correspondence to Dr Majd T Mrayyan, Department of Community and Mental Health Nursing, Faculty of Nursing, The Hashemite University, Zarqa 13133, Jordan; mmrayyan{at}hu.edu.jo

Background Research shows a significant growth in clinical leadership from a nursing perspective; however, clinical leadership is still misunderstood in all clinical environments. Until now, clinical leaders were rarely seen in hospitals’ top management and leadership roles.

Purpose This study surveyed the attributes and skills of clinical nursing leadership and the actions that effective clinical nursing leaders can do.

Methods In 2020, a cross-sectional design was used in the current study using an online survey, with a non-random purposive sample of 296 registered nurses from teaching, public and private hospitals and areas of work in Jordan, yielding a 66% response rate. Data were analysed using descriptive analysis of frequency and central tendency measures, and comparisons were performed using independent t-tests.

Results The sample consists mostly of junior nurses. The ‘most common’ attributes associated with clinical nursing leadership were effective communication, clinical competence, approachability, role model and support. The ‘least common’ attribute associated with clinical nursing leadership was ‘controlling’. The top-rated skills of clinical leaders were having a strong moral character, knowing right and wrong and acting appropriately. Leading change and service improvement were clinical leaders’ top-rated actions. An independent t-test on key variables revealed substantial differences between male and female nurses regarding the actions and skills of effective clinical nursing leadership.

Conclusions The current study looked at clinical leadership in Jordan’s healthcare system, focusing on the role of gender in clinical nursing leadership. The findings advocate for clinical leadership by nurses as an essential element of value-based practice, and they influence innovation and change. As clinical leaders in various hospitals and healthcare settings, more empirical work is needed to build on clinical nursing in general and the attributes, skills and actions of clinical nursing leadership of nursing leaders and nurses.

• clinical leadership
• health system
• leadership assessment

Data availability statement

Data are available on request due to privacy/ethical restrictions. https://authorservices.taylorandfrancis.com/data-sharing/share-your-data/data-availability-statements/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

http://dx.doi.org/10.1136/leader-2022-000672

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WHAT IS ALREADY KNOWN ON THIS TOPIC

Clinical leadership was limited to service managers; however, currently, all clinicians are invited to participate in leadership practices. Clinical leaders are needed in various healthcare settings to produce positive outcomes.

WHAT THIS STUDY ADDS

This study outlined clinical leadership attributes, skills and actions to understand clinical nursing leadership better. The current study highlighted the role of gender in clinical nursing leadership, and it asserts that effective clinical nursing leadership is warranted to improve the efficiency and effectiveness of care. The results call for nurses’ clinical leadership as essential in today’s turbulent work environment.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

Nurses and clinical leaders need additional attributes, skills and actions. Clinical nursing leaders should use innovative interventions and have skills or actions to manage current work environments. Further work is needed to build on clinical nursing in general and the attributes, skills and actions of clinical nursing leadership. Clinical leadership programmes must be integrated into the nursing curricula.

Introduction

Clinical leadership is a matter of global importance. Currently, all clinicians are invited to participate in leadership practices. 1 This invitation is based on the fact that people deliver healthcare within complex systems. Effective clinicians must understand systems of care to function effectively. 1 2 Engaging in clinical leadership is an obligation, not a choice, for all clinicians at all levels. This obligation is more critical in nursing with many e merging global health issues , 2 such as the COVID-19 pandemic.

The systematic literature review of Cummings et al 3 shows the differences in leadership literature. In early 2000, clinical leadership emerged in scientific literature. 4 It is about having the knowledge, skills and competencies needed to effectively balance the needs of patients and team members within resource constraints. 4 Clinical leadership is vital in nursing as nurses face complex challenges in clinical settings, especially in acute care settings. 4 Although developed from the management domain, leadership and management are two concepts used interchangeably, 5–9 leading to further misunderstanding of the relationship between clinical leadership and management. While different types of leadership have been evident in nursing and health industry literature, clinical leadership is still misunderstood in clinical environments. 8 Clinical leadership is not fully understood among health professionals trained to care for patients, as clinical leadership is a management concept, leaving the concept open to different interpretations. 10 For example, Gauld 10 reported that clinical leaders might be professionals (such as doctors and nurses) who are no longer clinically active, mandating that clinical leaders should also be involved in delivering care. 10

There is no clear definition of ‘clinical leadership’. However, effective clinical leadership involves individuals with the appropriate clinical leadership skills and attributes at different levels of an organisation, focusing on multidisciplinary and interdisciplinary work. 10 The main skills associated with clinical leadership were having values and beliefs consistent with their actions and interventions, being supportive of colleagues, communicating effectively, serving as a role model and engaging in reflective practice. 4–9 The main attributes associated with clinical leadership were using effective communication, clinical competence, being a role model, supportive and approachability. 4–9 Stanley and colleagues reported that clinical leaders are found across health organisations and are presented in all clinical environments. Clinical leaders are often found at the highest level for clinical interaction but not commonly found at the highest management level in wards or units. 4–9

With the increasing urgency to improve the efficiency and effectiveness of care, effective nursing leadership is warranted. 4 11–17 Clinical leaders can be found in various healthcare settings, 4 most often at the highest clinical level, but they are uncommon at the top executive level. 6–9 18–24 In the UK, the National Health Service (NHS) 25 empowers clinicians and front-line staff to build their decision-making capabilities, which is required for clinical leadership. This empowerment encourages a broader practice of clinical leadership without being limited to top executives alone. 25 26

Purpose and significance

This study assesses clinical nursing leadership in Jordan. More specifically, it answers the following research questions: (1) What attributes are associated with clinical nursing leadership in Jordanian hospitals? (2) What skills are important for effective clinical nursing leadership? (3) What actions are important for effective clinical nursing leadership? (4) What are the differences in skills critical to effective clinical nursing leadership based on the sample’s characteristics? (5) What are the differences in effective clinical nursing leaders’ actions based on the sample’s characteristics?

Nursing leadership studies are abundant; however, clinical leadership research is not well established. 8 27 Until fairly recently, clinical leadership in nursing has tended to focus on nursing leaders in senior leadership positions, ignoring nurse managers in clinical positions. 8 There has been significant growth in research exploring clinical leadership from a nursing perspective. 4 8 9 14–17 24 26–32 A new leadership theory, ‘congruent leadership’, has emerged, claiming that clinical leaders acted on their values and beliefs about care and thus were followed. 6–9 20 This study is the first in Jordan’s nursing and health-related research about clinical leadership. Clarifying this concept from nurses’ perspectives will support greater healthcare delivery efficiencies.

Search methods

The initial search was done using ‘clinical nursing leadership’ at the Clarivate database and Google Scholar database from 2017 to 2021, yielded 35 studies, of which, after abstracting, 14 studies were selected. However, Stanley’s work (12 studies), including those before 2017, was included because we followed the researcher’s passion and methodology of studying clinical leadership; also, some classical models of clinical leadership because they were essential for the conceptualisation of the study as well as the discussion, such as the NHS Leadership Academy (three studies; ref 25 33 34 ).

Another search was run using the words ‘attributes’, ‘skills’ or ‘actions’ using the same time frame; most of the yielded studies were not relevant, this search year was expanded to 2013–2021 because the years 2013–2015 were the glorious time of studying these concepts. Using ‘clinical leadership’ rather than ‘leadership studies’, 15 studies were yielded; however, Stanley’s above work was excluded to avoid repetition, resulting in using three studies (ref 29 30 35 ). A relevant reference of 2022 similar to our study (ref 36 ) was added at the stages of revisions. The remaining 16 of 49 references were related to the methodology and explanation of some results, such as those related to gender differences in leadership. The following limits were set: the language was English; and the year of publication was basically the last 5 years to ensure that the search was current.

Clinical leadership

Clinical leadership ensures quality patient care by providing safe and efficient care and creating a healthy clinical work environment. 4 10–17 27 31 32 It also decreases the high costs of clinical litigation settlements and improves the safety of service delivery to consumers. 4 11–17 32 For these reasons, healthcare organisations should initiate interventions to develop clinical leadership among front-line clinicians, including nurses. 8 9

Literature was scarce on clinical leadership in nursing. 4 8–10 14–17 27 28 31 Stanley and Stanley 8 defined clinical leadership as developing a culture and leading a set of tasks to improve the quality and safety of service delivery to consumers.

Clinical leadership is about focusing on direct patient care, delivering high-quality direct patient care, motivating members of the team to provide effective, safe and satisfying care, promoting staff retention, providing organisational support and improving patient outcomes. 31 Clinical leadership roles include providing the vision, setting the direction, promoting professionalism, teamwork, interprofessional collaborations, good practice and continued medical education, contributing to patient care and performing tasks effectively. 31 Moreover, the researchers added that clinical leadership is having the approachability and the ability to communicate effectively, the ability to gain support and influence others, role modelling, visibility and availability to support, the ability to promote change, advise and guide. 31 Clinical leadership competencies include demonstrating clinical expertise, remaining clinically focused and engaged and comprehending clinical leadership roles and decision-making. In addition, clinical leadership was not associated with a position within the management and organisational structure, unlike health service management. 31 33

Clinical leadership is hindered by many barriers that include the lack of time and the high clinical/client demand on their time. 8 9 Clinical leadership is limited because of the deficit in intrapersonal and interpersonal capabilities among team members and interdisciplinary and organisational factors, such as a lack of influence in interdisciplinary care planning and policy. 37 Other barriers include limited organisational leadership opportunities, the perceived need for leadership development before serving in leadership roles and a lack of funding for advancement. 38

This paper aligns with the theory of congruent leadership proposed by Stanley. 19 This theory is best suited for understanding clinical leadership because it defines leadership as a congruence between the activities and actions of the leader and the leader’s values, beliefs and principles, and those of the organisation and team.

Attributes of clinical leadership

The clinical leadership attributes needed for nurses 8 28 to perform their roles effectively are: (1) personal attributes: nurses are confident in their abilities to provide best practice, communicate effectively and have emotional intelligence; (2) team attributes: encouraging trust and commitment to others, team focus and valuing others’ skills and expertise; and (3) capabilities: encouraging contribution from others, building and maintaining relationships, creating clear direction and being a role model. 8 28 Clinical leadership attributes are linked to communicating effectively, role modelling, promoting change, providing advice and guidance, gaining support and influencing others. 28–30 Other attributes to include are clinical leaders’ engagement in reflective practice, 29 provision of the vision; setting direction, having the resources to perform tasks effectively and promoting professionalism, teamwork, interprofessional collaborations, effective practice and continued education. 27 28 31

Skills of clinical leadership

Clinical leadership skills include (1) a ‘clinical focus’: being expert knowledge, providing evidence-based rationale and systematic thinking, understanding clinical leadership, understanding clinical decision-making, being clinically focused, remaining clinically engaged and demonstrating clinical expertise; (2) a ‘follower/team focus’: being supportive of colleagues, effectively communicating communication skills, serving as a role model and empowering the team; and (3) a ‘personal qualities focus’: engaging in reflective practice, initiating change and challenging the status quo. 17 30 32 Clinical leaders have advocacy skills, facilitate and maintain healthier workplaces by driving changes in cultural issues among all health professionals. 17 29 Moreover, the overlap between the attributes and skills of clinical leaders includes being credible to colleagues because of clinical competence and the skills and capacity to support multidisciplinary teams effectively. 17 29 32

Actions of clinical leadership

A clinical leader is anyone in a clinical position exercising leadership. 26 The clinical leader’s role is to continuously instil in clinicians the capability to improve healthcare on small and large scales. 26 Furthermore, Stanley et al 9 demonstrated that clinical leaders are not always managers or higher-ups in organisations. Clinical leaders act following their values and beliefs, are approachable and provide superior service to their clients. 9 Clinical leaders define and delegate safety and quality responsibilities and roles. 14 32 39 They also ensure safety and quality of care, manage the operation of the clinical governance system, implement strategic plans and implement the organisation’s safety culture. 14 32 39 The Australian Commission on Safety and Quality in Health Care 39 also reported that clinical leaders might support other clinicians by reviewing safety and quality performance data, supervising the clinical workforce, conducting performance appraisals and ensuring that the team understands the clinical governance system.

In summary, clinical leadership attributes, skills and actions were outlined to understand clinical nursing leadership. The literature shows limited nursing research on clinical leadership, calling for clinical leadership that paves the road for nurses in the current turbulent work environment.

Study design

A descriptive quantitative analysis was developed to collect data about the attributes and skills of clinical nursing leadership and the actions that effective nursing clinical leaders can take. A cross-sectional design was employed to measure clinical leadership using an online survey in 2020. This design was appropriate for such a study as it allows the researchers to measure the outcome and the exposures of the study participants at the same time. 40

Sample and settings

The general population was registered nurses in medical centres in Jordan. The target population was registered nurses in teaching, public and private hospitals. Most nurses in Jordan are females working at different shifts on a full-time basis in different types of healthcare services. The baccalaureate degree is the minimum entry into the clinical practice of registered nurses. As previous nurses, we would like to attest that nurses in Jordanian hospitals commonly use team nursing care delivery models with different decision-making styles. The size of the sample was calculated by using Thorndike’s rule as follows: N≥10(k)+50 (where N was the sample size, k is the number of independent variables) (attributes, skills, actions), the minimum sample size should be 80 participants. 40 From experience, the researcher considers the sample’s demographics and subscales as independent variables (k=17); the overall sample should not be less than 220.

Research participants were recruited through a ‘direct recruitment strategy’ from the hospitals where the nursing students were trained. A survey was used to collect data using non-random purposive sampling; of possible 450 Jordanian nurses, 296 were recruited from different types of hospitals: teaching (51 of possible 120 nurses), public (180 of possible 210 nurses) and private (65 of possible 120 nurses), with a response rate of 66%, which is adequate for an online survey. The inclusion criteria were that nurses should work in hospital settings, and any nurses who work in non-hospital settings were excluded. No incentives were applied.

Using a direct measurement method, Stanley’s Clinical Leadership Scale ( online supplemental file 1 ) was used to collect the data using the English version of the scale because English is the official education language of nursing in Jordan. 8 9 The original questionnaire consists of 24 questions: 12 quantitative and qualitative questions relevant to clinical leadership, and 12 related to the sample’s demographics. Several studies about clinical leadership among nurses and paramedics in the UK and Australia used modified versions of a survey tool 5 8 9 18–24 ; construct validity was ensured using exploratory factor analysis or triangulation of validation. Cronbach’s alpha measures the homogeneity in the survey, and it was reported to be 0.87 8 9 and 0.88 in the current study.

Supplemental material

Several questions were measured on a 5-point Likert scale in the original scale, and others were qualitative. The survey for the current study consists of 12 quantitative and qualitative questions related to clinical leadership and 14 questions related to the sample’s demographics. However, the qualitative data obtained were scattered and incomplete; thus, only the quantitative questions were analysed and reported, and another qualitative study about clinical leadership was planned. For the current study, three quantitative questions only focused on clinical leadership, leadership skills and the actions of clinical leaders, and 14 questions focused on the sample’s characteristics relevant to the Jordanian healthcare system developed by the first author. The sample characteristics were gender, marital status, shift worked, time commitment, level of education, age, years of experience in nursing, years of experience in leadership and the number of employees directly supervised. Other characteristics include the type of unit/ward, model of nursing care, ward/unit’s decision-making style, formal leadership-related education (yes/no) and formal management-related education (yes/no). Before data collection, permission to use the tool was granted.

Ethical considerations

Nurses were invited to answer the survey while assuring the voluntary nature of their participation. The participants were told that their participation in the survey was their consent form. Participants’ anonymity and confidentiality of information were assured; all questionnaires were numerically coded, and the overall results were shared with nursing and hospital administrators. 40

Patient and public involvement

There was no patient or public involvement in this research’s design, conduct, reporting or dissemination.

Data collection procedures

After a pilot study on 12 December 2020, which checked for the suitability of the questionnaire for the Jordanian healthcare settings, data were collected over a month on 23 December 2020. Data were collected through Google Forms; the survey was posted on various WhatsApp groups and Facebook pages. Using purposive snowball sampling, nurses were asked to invite their contacts and to submit the survey once. To assure one submission, the Google Forms was designed to allow for one submission only.

No problem was encountered during data collection. The two attrition prevention techniques used were effective communication and asserting to the participants that the study was relevant to them.

The researchers controlled for all possible extraneous and confounding variables by including them in the study. A possible non-accounted extraneous variable is the organisational structure; a centralised organisational structure may hinder the use of clinical nursing leadership.

Data analyses

After data cleaning and checking wild codes and outliers, all coded variables were entered into the Statistical Package for Social Sciences (SPSS) (V.25), 35 which was used to generate statistics according to the level of measurement. A descriptive analysis focused on frequency and central tendency measures. 40 Part 1 of the scale comprises 54 qualities or characteristics to answer the first research question. Responses related to skills were measured on a 1–5 Likert scale; thus, means and SDs were reported to answer the second research question. Eight actions were rated on a 1–5 Likert scale; thus, means and SDs were reported to answer the third research question. Independent t-tests using all sample characteristics were performed to answer the fourth and fifth research questions.

The preanalysis phase of data analysis was performed; data were eligible and complete as few missing data were found; thus, they were left without intervention. The assumption of normality was met; both samples are approximately normally distributed, and there were no extreme differences in the sample’s SDs.

Characteristics of the sample

There were 296 nurses in the current study from different types of hospitals: teaching (51 nurses), public (180 nurses) and private (65 nurses), with a response rate of 66%. Most nurses were females (209, 70.6%), single (87, 29.4%), working a day shift (143, 48.3%) or rotating shifts (92, 31.1%), on a full-time basis (218, 73.6%), with a baccalaureate degree (236, 79.7%), aged less than 25 years (229, 77.4%) and 25–34 years (45, 15.2%), respectively. Also, 65.1% (166) of nurses reported having less than 1 year of experience in nursing; thus, they have few nurses under them to supervise (145, 49% supervise one to two nurses), and 23.3% (69) of nurses reported having 1–9 years of experience in leadership. Nurses reported that their unit or ward has a primary (81, 27.4%) or team nursing care delivery model (162, 54.7%), with a mixed (94, 31.8%) or participatory decision-making style (113, 38.2%), and had formal leadership-related education (191, 64.5%), and had no formal management-related education (210, 70.9%) ( table 1 ).

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Sample’s characteristics (N=296*)

Attributes of clinical nursing leadership

Nurses were asked to think about the attributes and features of clinical leadership. Based on Stanley’s Clinical Leadership Scale, 8 9 nurses were given a list of 54 qualities and characteristics and asked to select the most strongly associated with clinical leadership, followed by those least strongly associated with clinical leadership. Table 2 shows the respondents’ ‘top ten’ selected qualities in ranked order.

'Most’ and ‘Least’ important attributes associated with clinical nursing leadership (N=296)

Skills of effective clinical nursing leaders

On a Likert scale of 1–5, respondents were asked to rank the skills of effective clinical leaders from ‘not relevant’ or ‘not important’ to 5=‘very relevant’ or ‘very important’. The top skills were having a strong moral character, knowing right and wrong and acting appropriately which received a high rating, with a mean of 4.17 out of 5 (0.92). Being in a management position to be effective was ranked as the least skill of an effective leader, with a mean value of 3.78 out of 5 (1.00). As indicated by respondents, other skills of effective clinical leaders are shown in table 3 .

Skills of effective clinical nursing leaders (N=296)

Actions of effective clinical nursing leaders

On a Likert scale of 1–5, respondents were asked to rank the actions of effective clinical leaders. Leading change and service management achieved a high rating of 4.07 out of 5 points (0.90). Influencing organisational policy was rated last, with a mean score of 3.95 out of 5 (1.01), which may reflect the very junior nature of the majority of the sample. As described by respondents, some of the other actions of effective leaders are shown in table 4 .

Actions effective clinical nursing leaders can do (N=296)

Significant differences in skills of effective clinical nursing leaders based on gender

Independent t-tests using all sample’s characteristics were performed to answer the fourth research question. Gender was the only characteristic variable that differentiated clinical leadership skills. An independent t-test demonstrates that males and females have distinct perspectives on 3 out of 10 items measuring clinical leadership skills. Female participants outperform male participants in terms of ‘working within the team (p value=0.021)’, ‘being visible in the clinical environment (p value=0.004)’ and ‘recognizing optimal performance and expressing appreciation promptly (p value=0.042) ( table 5 )’.

Significant differences in skills and actions of effective clinical nursing leaders based on gender (n=296)

Significant differences in actions of effective clinical nursing leaders based on gender

Independent t-tests using all sample’s characteristics were performed to answer the fifth research question. Gender was the only characteristic variable that differentiated clinical leadership actions, and it was discovered that five of the eight propositions varied in their actions: the way clinical care is administered (p=0.010); participating in staff development education (p=0.006); providing valuable staff support (p=0.033); leading change and service improvement (p=0.014); and encouraging and leading service management (p=0.019). The independent t-test results revealed that female participants scored higher in those acts, corresponding to effective leaders’ competencies. The mean values of participants’ responses to the actions of effective clinical leaders are shown in table 5 .

The characteristics of the current sample are similar to those of the structure of the task force in Jordan. The remaining question is how men in Jordan be supported in nursing to develop clinical leadership skills on par with females. Al-Motlaq et al 41 proposed using a part-time nurses policy to address nurses’ gender imbalances. Although this is necessary for both genders, we propose to develop a clinical leadership training package to promote working male nurses’ clinical leadership. In Jordan, we apply the modern trend of using leadership in nursing rather than management. About 65% of the nurses reported having formal leadership-related education, while around 71% reported no formal management-related education.

The findings clearly showed what nurses seek in a clinical leader. They appear to refer to a good communicator who values relationships and encouragement, is flexible, approachable and compassionate, can set goals and plans, resource allocation, is clinically competent and visible and has integrity. They necessitate clinical nursing leaders who can be role models for others in practice and deal with change. They should be supportive decision-makers, mentors and motivators. They should be emphatic; otherwise, they should not be in a position of control. These findings align with other research on clinical leadership. 7–9 21 Clinical leaders should be visible and participate in team activities. They should be highly skilled clinicians who instil trust and set an example, and their values should guide them in providing excellent patient care. 8 9

Participants chose other terms or functions associated with leadership roles less frequently or perceived as unrelated to clinical leadership functions. Management, creativity and vision were among the terms and functions mentioned. The absence of the word ‘visionary’ from the list of the most important characteristics suggests that traditional leadership theories, as transformational leadership and situational leadership, do not provide a solid foundation for understanding clinical leadership approaches in the clinical setting. This result can also be influenced by the junior level of the majority of the sample.

Skills of clinical nursing leadership

Numerous studies have documented the characteristics and skills of clinical leaders. 27 29 31 Clinical leaders’ skills include advocacy, facilitation and healthier workplaces. 27 29 31 Our participants were rated as having high morals (similar to other studies) 27 29 31 and worked within teams. 29 In turn, they were flexible and expressed appreciation promptly. 7–9 21 They were clinically competent; thus, they improvised and responded to various situations with appropriate skills and interventions. They recognised optimal performance, initiated interventions, led actions and procedures and had the skills and resources necessary to perform their tasks.

The lowest mean was ‘ being in a management position to be effective ’. This lowest meaning ‘ somehow ’ makes sense; all nurses can be effective leaders rather than managers, assuming effective clinical leadership roles without having management positions. 28 42

Actions of clinical nursing leadership

Influential nursing leaders are clinically competent and can initiate interventions and lead actions; these skills translate to actions. Clinical leaders are qualified to lead and manage the service improvement change (similar to Major). 42 This role will not suddenly happen; it requires clinical nursing leaders who encourage and participate in staff development education (consistent with Major). 42 This is an essential milestone and an example of providing valuable staff support. As these were the lowest reported actions, clinical nursing leaders should initiate and lead improvement initiatives in their clinical settings, 42 resulting in service improvement. They also have to influence evidence-based policies to improve work–life integration 43 and enhance patients, nurses and organisational outcomes. These outcomes include quality of care, nurses’ empowerment, job satisfaction, quality of life and work engagement. 4 11–17 32

Female nurses had more clinical leadership skills. Because the findings of this study have never been reported in the previous clinical leadership research literature, they are considered novel. This finding indicates that one possible explanation is that the overwhelming majority of respondents were females, with the proportion of females in favour (70.6%) exceeding that of males (29.4%). Furthermore, the current findings could be explained because the study was conducted in Jordan, a traditionally female-dominated gender nursing career.

This study discovered that there are gender differences in the characteristics of nurses and their clinical leadership skills, with female clinical nursing leaders scoring higher on the t-test than male clinical nursing leaders in the following areas: this is contrary to Masanotti et al , 43 who reported that male nurses have a greater sense of coherence and, in turn, more teamwork than female nurses, who commonly have job dissatisfaction and less teamwork. These could apply to female clinical nursing leaders. These female nurses had more ‘visibility in the clinical environment’, as expected in female-dominated gender nursing careers. As they were commonly dissatisfied as nurses, 43 clinical nursing leaders would be competent in caring for their nurses’ psychological status. These leaders know that even ‘thank you’ is the simplest way to show appreciation and recognition; however, this should be given promptly.

In Arab and developing countries, the perception that females have more skills with effective clinical leadership characteristics than males is consistent with Alghamdi et al 44 and Yaseen. 45 They found that females outperform males on leadership scales, which may also apply to clinical leadership. This study shows consistency between female and male clinical nursing leaders’ general perceptions of clinical leadership skills in female-dominated gender nursing careers but not in male-dominated, gender-segregated countries, including Jordan.

Female nurses had more clinical leadership actions, which differed in five out of eight actions. Female clinical nursing leaders were better at impacting clinical care delivery, participating in staff development education, providing valuable staff support, leading change and improving service.

It is aware that the nursing profession has a difficult context in some Arab and developing countries. For example, a study conducted in Saudi Arabia could explain the current findings that male nurses face various challenges, including a lack of respect and discrimination, resulting in fewer opportunities for professional growth and development. 46 The researchers reported that female clinical nursing leaders are preferred over male nurses because nursing is a nurturing and caring profession; it has been dubbed a ‘female profession’. 46 Additionally, this study corroborates a study that found many males avoid the nursing profession entirely due to its negative connotations 47 ; the profession is geared towards females. These and other stereotypes have influenced male nurses to pursue masculine nursing roles.

The study’s findings are unique because they have never been published in the previous clinical leadership research literature. However, these results can be explained indirectly based on non-clinical leadership literature. Consistent with Khammar et al , 48 as it is a female-dominated profession, it is apparent that female clinical nursing leaders are better at delivering clinical care. This result could also be related to female clinical nursing leaders having a better attitude towards clinical conditions and managing different conditions. 48 Female clinical nursing leaders, in turn, are better at influencing patient care and improving patient safety 36 and overall care and services. This improvement will not happen suddenly; it should be accompanied by paying more attention to providing continuous support, especially during induced change.

The current study reported that female clinical nursing leaders supported staff development and education because it is a female-oriented sample. Yet, Khammar et al 48 reported that men had more opportunities to educate themselves in nursing; this is true in a male-dominated country like Jordan. They also noted that males could communicate better during nursing duties. Regardless of gender, all of us should pay attention to our staff’s working environment and related issues, including promoting open communication, providing support, encouraging continuing education, managing change and improving the overall outcomes.

Limitations

Even though the study’s findings are intriguing, further investigation is needed to comprehend them. Because of the cross-sectional design used in the current study, we cannot establish causality. For this reason, the results should be interpreted with caution. Also, the purposive sample limits the generalisability; thus, this research should be carried out again with a broader selection of nursing candidates and clinical settings. Moreover, the sample consists mostly of nurses with minimal experience compared with nurses in other international countries such as Canada, the UK and the USA. 5 The current study also included nurses in their 40s and above, with male nurses less represented, and this causes misunderstanding of the true clinical leadership in nursing.

Implications

For practice, our sample consists of nurses with minimal experience compared with nurses in other developed counties. Our sample reported ‘influencing organizational policy’ as the last clinical leadership skill, which reflects the very junior nature of the sample. Unlike our study, in their systematic review, Guibert-Lacasa and Vázquez-Calatayud 36 reported that the profiles of the care clinical nurses’ experience usually varied, ranging from recent graduates to senior nurses. If our nurses were more experienced, it might lead to different results. More nurses’ clinical experience would increase nurses’ abilities at the bedside, especially in areas related to reasoning and problem solving. 36 More experienced nurses tend to work collaboratively within the team with greater competency and autonomy. 36 More experienced nurses would provide high-quality care, 36 resulting in patient satisfaction. To generate positive outcomes of clinical nursing leadership, such early-career nurses should be qualified. Guibert-Lacasa and Vázquez-Calatayud 36 suggested using the nursing clinical leadership programme based on the American Organization for Nursing Leadership 34 competency model, pending the presence of organisational support for such an initiative. 36

‘Most’ important clinical nursing leadership attributes should be promoted at all organisational and clinical levels. Clinical nursing leadership’s ‘least’ important attributes should be defeated to achieve better outcomes. Clinical nursing leaders should use innovative interventions and have skills or actions conducive to a healthy work environment. These interventions include being approachable to enable their staff to cope with change, 28 using open and consistent communication, 28–30 being visible and consistently available as role models and mentors and taking risks. 28 Hospital administrators must help their clinical leaders, including nursing leaders, to effectively use their authority, responsibility and accountability; clinical leadership is not only about complying with the job description. A good intervention to start with to promote the culture of clinical leadership is setting an award for the ‘ideal nursing leaders’. This award will bring innovative attributes, skills and actions.

Moreover, as they are in the front line of communication, nurses and clinical nursing leaders should be involved in policy-related matters and committees. 49 An interventional programme that gives nurses more autonomy in making decisions is warranted. In turn, various patient, nurse and organisational outcomes will be improved. 13–17 32

The study’s findings revealed statistically significant differences in the skills and actions of effective clinical leaders, with female nurses scoring higher in many skills and actions. Hence, healthcare organisations must re-evaluate current leadership and staff development policies and prioritise professional development for nurses while also introducing new modes of evaluation and assessment that are explicitly geared at improving clinical leadership among nurses, particularly males.

For education, this study outlined clinical leadership attributes, skills and actions to understand clinical nursing leadership in Jordan better. Nevertheless, nurses and clinical leaders need additional attributes, skills and actions. Consequently, undergraduate nursing students might benefit from clinical leadership programmes integrated into the academic curriculum to teach them the fundamentals of clinical leadership. A master’s degree programme in ‘Clinical Nursing Leadership’ would prepare nurses for this pioneering role and today and tomorrow’s clinical nursing leaders. However, all nurses are clinical leaders regardless of their degrees and experience. Conducting presentations, convening meetings, overseeing organisational transformation and settling disagreements are common ways to hone these abilities.

For research purposes, it is worth exploring the concept of clinical leadership from a practice nurse’s perspective to provide insight into practice nurses’ feelings and perceptions. Thus, a longitudinal quantitative design or a phenomenological qualitative design might be adopted to assess the subjective experience of the nurses involved. It is better in future research to focus on both young and veteran clinical leaders; some of our nurses were aged 45 years and above, and those nurses may not be clinically focused.

Summary and conclusion

The current study put clinical leadership into the context of the healthcare system in Jordan. This study highlighted the role of gender in clinical nursing leadership. Nurses’ clinical leadership is a milestone for influencing innovation and change. The current study identified the ‘most’ and ‘least’ important attributes, skills and actions associated with clinical leadership. However, the male and female nurses found substantial differences in effective clinical nursing leadership skills and actions. This study is unique; little is known about the collective concepts of attributes, skills and actions necessary for clinical nursing leadership.

Nurses need leadership attributes, skills and actions to influence policy development and change in their work environments. Leadership attributes can help develop programmes that give nurses more autonomy in making decisions. As a result, nurses will be more active as clinical leaders.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

This study involves human participants and was approved by The Hashemite University, Jordan (IRB number: 1/1/2020/2021) on 18 October 2020. Participants gave informed consent to participate in the study before taking part.

Acknowledgments

The researchers thank the subjects who participated in the study, and Mrs Othman and Mr Sayaheen who collected the data.

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Original research article, sustainability of nursing leadership and its contributing factors in a developing economy: a study in mongolia.

• 1 School of Health Policy and Management, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
• 2 Department of International Relations, National University of Mongolia, Ulaanbaatar, Mongolia
• 3 Department of Healthcare Administration, Asia University, Taichung City, Taiwan
• 4 Fintech & Blockchain Research Center, Department of Finance, Asia University, Taichung City, Taiwan
• 5 Big Data Research Center, Department of Finance, Asia University, Taichung City, Taiwan
• 6 Department of Medical Research, China Medical University, Taichung City, Taiwan
• 7 Department of Economics and Finance, The Hang Seng University of Hong Kong, Shatin, Hong Kong SAR, China

The sustainability of nursing leadership is a very important problem. Every country continually strives to find the best ways to advance in nurse management and patient care services. Nursing leadership is most desirable in the delivery of health care services. Since there is limited information about leadership skills in Mongolia, to solve the problem of the sustainability of nursing leadership, we carried out this study to explore factors contributing to the sustainability of nursing leadership and their correlation relatively to nurse managers in healthcare institutions. A sample of 205 nurse managers from all forms of health facilities participated in this study. The data were analyzed by descriptive, correlation, and multiple linear regression models using SPSS 19 version. The linear combination of the five independent variables was significantly related to the dependent variable (nurse leadership). Both the behavior and problem-solving are significant regressors of the dependent variable. The correlation analysis significance of the independent study variables, two were found to have a significant effect on nursing leadership: behavior and performance of nurses significantly and positively effect nursing leadership. The transformational role and nurse leadership produced a significantly positive Correlation coefficients give a direction of causation in the relationships of variables, and the multiple linear regression analysis says that two of the variables, namely, behavior and problem-solving, positively contribute to nursing leadership, two of the variables namely, work environment and performance nurse manager do not support; however, variable transformational ability majorly contributes to the sustainability of nursing leadership.

Introduction

The sustainability of nursing leadership is a very important problem. Healthcare is one of the challenging industries that require complex demands, and needs successful recruitment strategies; however, it is quite difficult to select competent professionals and keep them for a longer period of time. As a growing segment of the population ages, each country strives to find the best way to improve its nursing management and patient care system. Nurses play an important role as doctors in the delivery of health care services. Due to the increased demand for nurse managers, the form of leadership is most desirable in the daily working environment of nurses ( 1 – 4 ).

Nurse managers engage in a range of leadership activities in their daily routine that some will naturally adopt an effective leadership style and provide higher leadership roles, while others may find the concept of leadership is difficult to understand or see themselves not so much competent. Nurse leaders should have rational thinking and exceptional communication skills that are measured by the positive influential ability to reach the goals of health care. The key role of nurse managers is to motivate their subordinates to be autonomous in making patient care decisions and perform safe patient care according to the standards of nursing practice ( 5 – 7 ).

Leadership is important in high-quality patient care and facilitating positive staff development in healthcare settings. Effective leadership significantly influences reducing turnover of nurses and increasing job satisfaction in the workplaces ( 8 , 9 ). According to literature, leaders should be able to work under pressure and take immediate actions to solve problems, and, at the same time, be both taught and learned in the work environment. Nevertheless, leaders must show emotional intelligence to manage their own and others' feelings. In addition, leaders must have a transformational role to influence their own and others' performances that impact problem-solving in the workplace ( 9 , 10 ).

Nowadays, the leadership role of nurses depends on rapid technological changes, communication style, information transparency, needs of patients, service quality, and compliance with regulations and standards ( 8 ). Besides, the nurse manager is a coach, while nurses provide high-quality patient service, stabilize workload and stress, and increase efficiency in the workplaces. Typically, the leadership of nurse managers is developed through specific educational activities by modeling and practicing competencies ( 11 ). Nevertheless, cultural differences influence nursing leadership, for instance, in Arabic countries, nurse managers have an integrative leadership role; in spite of it, in western countries, nurse managers prefer to be decentralized ( 12 , 13 ).

With the notable shift in the healthcare needs of global populations, healthcare institutions across the world face enormous challenges to be more responsive and efficient, a responsibility that cannot be met without ensuring good quality of nursing care. Yet, due to inconsistent economic development, the quality of nursing varies significantly from country to country. In developing countries, such as Mongolia, nurses work, often under difficult circumstances, in health services that are grossly underfunded and are a vailable only to those who can pay ( 14 ).

Over the last decades, the health care industry in Mongolia has faced a series of problems, such as low quality in care provision, human resources scarcity, inadequate training, and insufficient ongoing education for nurses and nursing leadership, as well as poor working environments. In spite of that, nurses work hard to facilitate their resources to their job without considering the environment.

In brief, Mongolia is a landlocked developing country, which is between China and Russia, with a population of 3 million, the majority of which live in the capital city. As of 2020, the life expectancy in Mongolia was 69.9 years. By 2012, there were 9,916 registered nurses (see Table 1 ), while this number increased to 10,948 in 2016 ( 4 , 15 , 16 ).

Table 1 . Number of hospital and nurses.

Studies discuss that insufficiency in autocratic nursing leadership is common within hospital settings of Mongolia, which is the main problem of this study ( 8 ). According to the literature, the common factors that have a positive effect on nursing leadership are work environment, performance, behavior, problem-solving, and transformational role ( 18 ), which are discussed in section Literature Review and Research Hypotheses more in detail. Thus, the purpose of this study is to explore factors that affect nursing leadership in healthcare institutions of Mongolia. We hope that this study will also serve as a catalyst for further exploration of influencing factors on leadership in developing countries. This study provides instruments in helping hospital administrators to meet the needs of long–term employment of nurses in their organizations. A greater understanding of nurse leadership changes people's minds and functions and increases healthcare quality and patient care services in hospitals of Mongolia. This study has a critical implication on Government policies and regulations on how to develop nurse managers in healthcare settings around the country.

The remainder of the paper is organized as follows. Section Literature Review and Research Hypotheses reviews relevant literature and describes the hypotheses to test. Section Methods presents the methodology. Empirical results are reported in section Data Analysis, while section Conclusions and Discussions presents the conclusions of the paper.

Literature Review and Research Hypotheses

The theoretical foundation of this study is based on leadership theory, management theory, and psychological theory of nurse managers that influence the activities and competence of an individual or a group in efforts to have goals of achievement in a given situation. Leadership theory says that some people are born to be leaders, while, according to management theory, leadership is a position and a skill that can be earned and developed through years of experience ( 11 , 19 ). According to the psychological theory, naturally, women have lower aggressiveness that restrains women from leadership positions. Nevertheless, gender plays an important role in the nursing profession and remained predominantly female ( 20 , 21 ).

There are a number of definitions and typologies for the leadership role of nurse managers. The majority of studies used the theoretical framework of Hersey and Blanchard's Situational Leadership Model, Kouzes and Posner's Leadership Challenge, Burns' Transformational Leadership, Bass and Avolio's Transformational and Transactional Leadership, McLelland's Theory of Leadership Motivation ( 22 ). They found 20 factors that affect the leadership role and categorized the factors into four groups: [1] behaviors and practices; [2] traits and characteristics; [3] context and practice settings; and [4] educational activities.

Other scholars described nurse roles functions as an independent role function, a dependent role function, and an interdependent role function ( 23 ), which are similar to the classification of managerial theory ( 18 ) as classified into three major roles: [1] interpersonal, derived from authority and status including the role's figurehead, leader, liaison; [2] informational, derived from interpersonal roles, including the role's monitor, disseminator, and spokesman, and [3] decisional, derived from a manager's information, including the roles of entrepreneurs, disturbance handlers, resource allocators, and negotiators.

As stated in the research of Ramey ( 5 ), the leadership role prevents turnover and promotes retention, which is economically important for hospitals and healthcare institutions. Koy et al. ( 9 ) found that nursing leadership plays an important role in nursing managers' job satisfaction, organizational commitment, and workplace empowerment.

Thus, this study makes a general proposition (see Figure 1 ) that factors, such as work environment, performance, behavior, problem-solving, and transformational role, affect positively nursing leadership.

Figure 1 . Theoretical framework.

Work Environment

A nurse's role in the workplace encompasses illness prevention and care, health promotion and disabilities and palliative care, whereas a leader's role of nurses in the workplaces is to create a conducive work environment ( 23 – 25 ). Nurses are required to work overtime, and extra shifts are creating a stressful work environment. Therefore, nurse managers aim at maximizing nursing productivity and minimizing the direct and indirect costs of overtime work. Nursing has an important impact on hospital costs and the rational use of resources and reduced waste that reduce delivery of care cost and enable larger investment in quality ( 3 , 11 , 26 ).

Rajbhandary and Basu ( 3 ) identified that improving the work environment has to be identified as one retention strategy, so it is important to identify mechanisms to retain nurses and increase nurse satisfaction while improving the work environment and working conditions. In the healthcare system, a healthy work environment should be created for the appropriate nursing staff level. Nurse managers experience severe psychological stress and a heavy burden at work, which could have conflict in the work environment. A stressful work environment would likely constitute less autonomy, less control, and a lack of respect. Moreover, they create a safe environment for effective management of the conflict to stimulate personal growth and ensure quality patient care ( 9 , 12 , 20 , 24 ).

Many researchers used the Revised Nursing Work Index (NWI –R) and Environment Scale of the Nursing Work index (PES-NWI) to measure factors in the work environment to support professional nursing practice, and explored that leader's role is a critical factor in the work environment ( 27 ). Clinical leaders foster a supportive work environment to empower their subordinate nurses in management positions ( 9 ). A positive leadership role encourages nurses in managerial positions to involve in a common organizational commitment that contributes to an optimal work environment ( 9 , 28 ).

Casida ( 6 ) found that the leadership role of nurse managers is directly influenced by the nursing unit and organizational culture that is responsive to the external and internal perspectives forward to the hospital goals and vision. A positive work environment does not naturally occur, instead created and fostered by strong nurse leaders their visibility, accessibility, consultation, recognition, and support ( 27 ). Thus, the following hypothesis is set to test whether the work environment is positively related to nursing leadership:

Hypothesis 1: Work environment is positively related to nursing leadership.

Performance

The performance of a nurse in a healthcare institution is an interaction between people to work together and help the patients, thereby reducing the power imbalance between the patient and the physician and creating dependency on the part of the patients. Nursing performance is critical to the management of a nursing ward and closely tied to role enhancement of nurse managers and job satisfaction ( 11 , 26 , 29 ).

Health care organizations, including nurse care departments face formidable challenges in improving nurse performance, which is the fundamental aspect to successfully excel in many organizational elements and effectively enhance health care quality to patients. Nurse managers with high performance successfully achieve their responsibility in an organization and have a positive influence on nursing leadership; however, nurse managers with weak performance spent considerable energy, articulating the importance of nursing to the organization ( 9 , 21 , 30 ).

Hypothesis 2: Performance is positively related to nursing leadership.

Koy et al. ( 9 ) state that demand for care is skyrocketing, and supply for a caregiver is plummeting that behavioral component is essential for nurse managers. Nursing intervention is defined as assisting a patient, significant others, and/or family to improve relationships by clarifying and supplementing specific role behaviors. Some researchers argue that a behavior element has a positive effect on the nurse manager's role based on the leader-member exchange theory. The behavior of nurse managers is most important in staff nurse satisfaction, engaging nurses in the work environment ( 27 ).

According to Nilsson et al. ( 25 ), role modeling of leadership behaviors by managers, clinical nurse specialists, and other colleagues is developed through a nurse leadership program. Theories of leadership also emphasize positive behaviors are the essential part for leaders. The development of leadership expertise has been described as a process of developing competencies and behaviors over time through education, preceptorship, and mentoring. Supportive interpersonal behavior at work is an important dimension of a nurse manager ( 11 ) that managerial support is directly impacted by the attitude and behaviors of the nurse leaders.

Several studies ( 29 ) used the Collaborative Behavior Scale created by Stichler ( 31 ) to determine the extent of collaboration behaviors that generally exist between nurses and nurse managers. Results of their study show that positive behavior influences positively the leadership role and favorable work environment. They conclude that bad behavior increases workload, turnover, lack of responsibility. Furthermore, the authors suggest that hospital management should stimulate the autonomy of the nurse managers by creating an environment in which career opportunities are clearly delineated in terms of behavior.

In reality, nurses exhibit diverse behaviors, and most of the nurses do not engage in effective conflict resolution, sharing ideas, understanding each other, and communication about what needs to be done for the patient. Therefore, we developed the third hypothesis to examine whether the behavior is positively related to nursing leadership:

Hypothesis 3: Behavior is positively related to nursing leadership.

Problem-Solving

Problem-solving ability is one of the most important attributes for nurse managers to promote team integration to achieve maximum efficiency. Furukawa and Cunha ( 8 ) argue that, in nursing, problem-solving within teamwork emerged in the 1950s in the USA through experience and a solution to the issue of better use of personnel, as leaders develop and learn new skills and they demonstrate and use these skills in practice while setting teamwork as well as teaching others ( 9 , 22 , 24 ).

According to Aiken et al. ( 7 ), nursing leadership and problem-solving between groups increased significantly following an intervention and communication. Nurses' daily responsibilities are demonstrated by a critical path, a clinical path, or a care path that is an example of how problem-solving is weaved. To improve clinical problem-solving performance then, it would seem fruitful that nurses should be encouraged to develop a strong nursing leadership and well-structured knowledge base in the context of their discipline.

Hospitals do not provide education regarding problem-solving; thus, nurse managers shall have their own ability to solve a problem. Moreover, the nursing department or unit may develop its own module for nurses. Thus, this study postulates the following proposition to test whether problem-solving has a positive effect on nursing leadership:

Hypothesis 4: Problem-solving ability is positively related to nursing leadership.

Transformational Role

One of the main roles of a nurse manager is to motivate followers and value specified and idealized goals, which are determined by the transformational role. A number of studies used the Leadership Practice Inventory approach to measure nurse managers in perception of leadership abilities to deemphasize that extraordinary nursing leadership composes of transformational roles. Using the method, Krugman and Smith ( 32 ) compared outcomes between two units: one with transformational leadership and the other one with conventional management. Their finding shows that nurses with transformational roles have a high rate to be nurse leaders, respected within an institution by departments and physicians.

Registered Nurses' Association ( 33 ) reports that support from colleagues with transformational qualities is important for nurse leaders. A transformational leadership ability of individuals broadens and motivates both parties to achieve greater levels of achievement, thereby transforming the work environment; moreover, it could be a great way to generate an optimum decision.

Highly and moderately relevant transformational roles are common among experienced nurses, while low and moderately relevant interpretations were more evident among young or non -experienced nurses ( 25 ). Researchers found that the transformational role of nurse managers is positively related to empowerment, and transformational leaders have a clear vision for the future and values in an ongoing dialogue with nurses. Nurse managers empower subordinates by motivating them to share in the vision and make it a reality; thus, they should have a transformational role to some extent. Consequently, the following hypothesis is set to examine whether the transformational role has a positive impact on nursing leadership:

Hypothesis 5: The transformational role is positively related to nursing leadership.

Nursing Leadership

It is evident that leadership in nursing is of supreme importance at this time. The managerial career and nursing leadership are frequently seen as an award, an acknowledgment of a nurse's contribution to an organization and patient care services ( 8 ). Casida ( 6 ) discusses that a competitive leadership role is crucial for patient satisfaction and must be the survival of any healthcare facility that remains a priority of nurse managers. Nurse managers find themselves facing a challenging global nursing shortage—that the need for health care grows rapidly worldwide.

There are a variety of standards applicable to the practice of nursing leadership. The standards are based on the values of the profession, work environment, nursing actions, and interventions that a nurse implements to achieve desired outcomes in a particular hospital setting. Despite it, the hospital size is considered to be a fundamental feature with important implications for nursing leadership in hospital settings. Furthermore, nursing leadership is higher in bigger hospitals than in small ones ( 10 ).

Generally, it is acknowledged that one learns to be a leader by serving as a leader. One is a leader when he or she exercises leadership. Nurses progress throughout their careers as they face new challenges and conflicts in the workplaces. The establishment of criteria for the selection of nurse managers depends not only on years of experience but also on personality and management skills ( 4 , 9 , 12 ).

Nurse managers with positive leadership effects have their own self-interest for a higher purpose and stimulate followers, while those with negative leadership effects avoid leadership responsibilities and take action when issues become serious. When positive nursing leadership exists within nurse managers, patient satisfaction tends to be high, while turnover of nurse staff becomes low. Nevertheless, leadership policy shall be formulated by the human resources department, involving all management levels.

To solve the problem of the sustainability of nursing leadership, the purpose of this study was to examine the relationship between nursing leadership and contributing factors to it, such as work environment, performance, behavior, problem-solving, and transformational role. We used a multifactor questionnaire survey method to collect data. This study has a descriptive and predictive design. Thus, the empirical data examination procedure consists of descriptive statistics, correlation, and multiple linear regression analysis.

Sample and Design

During the study period, a total of 9,916 nurses worked in 2,881 health care settings of Mongolia, of whom 406 were registered nurse managers having worked as nurse managers for at least 1 year ( 17 ). On average, a nurse manager supervises 24 nurses. To design the sample, the first step consisted of listing all level health care institutions in Mongolia. These comprised 492 primary-level health care institutions, 28 secondary-level health care institutions, 21 tertiary-level health care institutions, and 2,340 other health care institutions, representing 128, 83, 79, and 116 nurse managers, respectively. Since the target population, 406, is not large, we purposively distributed the coded questionnaire to all nurse managers.

Questionnaires were distributed to the nurse managers of each participating hospital. The response rate achieved in this study was relatively high. All analyses were conducted at the 0.05 significance level. The participants were informed that the findings of this study may not benefit them directly, but, by being part of this study, they contribute to a better understanding of nurse leadership, patient care, and hospital structure of the Mongolian healthcare system. A copy of the summary of findings from the study was submitted to the Ministry of Health of Mongolia for a further policy implication. The coded questionnaire was taken from 205 nurse managers as over 50.4% of the total nurse managers in Mongolia in various hospitals of Ulaanbaatar and provinces. SPSS version 19 was used in data analysis.

The following procedures were employed to study the relationship between the dependent variable, nursing leadership, and the independent variables, including work environment, performance, behavior, problem-solving, and the transformational role. In each hospital, the head of nursing distributed the questionnaires to their nurse managers, and, when completed, they were collected from the nursing unit. The questionnaires were given to their home to respond with their convenience and returned a week later through the head or director nurses.

The response rate achieved in this study was comparatively good in comparison with other studies on nurse managers and leaders. Data collection that started in June 2013 was completed by September 2013. Basic demographic information about gender, age, education level, position level, and years of experience was added to the survey tool for all the participants to investigate how the demographics affect nursing leadership.

Study permission was obtained from seven hospital directors. All the participants had signed on the consent form prior to data collection and their rights to privacy and confidentiality.

The following are the seven parts of the survey questionnaire (see Appendix A ).

1. Demographics include gender, age, education, position, and years of experience.

2. Fundamental features include organizational structure, basic knowledge of “leadership” and policy of particular hospital settings.

3. Work environment represents how nurse manager environment allows making autonomous nursing care decisions to suit patient needs that impact nursing leadership.

4. Performance represents how a nurse manager assesses nurse performance, how to decide to provide training sessions to teach new nursing technologies, develop new medical techniques, improve performance, anticipate and prevent misunderstanding/conflicts, redefine goals, consolidate teamwork for effective nurse leadership.

5. Behavior—how nurse managers enact the behaviors that convey support to staff and impact nursing leadership.

6. Problem-solving—how nurse managers effectively solve problems to be able to decrease the cost of health care and to increase the quality of patient care, and

7. Transformational role—how nurse managers adapt innovativeness of their approaches to the work and impact nursing leadership.

The five factors significantly contribute to nursing leadership that tested for the build, convergent, and distinguishable validity. The questionnaire consisted of a series of items with a five-point Likert scale (5 = strongly agree,…, 1 = strongly disagree) that reflects five factors of nursing leadership.

Fundamental features include the level of hospital size as to whether primary, secondary, tertiary, or other types of healthcare institutions. A few questions were asked from the participants to know nurses' knowledge about leadership and how hospital policy influences career development and nurse leadership. These fundamental questions are to identify an area of focus of nurses, hospitals, and to determine an area that needs attention to strengthen the effectiveness of leadership in the future.

Operational Definitions

• Behavior of leadership is the ability to think critically, ability to solve problems, have respect for people, communicate skillfully, have the tendency to set goals, share vision, and have development of self and others ( 9 ).

• A healthcare institution is any hospital, convalescent hospital, health maintenance organization, health clinic, nursing home, extended care facility, or other institution devoted to the care of a sick, infirm, or aged person ( 18 ).

• Leadership is the position or function that organizes and guides a group of people to achieve a common goal and may or may not have any formal authority. The leadership role is building tolerance for ambiguity, setting performance standards for confidence, and holding subordinates accountable to those standards ( 18 ).

• Nurse is the protection, promotion, and optimization of health and abilities; prevention of illness and injury alleviation of suffering through the diagnosis and treatment of human responses and advocacy in health care for individuals, families, communities, and populations ( 33 ).

• A nurse manager is the nurse with management responsibilities of a nursing unit and requires strong leadership ability, clinical nursing knowledge, and decision–making within organizations employing nurses. The nurse manager does planning, organizing, staffing, directing, and controlling. The nurse manager is a middle manager who has 24-h responsibility for one or more hospitals or clinic units, regardless of the title assigned to that position. This position includes direct supervision of charge and staff nurses on all shifts and accountability for those positions [( 4 )].

• Performance is the accomplishment of a given task measured against preset known standards of accuracy, completeness, cost, and speed, which is the process of creating a work environment to enable perform best of the nurses' abilities [( 25 )].

• A problem solver is able to do direct and indirect interventions, delegation, purposeful inaction, consultation, and collaboration with others ( 4 ).

• A transformational role is “Four I's” as an idealized influence, inspirational motivation, intellectual stimulation, and individualized consideration ( 14 ).

• Work environment includes the surroundings, and conditions of influences that affected performance, role enhancement, and professional relationship in the short and long terms ( 21 ).

Data Analysis

This section presents the demographics, analysis on fundamental features, correlation analysis, and multiple linear regression analysis.

Demographics

This part is about participant demographics. Demographics include gender, age, education, work experience, and position with effects on both nurse retention and nursing leadership. First, descriptive statistics are used to describe the demographics of nurse managers.

Table 2 shows that 96% of the participants were female and only 9 male nurse managers. The data mean that nursing positions are dominated by the female group, which influences the leadership position as stated gender plays an important role in the nursing profession and remained predominantly female.

Table 2 . Gender of participants.

Table 3 shows that 42% of the sample was aged 41–50 years old, 37.6% of them were 31–40 years old, 11.3% of the participants were 20–30 years old, and 9.3% of them were aged 51–60 years old, respectively.

Table 3 . Age of the participants.

These data show that the majority of nurse managers aged between 31 and 50, which were able to gain work experience, the transition of knowledge, and clinical “know-how” from one generation of nurses to another, are imperative for nurse managers. Nurses with <1 year in the profession are more likely to quit their jobs. Nursing leadership makes older nurses stay in the workforce as long as they want by making a simple adjustment to the work environment.

Table 4 shows that 59.5% of the respondents have an associate diploma education, 40% of participants have a bachelor's degree, and only one nurse has a master's degree. All the nurses were graduated in Mongolia.

Table 4 . Education of participants.

Nursing education and the profession have a paralleled opportunity in today's health care system. Unfortunately, the current nursing education is not adequate to meet the needs of the future. Education must develop new partnerships with the community and healthcare institutions. More emphasis and resources must be directed to preparing bachelor's- and master's-level nurses that effective nursing leadership is grounded in the education of nurses in order to achieve successful outcomes.

Table 5 shows that 57% of the nurses are head nurses, 26% of them are registered nurses, about 10% of them are methodologist nurses, and around 6% of the participants are chief nurses.

Table 5 . Position of participants.

Leadership myth is associated with the position. Moreover, the values of leadership involve occupying the top position in a hierarchy. A nurse manager is general terminology and divided into several positions, such as a director nurse of the nurse department; head nurses are senior nurses in a nurse unit or nurse department, and methodologist nurses are trainers of nurse staffs, who are supervised by the director of hospital settings, respectively. Nurses are former nurse managers; however, they currently hold the position of a nurse.

Table 6 shows that approximately 43% of the participants have 21–30 years of work experience, around 33% of them have 11–20 years of work experience, 16.6% of them have 0–10 years of work experience, and 7.8% of them have 31–40 years of work experiences. Data support the relationship between characteristics of the nurse manager workforce and the nurse leadership, which means nurses with longer work experiences are significantly more satisfied than their less-experienced colleagues with most of the facets of their work ( 34 ).

Table 6 . Years of experience of the participants.

Our data show that between 11 and 30 years of work experience affects nurse managers' positions. Nurses with <10 years of work experience or more than 30 years of work experience do not hold a nurse manager position.

Analysis of Fundamental Features

The study took place at public and private hospitals in the capital city, Ulaanbaatar, and other provinces of Mongolia. The nursing population was diverse, including large hospitals and small healthcare settings. Fifty-one nurse managers are from primary-level hospitals as 24.9% of total participants, 72 nurse managers are from secondary-level hospitals as 35.1% of the total participants and 40 nurse managers are from tertiary hospitals as 19.5% of the total participants, and 42 nurse managers are from other healthcare institutions as 20.5% of the total participants.

The primary hospitals require having 4–20 nurse staff, and one head nurse supervises other nurses, but it does not have a director nurse or a methodologist nurse. Every secondary and tertiary hospital must have a nurse department consisting of one nurse director, two to five methodologist nurses, and around 20 heads in order to manage 250 nurse staff. Other hospital settings, such as healthcare departments in 21 provinces and Ulaanbaatar city, must have at least one nurse manager, either in the position of a director nurse or head nurse.

In addition, we investigated whether nurse managers have knowledge about “leadership”; hence, first questions were “Do you know the word “Leadership?” About 157 nurse managers or 76.58% of the total participants know about it; unfortunately, 48 nurse managers or 23.41% of the total participants do not know about the term “leadership.”

Also, some policy-related questions were asked and analyzed as follows. First, “Do hospital policies and procedures have to support the leadership of nurse managers?” About 118 nurse managers or 57.5% of the total participants answered “Yes,” 38 or 18.5% answered “No,” and 49 nurse managers or 23.9% gave an answer of “Do not know.” Second, “Does a nurse manager influence mission and decision-making of general administration issues of the organization?” About 161 nurse managers or 78% of the total participants answered “Yes,” 33 or 16% answered “No,” and 11 nurse managers or 5.3% gave an answer of “Do not know.” Third, “What level of leadership responsibility does nurse manager need?” About 161 nurse managers or 78.5% said “High,” 33 nurse managers or 16% said “Medium,” and 11 nurse managers or 5.5% of the total participants said “Low.”

These fundamental questions are considered to know nurse managers' complaints and suggestions about leadership in the nursing department and hospital settings. Managers who talk to their staff on a regular basis are more informed and have less difficulty when situations occur and increase job satisfaction of nurses, furthermore effects to nursing leadership. Nurses should participate in the policy arena and the decision-making procedure and be engaged in health care reform-related implementation efforts. Increasing the involvement of nurses in high-level leadership contributes to a more stable workforce and, in turn, positively impacts patient quality and safety and transparency and accountability of hospital settings structure.

Correlation Analysis

The relationship between the dependent variable as nursing leadership and five independent variables as work environment, performance, behavior, problem-solving, and transformational role was examined using correlation analysis. Significance was tested at the alpha = 0.05 level. Correlation studies are appropriate when there is a need to clarify the relationship, and little or no previous research has been undertaken. Possible relationships were examined using Pearson correlation coefficients shown in Table 7 .

Table 7 . Pearson correlation.

In terms of the independent study variables, two were found to have a significant effect on nursing leadership: behavior and performance of nurses significantly ( p < 0.05) to nursing leadership positively. The transformational role moderately ( p < 0.05) intercorrelated with nursing leadership. However, the work environment and performance were found not to be strongly related to nursing leadership when entered with the other independent variables.

Table 7 shows the results of a Pearson correlation coefficients; nurse leadership ( n = 205), informed that there was a strong correlation r (205) = 0.90, p = 0.000 between the behavior and nurse leadership and r = 0.36, p = 0.000 between problem-solving and nurse leadership. Also, the transformational role and nurse leadership produced a positive correlation r = 0.159, p = 0.023. However, there is no relationship between performance and nurse leadership r = 0.092, p = 0.189, and between work environment and nurse leadership r = 0.047, p = 0.505.

The results suggested that successful nurse leadership is based on behavior and problem-solving. This opens the floodgates to nurse leadership development, as opposed to simple psychometric assessment that sorts those with leadership potential from those who will never have the chance. Leaders must be taught how to adapt and change constantly to keep up. Also, problem-solving is the most crucial and common thinking process used in nursing that requires various mind actions. This enables them to more accurately represent the nature of the clinical problem and to deal with the problem less in sequential terms in order to override clinical concepts. Thus, the findings support Hypotheses 3 and 4.

The majority of nurse managers are female, and the female leaders scored higher than the male leaders on all transformational roles, because it provides them with a means of overcoming the dilemma of the role and ability to meet the requirement of their leadership role. Therefore, this study supports Hypothesis 5 that the transformational role positively affects nursing leadership.

The work environment and performance are outcome variables that are determined to be mediated by the workload of nurses ( 3 ); however, the findings of this study do not support Hypotheses 1 and 2 that variables significantly low contributes to nursing leadership at the hospital level. These results show that, in Mongolia, nursing leadership is strongly correlated with behavior, problem-solving, and transformational roles, and nurses' performances and work environment must be improved to create a professional practice environment for nurse managers.

Multiple Linear Regression Analysis

Inferential statistics, including R-square, regression, and multiple linear regression analysis, are used to test the validity of the set hypotheses. Multiple linear regression analysis determines whether nurse leadership perceives work environment, performance, behavior, problem-solving, and transformational role. The linear combination of the five independent variables was significantly related to the dependent variable (nurse leadership), R squared = 0.83, adjusted R squared = 0.83, or 83% of the total variance in the dependent variable.

Table 8 contains the ANOVA and shows the factors that contribute to nursing leadership. The analysis shows that there is a difference with an F score of 5, 199 = 204.81 and significance (0.000) well-beyond the alpha < 0.05 standard.

Table 8 . Multiple linear regressions for a single set of predictors: a model summary.

The multiple linear regression analyses showed that behavior and problem-solving positively contribute to nursing leadership. But work environment, performance, and transformational roles do not contribute to nursing leadership. The level of statistical significance was set a priori at = 0.05. Table 9 shows that the model analysis included the five independent variables of the work environment, performance, behavior, problem-solving and transformational ability. The behavior ( t = 29.058, p < 0.05) and problem-solving ( t = 4.693, p < 0.05) are emerged as a significant coefficient of the dependent variable. No other variables in the model were significant.

Table 9 . Multiple linear regressions for a single set of predictors: coefficients.

There is, therefore, a need to develop a work environment in a hospital setting and enhance performance and encourage transformational roles in order to strengthen the effectiveness of nursing leadership.

The results from the regression equation for the standardized variables were as follows: Predicted work environment score = 0.006 + (−0.104) (performance) + 1.017 (behavior) + 0.155 (problem solvency) + 0.025 (transformational ability) ( Table 9 ). The findings provide support for the hypotheses (H3 and H4). These findings answer Research Questions 1 and 2 positively. The 0.000 significance level is less than the level of significance for the test of (0.05). However, the findings do not support Hypotheses 1 and 2, and weak support Hypothesis 5. Behavior was determined to be the strongest predictor of the five variables, and work environment was the weakest predictor of nursing leadership.

Nurse managers must have positive behavior and capable problem-solvers because their profession requires a high level of cognitive reasoning and discretionary decision-making that supports Hypotheses 3 and 4 as behavior and problem-solving contribute to nursing leadership. The transformational role is more focused on processes that motivate followers to perform to their full potential by influencing change and providing a sense of direction for nurse managers. Therefore, this study found that the transformational role slightly contributes to the nursing leadership as finding supports Hypothesis 5.

Minimizing nurse staff workload and enhancing nurse staff job satisfaction should be consistent with retaining nurse leaders in the profession. Unfortunately, this study does not support Hypothesis 1 that the work environment does not contribute to nursing leadership. The nurse manager must assess and improve nurse staff's performance, decide to provide training sessions to teach nursing technologies, and consolidate teamwork. But this study does not support Hypothesis 2 that performance does not contribute to nursing leadership.

Conclusions and Discussions

To solve the problem of the sustainability of nursing leadership, the purpose of this study is to examine the factors that contribute to nurse leadership in hospital settings in Mongolia. This section discusses the findings in relation to the theoretical framework, stated limitations, and presented suggestions and concluding remarks on the further implication of research.

This study is the first research in the literature to assess nursing leadership in Mongolia. Correlation coefficients give the direction of causation in the relationships of variables. According to the results of multiple linear regression analysis, two of the variables, namely, behavior and problem-solving, have strong positive influence on nursing leadership. Nonetheless, work environment and the transformational role do not have significant impact on nursing leadership. Finally, performance has a weak significant influence on nursing leadership.

This study is essential to develop nursing practice, increase the reputation of nurses, and motivate nurses to work in hospital settings for independent decision-making of patient care. Leadership is an observable, learnable set of practices with the desire and persistence to lead—to make difference—that can substantially improve nurse abilities.

The realities of a global society, expanding technologies, and an increasingly diverse population require nurses to master complex information, to coordinate a variety of care experiences, to use technology for health care delivery and evaluation of nursing outcomes, and to assist clients with managing an increasingly complex system of care, which wholly requires to have nursing leadership.

Nursing leadership promotes harmonious interaction between persons and their environment, strengthens the wholeness of an individual, and redirects human and environmental patterns or organization to achieve maximum health. The nursing leadership congress is designed to help nurses become catalysts, and it provides an opportunity to share practical experiences in solving many problems in the health care industry. It focuses mainly on practical experience rather than a theoretical approach. By postulating new factors and relationships and confirming the relevance of leadership factors and their relationships, the study has opened up new horizons for other researchers to investigate more deeply and precisely.

Whereas correlation coefficients give the direction of causation in the relationships of variables, the multiple linear regression analysis attempts to explore the relationship between independent and dependent variables. Hypothesis tests were performed to answer the following research question as “How do specific factors (work environment, performance, behavior, problem-solving and transformational role) contribute to nursing leadership in Mongolia?”

The finding of this study says that two of the variables, namely, behavior and problem-solving, positively contribute to nursing leadership and nurses' perceptions of their leader's effectiveness. This means that this study supports two out of the five hypotheses and does not support three hypotheses. The results suggest that an individual behavior and characteristics (problem-solving ability and the transformational role) strongly reflect leadership. In contrast, the reflection of external variables depends on the profession and specialty, as nurses have a high workload; therefore, work environment and performance do not contribute to the nursing leadership.

The nurse department consists of nurses with different types of behaviors, but individual behavior affects the outcome of the nurse leadership. Registered Nurses' Association ( 33 )'s guideline states that the individual behavior of a leader is important, but, also, the culture, climate, and values of organizations are essential to building the behavior of an individual. Since nursing research is not common in Mongolia, it is necessary to explore the way how behavior influences nursing leadership and, in turn, how the behavior of the nurse leadership influences the organizational outcome.

What Are the Multiple Correlations Between the Predictors (Work Environment, Performance, Behavior, Problem-Solving, and Transformational Ability) and the Nursing Leadership?

The multiple regression performed in this study indicated 83% of the variance in nursing leadership was accounted for by the linear combinations of work environment, performance, behavior, problem-solving, and the transformational role. Therefore, it is important to explore variable factors to impact nursing leadership in hospital settings in Mongolia.

The results in this study revealed a positive correlation existed between the dependent variable, nursing leadership, and three independent variables, behavior, problem-solving, and the transformational role. Behavior reflected the strongest correlation, followed by perceived problem-solving and the transformational role of nursing leadership. This means that nurse leaders should accurately anticipate and prevent misunderstanding and conflicts, redefine the goals of nurse managers, develop new medical techniques, and facilitate desirable strategic decision-making.

Registered Nurses' Association ( 33 ) identified that there is a growing understanding of the relationship between nurses' work environment, patients' outcomes, and healthcare institutions' performances. However, our study did not confirm that the work environment influences nurse leadership. Moreover, there is some research on the direct impact of the work environment on developing and sustaining nursing leadership. Nurse manager turnover is usually associated with a range of negative outcomes, including training new nurses, increased workload, and the salary range.

This research suggests that gender roles are higher from their management identity as nurse managers in hospital settings. For those who evaluate the competence and effectiveness of nursing leadership in hospital settings that are mostly female, the data suggest that females may be more effective leaders since females are more likely to practice a transformational role. This is a very important implication in order to develop a policy framework for health care settings.

Why Do We Need to Study Factors Contributing to the Sustainability of Nursing Leadership?

When we know the factors that contribute to nursing leadership, healthcare institutions are able to develop leadership styles among nurses in the nursing department. The study increases the effectiveness of current nurse managers and guides the identification of future nurse leaders.

Currently, in Mongolian hospitals, almost more than 50 percent of nurse managers' performances spent for administrative work include making a list of all the prescription drugs, counting the number of beds and linens in a hospital, and monitoring shift change of nurse staffs. Therefore, very few percentages of performances are spent on hospital care. Thus, performance was not contributed to the nurse leader in the Mongolian case. In the future, it must change the nurse manager's role that enables high performance for quality care of patients and hospital care.

Moreover, nurse managers experience a higher workload than ever before due to several reasons, although the work environment does not support nurse leadership. The reasons are, first, hospitals do not have online patient registration; therefore, the nurse managers fill out all registration forms by hand, and, hence, they spend most of their working hours in the workplace. Second, there is no consolidated database of nurse performance within hospitals, compared to the physicians. For instance, hospitals have an integrated database for all physicians; however, neither nurse managers nor nurses have an integrated database. Third, the high workload of nurse managers does not allow training other nurse staff due to shortage of time. Finally, there is a lack of technology, including the internet environment and patient care resources.

The specialty nursing expertise is generally obtained on the job, also through nursing programs to attract new graduate nurses and motivate them further in nursing leadership. In Mongolia, around 1,000 nurses graduate from the National Medical University and its three branches, and private three universities per year. Nursing leadership programs must be offered through undergraduate and graduate education in formal and informal ways. Unfortunately, currently, nursing leadership programs are offered neither by universities nor hospitals. High school graduates are less likely to major by the nurse due to low reputation and low career development. Moreover, promoting higher education to nurses of all educational levels is critical to developing nurse leadership in hospital settings. Hence, another main reason that why the work environment and performance of nurse managers do not support our hypotheses.

How Does Nurses' Role Function Transfer to a Leadership Role in the Hospital Care Delivery System?

Nurse managers' autonomy over decisions affects the work at the unit level, patient care services, and health care institutions' commitment. When nurse leadership is high among nurses, nurse managers feel empowered and influential not only in their current role but also regarding impacts on nursing staff.

Leadership is rewarding and important for building succession, and it is a significant level of commitment to a job ( 18 ). But, in the Mongolian case, it is controversial as nurses are at the same level as kindergarten teachers and elementary school teachers; unfortunately, their salary range is lower than theirs. A nurse manager earns only one percent higher salary than nurses; however, less-experienced nurse managers have the same salary range as nurses. Therefore, the performances of nurse managers that are weak, do not motivate them to be leaders. In the last few years, the education level of nurse managers has been increased, and almost 50 percent of nurses have a bachelor's degree. However, the higher education level does not increase salary.

Promotion is not common among nurse managers and nurses that raise a negative impact to nurse performance and nurse leadership. The performance assessment is not clear in hospital settings. The nurse service quality is far away from the international standards; therefore, patients have more complaints on nurse performance, which directly affects nursing leadership. Quality of care is based on confidence and competence, which nurse leaders need support now more than ever.

Physicians and doctors do not recognize the nurse leadership role in patient care service and do not have the legal environment to support the nurse manager's performance and work environment.

Is Nursing Leadership Essential for a Hospital? If Yes, How?

The nurse staff is working longer hours and taking an increased patient assignment. Moreover, job satisfaction highly reflects nurse turnover. Therefore, involving nurse staff at a high level in policy and procedure development will score high on the retention scale and motivate nurse leadership among nurse managers in hospital settings. Moreover, strengthening nursing leadership is particularly critical not only in nursing and medicine but also in society.

Head nurses and director nurses include the members of management of a hospital; indeed, they must be involved in decision-making for patient care and policy development of an organizational structure. Unfortunately, nurse managers have a weak nurse leadership role, which cannot reflect strong policy development in a whole organizational setting.

Overall, these results suggest an important role of nurse leadership in strengthening hospital development and patient care services in hospital settings. The nursing unit must set behavioral standards, problem-solving approaches, and transformational roles among nurses that most positively influence the nursing leadership. On the other hand, the external variables, as work environment and performance, have to reflect the demanding role of today's nurse managers at the surface level of a hospital.

Limitations

The data were gathered using a self-report questionnaire, like the majority of earlier studies, and no objective measures were used. Self-report data might be contaminated by common method variance because five independent variables and dependent variables are based upon one source of information. Nevertheless, this study has stated that leadership has a strong and positive impact regardless of whether outcomes are measured subjectively or objectively.

Future studies need to identify the work environment and performance of nurses in the hospital settings in regard to nursing populations.

Suggestions

Health care organizations must invest in educational programs to develop leadership competencies in the workplaces to enhance their roles. Accordingly, the Ministry of Health of Mongolia must organize fruitful leadership programs in that nurses and new graduates should be encouraged to develop a strong and well-structured knowledge base in the context of their discipline. The curriculum should make an explicit reference to the international experience base and further development of nurses.

Nurse managers must have the higher professional expertise to sustain nursing leadership comparing nurse staff; however, there are no criteria between nurse managers and nurse staff to compare the effectiveness of leadership roles. An online database of nurses and nurse managers must be developed, and promotional activities are vital for effective nursing leadership.

Recently, the educational level of nurses has been increased, but there are no differences in terms of reference between position levels of nurses. The key recommendation is for the reinvention of nursing education and work environments to address and appeal to the needs and values of a new generation of nurses and enhance the quality of patient care.

Effective nursing practice, education, research, and leadership are grounded in the complexity of human relationships and, therefore, require systematic and careful thinking in order to achieve successful outcomes of nurse performance. A hospital organizational structure must allow having a voice in policymaking for nursing service and patient care. We need a stronger model for developing and grooming nurse leaders. The nurse career model must include differential salary ranges between nurses and nurse managers that positively impact nursing leadership.

Currently, the basic techniques in hospitals are very old, and they must change the techniques in a complex way and renovate the hospital buildings, which can impact the work environment and enhance patient care services. Unfortunately, due to financial shortage, Government is not able to support hospitals, which has negative reflects on nursing leadership. The supply of hospital equipment and linens is not sufficient for hospital settings; therefore, we have widely recognized the quality of supply apart from product quality that strengths the work environment of nurses and, moreover, impacts the nursing leadership.

The policy of hospitals has greater uncertainty and ambiguity; therefore, in the forthcoming years, we will likely see greater revision and practical approaches to promote nursing leadership. Moreover, it is necessary to collectively determine the purpose of nursing leadership and to make changes in our healthcare systems that positively impact patient care services. This guiding purpose will help us determine what we are likely to do, and where we are likely to go from here. Our paper applies descriptive and correlation analysis and employs multiple linear regression models to examine nurse management and patient care services. Extensions of our paper include using our approach to examine food waste reduction ( 35 , 36 ), network analysis ( 37 ), carbon emissions ( 38 ), procurement system ( 39 ), and many others. Readers may read Wong ( 40 ) for other areas in that academics and practitioners could apply the approach used in our paper for their studies. This paper studies the sustainability of nursing leadership; scholars can apply the approach used in this paper to study the sustainability of herding behavior (( 41 )), portfolio selection ( 42 ), organizational climate and work style ( 43 ), supply chains ( 44 ), health insurance ( 45 ), and many others.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics Statement

Ethical review and approval was not required for this study in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

Author Contributions

BW, DD, and M-UB: conceptualization. BW: methodology. DD: data curation and writing—original draft. BW and DD: formal analysis. W-KW: supervision. M-UB and OS: writing—review and editing and funding acquisition. W-KW and M-UB: project administration. All authors contributed to the article and approved the submitted version.

This research was supported by Chinese Academy of Medical Sciences and Peking Union Medical College, China (Grant number: 2021-RC630-001), National University of Mongolia, Asia University, China Medical University Hospital, The Hang Seng University of Hong Kong, Research Grants Council (RGC) of Hong Kong (project numbers 12502814 and 12500915), and the Ministry of Science and Technology (MOST, Project Numbers 106-2410-H-468-002 and 107-2410-H-468-002-MY3), Taiwan. However, any remaining errors are solely ours.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Acknowledgments

The authors thank the Editor-in-Chief and the referees for their helpful comments which help to improve our manuscript significantly. W-KW would like to thank Robert B. Miller and Howard E. Thompson for their continuous guidance and encouragement.

Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpubh.2022.900016/full#supplementary-material

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Keywords: nurse leadership, work environment, performance, problem-solving, transformational role

Citation: Wang B-L, Batmunkh M-U, Samdandash O, Divaakhuu D and Wong W-K (2022) Sustainability of Nursing Leadership and Its Contributing Factors in a Developing Economy: A Study in Mongolia. Front. Public Health 10:900016. doi: 10.3389/fpubh.2022.900016

Received: 23 March 2022; Accepted: 07 April 2022; Published: 25 May 2022.

Reviewed by:

Copyright © 2022 Wang, Batmunkh, Samdandash, Divaakhuu and Wong. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Wing-Keung Wong, wong@asia.edu.tw

This article is part of the Research Topic

Asian Health Sectors Growth in the Next Decade - Optimism despite Challenges Ahead

For Others, With Others

Management skills for nurses of community-based integrated care and interprofessional work

• # Faculty of Human Sciences
• # Department of Nursing

Mihoko Ryoha Professor Department of Nursing Faculty of Human Sciences

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Professor Mihoko Ryoha from the Department of Nursing conducts research about the characteristics of community-based activities undertaken by public health nurses of municipalities to unravel the management skills needed by professional nurses today. What are management skills—built upon decision-making and problem-solving skills—and why are they needed?

Management is a term used to refer to activities that use management resources—such as people, things, money, and information—to govern an organization. I explore the management skills needed by professional nurses while conducting research on their management activities.

It began about 20 years ago when I encountered management in nursing, a new field of study. It is a field for professional nurses who seek high-quality nursing, with emphasis on how management should be practiced. I thought of focusing on public health nurses, the subject of my research at that time, to delve deeper into how they should practice management.

Public health nurses work at local government agencies and, as professional nurses, are in charge of health management for residents, and public health guidance. At the same time, they also support efforts by local residents to improve and invigorate the community. I wanted to know the kind of management skills being applied by them.

Recommencement of suspended community-based activities through the support of public health nurses

At first, I interviewed experienced public health nurses who have worked at local government agencies for at least 10 years.

As a result, I learned that they support the health activities of local residents while applying their individual management skills. Examples of this include gaining support to develop projects that address people’s needs, turning local gatherings into opportunities for health education, and collaborating with other agencies to develop human resources that support local residents.

Turning such knowledge of activities by public health nurses into the subject of academic research and formalizing it into words is important for the future of nursing. After conducting various studies and consolidating data, I presented this information as a research paper, which made me feel happy for having somewhat contributed to the world of nursing.

In addition, through being part of the activities by public health nurses, I was able to see for myself the achievements of their management activities. In one community, for example, the activities of “health mates”— a nutrition specialist volunteer program supported by Japan’s Ministry of Health, Labour and Welfare—had been suspended for several years.

Health mates are volunteers with training in nutrition and dietary education. They conduct nutrition improvement activities to help prevent frailty, lifestyle diseases and other issues which can be caused by poor nutrition.

The health mates in the community in question wanted to recommence activities but did not know how. Progress was made with the public health nurses’ support centered on the approach of management, and planned events also drew huge crowds.

In supporting the activities, the nurses raised the issues of properly running organizations and the goals of activities to health mates, implementing measures such as creating opportunities for discussions.

It is easy for public health nurses to use their expertise to lead volunteers, but doing so will not be sustainable in the long run. Therefore, it can be said that they succeeded due to strategic involvement, making the health mates the core of the activities and having a clear vision of the goal.

Having professional nurses view things from the same perspectives as the top management of organizations

Management by head nurses and others in managerial positions is a well-known aspect of management by professional nurses. However, as I continue with my research, I believe it is necessary for nurses in general to have management skills that view things from the same perspectives as the top management of organization in making decisions, solving problems, and offering services.

Such skills will be helpful in community-based integrated care being developed in an aging society, as well as medical frontlines where team medicine is common.

Going forward, my goal is to develop methods for professional nurses to acquire these management skills and to create manuals and textbooks. I aim to let students—who will become professional nurses in the future—learn these methods to provide them with knowledge and practice that will allow them to contribute at nursing frontlines when they step into society.

The book I recommend

“Chi no Tanoshimi Chi no Chikara”(The Joy and Power of Knowledge) by Shizuka Shirakawa and Shoichi Watanabe, Chichi Publishing

This book is a record of dialogues about knowledge and education between Shizuka Shirakawa, an authority in Oriental studies, and Shoichi Watanabe, a critic as well as professor emeritus of Sophia University. When I first started teaching in university, I wondered about what to convey to students and took up this book wanting to deepen my understanding about education.

Mihoko Ryoha

• Professor Department of Nursing Faculty of Human Sciences

Graduated from the School of Nursing, Chiba University, and received her Ph.D. in Nursing after completing the doctoral program of the university’s Graduate School of Nursing. Took on several positions—such as public health nurse of Gifu City and research assistant, lecturer, associate professor, and professor at the Undergraduate School of Nursing, Gifu College of Nursing—before assuming her current position in 2021.

Interviewed: December 2022

• # The Knot- Nexus of Knowledge by Sophia Professors

The Knot- Nexus of Knowledge by Sophia Professors

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Ethics in Health Informatics: What Nurses Need to Know

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Essential Leadership Skills for Nurse Managers

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Application of Project Management to Healthcare

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How Leaders Approach Problem-Solving

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Information Technology in Healthcare

Administering consistent, high-quality patient care requires access to vast fields of data. However, because the technology that collects and houses this data is constantly changing,

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