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Copyright INHL 2007
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Knowledge and Influence of the Nurse Leader
A Survey of Participants from the 2006 Conference
The Institute for Nursing Healthcare Leadership
Report Prepared by
Jeffrey M. Adams, PhD(c), RN Jeanette Ives Erickson, MS, RN Mary E. Duffy, PhD, RN, FAAN
Dorothy A. Jones, EdD, RN, FAAN Alicemary Aspell Adams, MBA, BSN, RN Joyce C. Clifford, PhD, RN, FAAN
Copyright INHL 2007
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This report was made possible through the generosity of
200 Cordwainer Drive, Suite 100,
Norwell, MA 02061
Tel 781 871 6770
www.navinhaffty.com
55 Fruit Street
Boston, MA 02114
Tel 617 726 3100
www.massgeneral.org
450 East Romie Lane
Salinas, CA 93901
Tel 831 757 4333
www.svmh.com
Nine Waterville Street, Suite 4C
Portland, ME 04101
Tel 207 749 2680
www.bogartgroup.com
A special thank you to
Elaine Cohen, MS, RN
Sandra Cortes
Karen Poznick
Copyright INHL 2007
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TABLE OF CONTENTS
Page
Title and Authors .. 01
Survey Sponsors .. 02
Perspective .. 04
Survey Overview .. 05
SECTION I: Survey Respondents Demographics & Conference Attendance Statistics
Age, Gender, Organization Size .. 06
Primary Title, Primary Employer, Employment Community 07
State (location) of Primary Employment .. 08
Highest Education Level (Nursing) & (Any Degree), Country of Employment .. 09
Years Experience in Current Role, Years Experience Direct Patient Care, Number of Employers since Graduation ...10
Years Experience in Health Care Administration, Most Appealing Aspects of INHL Conference .. ...11
SECTION II: Research Question Results
Survey Methodology .. 12
Self Reported Knowledge and Influence .. 13
Research Question 1: .. 14
Research Question 2: .. 15
Research Question 3: .. 16
Research Question 4: .. 17
Discussion: .. 18
Research Questions 5 & 6: .. 18
Research Questions 7 & 8: . . 19
Discussion: .. 20
SECTION III: Most Pressing & Time Consuming Issues for Nurse Leaders
Research Question 9 & 10: . . . 20-21
Discussion: .. 22
SUMMARY:
Summary and Future Directions: . . .. 22
References .. . 23
Copyright INHL 2007
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Dear Colleagues- June 12, 2007
While healthcare organizations have a myriad of leadership roles with various responsibilities and workloads, the Nurse Executive Leader (NEL) is faced with what
is likely the most complex of these roles. There are approximately 5000 nurse executive leaders in acute care settings (Health Forum, 2006) in the United States,
this population of 5000 serve as the gatekeepers for the advancement of the majority (3/5) of the 2.4 million nurses practicing in the U.S. (US Department of Labor
- Bureau of Labor Statistics 2007), and it is very likely that the impact of nursing executive leaders is similar throughout the international community.
In our previous report, “Knowledge and Influence of the Nurse Leader” (Adams, Duffy & Clifford 2006), we asked the questions, “Having gotten to the table now
what?” and “Do nurses have the knowledge and influence needed to make a difference?” These questions were based upon existing nurse executive research
which has identified the conflict and ethical dilemmas of nurse executive leaders pursuing both organizational and professional leadership goals. After a year of
reflection, discussion, literature review, and experiences within acute care executive teams both in the United States and abroad, we feel it is time to officially
phase out nurses celebration of “getting to the table” and ask the question ”What is the appropriate definition and measurement of nurse executive leader
success?”
Toward this end, nursing research has made significant advancements assisting the NEL in identifying, understanding and justifying what nurses need and how
this melds with the organizational mission. However, this research is not yet universally translating to practice. Just over half (56%) of CEOs and less than a
quarter (21%) of staff nurses rate their CNEs as strong performers (Advisory Board Company 2003). A unified and defined measure of nurse executive leader
success is necessary to understand how NELs are valued and evaluated differently by the executive peers, staff nurses and academics. There is great
opportunity and benefit to standardizing the role of the CNE in for profit, not for profit, government, academic medical centers and community hospitals alike. This
standardization will allow for continued consistent evaluation at an individual, national or international level and likely lead to individual improvement in personal,
patient and nursing environment expectations and outcomes.
AONE took the initial steps toward developing a measure of success for the nurse executive/ leader when it released its core competencies for nurse executives
American Organization of Nurse Executives 2005). These competencies are designed as an inclusive list of skills that are useful/ necessary for nursing
leadership. However, we believe it is simply not enough to identify competencies, but to set expectations of the nurse executive role for all constituents. This
survey serves as a starting point toward limiting role conflict, defining “role clarity” and measuring success for the nurse executive leader through understanding
self perceived knowledge and influence.
We feel it is the responsibility of INHL, AONE, nursing administration researchers, along with nurse executives, past, current and future to set a measurable
definition of success. As healthcare continues to evolve, so too will the role responsibilities of the Nurse Executive Leader. As a discipline and profession, nursing
must continue to advocate for and measure the success, influence and impact of the NEL, because they (you) are leading us, at what pace and in what direction
cannot be left to chance.
Jeffrey M. Adams, PhD(c), RN Jeanette Ives Erickson, MS, RN Mary E. Duffy, PhD, RN, FAAN
Principal, The Bogart Group, Inc.
Doctoral Fellow, Massachusetts General Hospital
Research Associate, Institute for Nursing Healthcare Leadership
Doctoral Candidate, Boston College Connell School of Nursing
Senior Vice President of Patient Care Services &
Chief Nurse, Massachusetts General Hospital
Professor & Director, Center for Nursing Research
Boston College Connell School of Nursing
Senior Research Scientist, Yvonne Munn Center for Nursing
Research at Massachusetts General Hospital
Dorothy A. Jones, EdD, RNC, RN, FAAN Alicemary Aspell Adams, MBA, BSN, RN Joyce C. Clifford, PhD, RN, FAAN
Professor, Boston College Connell School of Nursing
Director, Yvonne Munn Center for Nursing Research at
Massachusetts General Hospital
President, The Bogart Group, Inc. President & CEO, Institute for Nursing Healthcare Leadership
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We thank those that participated in this survey and all those that work for the continued improvement of nursing leadership. We appreciate the wealth of knowledge nurse leaders’
exhibit and look forward to being a part of the continued development of nurses as effective leaders in the ever changing and complex healthcare system. Should you be interested
in discussions surrounding the development of a defined measure of success for the Nurse Executive Leader, please contact us at jeff.adams@bogartgroup.com.
This document reports the results of the INHL Executive Nurse Leadership Survey distributed at the Institute for Nursing Healthcare Leadership Conference in
June 2006. The report was prepared by; Jeffrey M. Adams, PhD(c), RN, Jeanette Ives Erickson, MSN, RN, Mary E. Duffy, PhD, RN, FAAN, Dorothy A. Jones,
EdD, RNC, ANP, FAAN, Alicemary Aspell Adams, MBA, BSN, RN, President, The Bogart Group, Inc. and Joyce C. Clifford, PhD, RN, FAAN.
IRB approval was obtained through Massachusetts General Hospital #2007-P-000659/2
The study sought to answer the following research questions (RQ):
RQ1: How do nurse leaders perceive their knowledge about specific management and leadership topics in comparison to non-nurse healthcare
executives within their primary employment organization?
RQ2: How do nurse leaders perceive their influence about specific management and leadership topics in comparison to non-nurse healthcare
executives within their primary employment organization?
RQ3: How do nurse leaders perceive their knowledge about specific management and leadership topics in comparison to fellow nurse leaders within
their primary employment organization?
RQ4: How do nurse leaders perceive their influence about specific management and leadership topics in comparison to fellow nurse leaders within
their primary employment organization?
RQ5: Do the total knowledge scores of Vice Presidents/ CNOs differ from the total knowledge scores of Directors and Managers in comparison to
non-nurse healthcare executives?
RQ6: Do the total knowledge scores of Vice Presidents/ CNOs differ from the total knowledge scores of Directors and Managers in comparison to
fellow nurse leaders?
RQ7: Do the total influence scores of Vice Presidents/ CNOs differ from the total influence scores of Directors and Managers in comparison to non-
nurse healthcare executives?
RQ8: Do the total influence scores of Vice Presidents/ CNOs differ from the total influence scores of Directors and Managers in comparison to fellow
nurse leaders?
RQ9: What are the most pressing issues for nurse leader attendees at the 2006 INHL conference?
RQ10: What are the most time consuming issues for nurse leader attendees at the 2006 INHL conference?
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I. Section one of this document reports the demographic and conference attendance statistics.
Typical survey respondents were 52 year old females from New England with a graduate nursing education. The majority of respondents (81%) held care
delivery management roles as Vice President/ Chief Nursing Officer, Associate Vice President, Director or Manager primarily in hospitals and/ or medical
centers (93%) in major metropolitan areas (49%). On average (51%), survey respondents had 5 years or less experience in their current employment
position with 76% having less than ten years experience in their current role. Respondents found applicability of topics to work and networking with other
senior level nurses among the most appealing reasons for attending the conference. The following pages (Tables and Charts 1-15) provide more insight
into the profile of the INHL conference attendees/ survey respondents.
Table 1: Participant's Age
Valid Cumulative
Participant's Age Frequency Percent Percent
30 – 35 Years 2 3 3
36 – 40 Years 5 6 9
41 – 45 Years 5 6 15
46 – 50 Years 17 20 35
51 – 55 Years 30 36 71
56 – 60 Years 20 24 95
> 60 Years 4 5 100
83 100
Table 2: Participant's Gender
Valid Cumulative
Frequency Percent Percent
Female 81 98 98
Male 2 2 100
83 100
Table 3: Organization Size for Survey Respondents
Valid Cumulative
Frequency Percent Percent
000 – 200 Beds 15 22 22
201 – 400 Beds 19 28 50
401 – 600 Beds 17 25 75
601 – 800 Beds 11 16 91
801 - 1000 Beds 7 9 100
69 100
Chart1: Participant's Age
3% 6% 6%
20%
36%
24%
5%
30 - 35 Yrs.
36 - 40 Yrs.
41 - 45 Yrs.
46 - 50 Yrs.
51 - 55 Yrs.
56 - 60 Yrs.
> 60 Yrs
Chart 2: Participant's Gende
r
98%
2%
Female
Male
Chart 3: Organization Size for Survey Respondents
22%
28%
25%
16%
9% 0 - 200 Beds
201 - 400 Beds
401 - 600 Beds
601 - 800 Beds
801 - 1000 Beds
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Table 4: Primary Title of Survey Respondents
Sr. V.P./Chief Nursing Officer 28
Associate V.P. 7
Director 32
Manager 2
Dean/Faculty 10
Other 6
85
Table 6: Employment Community
Valid Cumulative
Frequency Percent Percent
Major Metropolitan Area 40 49 49
Mid Sized City 17 21 70
Small City or Town 23 28 98
Sparsely Populated Rural Area 1 2 100
81 100
Table 5: Primary Employer of Survey Respondents
Hospital or Medical Center or Health Care System 68
School of Nursing 10
Other 4
82
Other: Titles of Survey Respondents
x Association Executive
x CEO
x Consultant
Other: Primary Employers of Survey Respondents
x Ambulatory Care Facility
x Home Care Agency
x Health Care Vendor – Consulting Group
x Professional Membership Organization
28
7
32
2
10
6
0
5
10
15
20
25
30
35
Chart 4: Primary Title Of Survey Respondents
Sr. V.P./Chief Nursing
Office
r
A
ssociate V.P.
Directo
r
Manage
r
Dean/Faculty
Othe
r
Chart 5: Primary Employer of Survey Respondents
83%
12% 5%
Hospital or Medical
Center or Health Care
System
School of Nursing
Other
Chart 6: Employment Community
49%
21%
28%
2%
Major Metropolitan
A
rea
Mid Sized City
Small City o
r
Town
Sparsely Populated
Rural Area
Copyright INHL 2007
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CA
3%
TX
4%
HI
3%
IN
1%
WI
1%
MN
1%
UT
1% VA
1%
NM
1%
NY
8%
PA
8%
ME
3%
VT
1%
NJ
1%
CO
1%
MD
3%
CT
3%
MA
43%
NH
10%
RI
3%
Table 7: State of Respondent’s Employment
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Table 8: Highest Nursing Education Level
Valid Cumulative
Frequency Percent Percent
Associates Degree 3 4 4
Bachelors Degree 11 13 17
Masters Degree 47 55 72
Doctoral Degree 24 28 100
85 100
Table 9: Highest Educational Level of Any Degree
Valid Cumulative
Frequency Percent Percent
Associates Degree 1 1 1
Bachelors Degree 3 4 5
Masters Degree 49 61 66
Doctoral Degree 27 34 100
80 100
Table 10: Country of Employment
Valid Cumulative
Frequency Percent Percent
USA 80 94 94
Other 5 6 100
85 100
3
11
47
24
0
10
20
30
40
50
60
Chart 8: Highest Nursing Education Level
A
ssociates Degree
Bachelors Degree
Masters Degree
Doctoral Degree
13
49
27
0
10
20
30
40
50
60
Chart 9: Highest Educational Level of Any Degree
A
ssociates Degree
Bachelors Degree
Masters Degree
Doctoral Degree
Chart 10: Country of Employment
80
5
USA
Othe
r
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Table 11: Respondents Years Experience In Current Role
Valid Cumulative
Frequency Percent Percent
00 - 05 Years 44 51 51
06 - 10 Years 21 25 76
11 - 15 Years 9 11 87
16 - 20 Years 5 6 93
> 20 Years 6 7 100
85 100
Table 13: Number of Employers Since RN Graduation
Valid Cumulative
Frequency Percent Percent
01 - 05 Employers 50 59 59
06 - 10 Employers 29 34 93
11 - 15 Employers 3 4 97
16 - 20 Employers 1 1 98
> 20 Employers 2 2 100
85 100
Table 12: Number of Years of Direct Patient Care Provided by Respondents
Valid Cumulative
Frequency Percent Percent
00 - 10 Years 36 42 42
11 - 20 Years 28 33 75
21 - 30 Years 14 17 92
31 - 40 Years 6 8 100
84 100
Chart 11: Experience in Current Role (Years)
51%
25%
11%
6% 7% 0 - 5 Yrs.
6 - 10 Yrs.
11 - 15 Yrs.
16 - 20 Yrs.
> 20 Yrs.
Chart 12: Years of Patient Care Provided by Each Respondent
43%
33%
17%
7%
0 - 10 Years
11 - 20 Years
21 - 30 Years
31 - 40 Years
Chart 13: Number of Employers Since RN Graduation
59%
34%
4%
1% 2%
1 - 5 Employers
6 - 10 Employers
11 - 15 Employers
16 - 20 Employers
> 20 Employers
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Table 14: Number of Years of Health Care Administrative Experience
Valid Cumulative
Frequency Percent Percent
00 - 10 Years 27 31 31
11 - 20 Years 33 39 70
21 - 30 Years 21 25 95
31 - 40 Years 4 5 100
85 100
Table 15: Most Appealing Aspects of the INHL
Conference
Networking with other senior level nurses 71
Being part of an invitational conference 40
The limited size of the audience 35
The Convenient Location 34
Topics are applicable to my work 75
Other: Most Appealing Aspects of the INHL Conference
x New ideas, information and challenges
x Opportunity to share my thoughts and ideas
x Quality of presenters
x Quality of speakers
x Service and education mix
x The high level of topics and speakers
Chart 14: Years of Health Care Administrative Experience
31%
39%
25%
5%
0 - 10 Years
11 - 20 Years
21 - 30 Years
31 - 40 Years
71
40
35 34
75
0
10
20
30
40
50
60
70
80
Chart 15: Most Appealing Aspects of the INHL Conference
Networking with other
senior level nurses
Being part of an
invitational conference
The limited size of the
audience
The Convenient
Location
Topics are applicable to
my work
Copyright INHL 2007
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II. Section two of this document reports the results of research questions (RQ) 1-9.
Survey Methodology
The following methodology was used in the development and evaluation of the survey tool. Nursing administration content area specialists
identified areas of management and leadership pertinent to the nurse leader. Those areas were then consolidated and organized into a thirteen
item scale and used to identify the self reported knowledge and influence of the contemporary nurse leader respondents in comparison to both non-
nurse healthcare executives and fellow nurse leaders within their primary work organization. The thirteen topic areas were;
1) Clinical information technology clinical requirements and system selection. 8) Organizational Magnet status requirements.
2) Integration of standardized nursing language(s) into practice. 9) Staffing: skill mix/& patient ratio issues.
3) Implementation of patient safety programs. 10) Quality reporting: JCAHO, CMS, NDNQI, etc.
4) Organizational integrity: stewardship, ethics, accountability 11) Financial management & budget development.
5) Process management: principles of analysis and design. 12) Health care policy
6) Clinical staff leadership development strategies and issues. 13) Clinical practice (direct care delivery)
7) Management leadership development strategies
The rating scale was scored one through five. A score of one being the lowest self perceived knowledge or influence in comparison to nurse and
non-nurse leaders. Thus, total scale scores would pose a minimum of 13 to identify the least knowledgeable or influential and 65 the most
knowledgeable or influential in comparison to fellow nurse leaders or non-nurse healthcare executives.
Attendees at The Institute for Nursing Healthcare Leadership (INHL) national invitation conference in June 2005 provided a purposive sample of
nurse leaders. Of the180 attendees, 76 (42%) sufficiently completed at least one section of the survey in its entirety. The results of this were
tabulated and statistically analyzed. Demographic information (primary title, primary employer, years of experience and employment community)
were also identified as valuable to include for collection and analysis.
A preliminary psychometric evaluation of each of the 13-item knowledge and influence scales was undertaken with the sample of valid survey
respondents (n=76). Cronbach’s alpha internal consistency reliability were computed on the four 13 item scales. Since these were satisfactory i.e.,
(>.70) the four subscales were then formed. The standardized Cronbach's alpha coefficients for the subscales were:
x Self-reported knowledge in comparison to non-nurse healthcare executives was 0.90
x Self-reported influence in comparison to non-nurse healthcare executives was 0.91
x Self-reported knowledge in comparison to fellow nurse leaders was 0.85
x Self-reported influence in comparison to fellow nurse leaders was 0.91
Finally, each respondent was asked to answer two qualitative questions; 1. What are the three most challenging issues you are currently
dealing with in your role as a nurse leader? 2. What three issues you are currently dealing with in your role as a nurse leader consume the greatest
amount of your time? Directed content analysis (Hsieh & Shannon 2005) was used to categorize the results of these questions into the identified
American Organization of Nurse Executive Core Competencies (AONE 2005).
** Caution should be exercised, due to the small sample size, no further psychometric analysis were completed due to the small sample size in this study.
Copyright INHL 2007
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Table 16 reports the mean specific item scores, standard deviations and the total subscale scores and standard deviations. The specific item rating
was scored 1 for the lowest score and 5 was the highest score. Thus, the total subscale scores could range from a lowest possible score of 13
(scoring of 1 on each specific item score) to a maximum 65 (scoring of 5 on each specific item scale).
TABLE 16: Nurse Leaders Self Reported Knowledge and Influence in Comparison to Nurse and Non-Nurse Healthcare Leadership
RQ1: Self-perceived
knowledge in
comparison to non-
nurse healthcare
executives
RQ2: Self-perceived
influence in
comparison to non-
nurse healthcare
executives
RQ3: Self-perceived
knowledge in
comparison to fellow
nurse leaders
RQ4: Self-perceived
influence in
comparison to fellow
nurse leaders
N Mean (SD) N Mean (SD) N mean (SD) N Mean (SD)
Clinical information technology clinical
requirements and system selection.
60 3.3 1.0 57 3.6 1.0 76 3.8 0.8 76 3.9 0.9
Integration of standardized nursing
language(s) into practice.
60 3.1 1.6 57 3.2 1.3 76 3.9 0.8 76 4.0 1.0
Implementation of patient safety
programs.
60 3.9 1.0 57 3.8 1.0 76 4.3 0.7 76 4.4 0.7
Organizational integrity: Stewardship,
Ethics, Accountability.
60 4.1 0.9 57 4.0 0.9 76 4.4 0.8 76 4.3 0.7
Process Management: Principles of
Analysis and Design.
60 3.8 0.9 57 3.7 0.9 76 3.9 0.8 76 4.0 0.8
Clinical staff leadership development
strategies and issues.
60 3.8 1.2 57 3.7 1.1 76 4.4 0.8 76 4.4 0.7
Management leadership development
strategies
60 3.9 1.0 57 3.9 0.9 76 4.2 0.9 76 4.3 0.8
Organizational Magnet status
requirements.
60 3.5 1.4 57 3.6 1.4 76 4.2 1.0 76 4.4 0.8
Staffing: skill mix/& patient ratio issues. 60 3.5 1.4 57 3.5 1.2 76 4.4 0.9 76 4.4 0.9
Quality reporting: JCAHO, CMS, NDNQI,
etc.
60 3.8 1.1 57 3.6 1.0 76 4.2 0.8 76 4.2 0.9
Financial management & budget
development.
60 4.0 1.0 57 3.8 1.0 76 4.0 0.8 76 3.9 0.9
Health care policy 60 3.6 1.1 57 3.5 1.0 76 3.7 0.9 76 3.8 0.9
Clinical practice (direct care delivery) 60 3.6 1.3 57 3.7 1.3 76 4.3 0.9 76 4.4 0.8
TOTAL (min 13 - max 65) 60 47.8 10.3 57 47.8 10.0 76 53.7 6.6 76 54.5 7.6
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RQ1: How do nurse leaders perceive their knowledge about specific management and leadership topics in comparison to non-nurse
healthcare executives within their primary employment organization?
Respondents to this survey self reported their total knowledge in comparison to non-nurse healthcare executives as 47.8 + 10.3 (possible range
13 minimum – 65 maximum). Each of the specific topic items mean scores were greater than the midpoint score of 3.0. Nurse leaders, when
comparing themselves to non-nurse healthcare executives identified “Integration of standardized nursing language(s) into practice” (score 3.1 +
1.6) and “Clinical information technology clinical requirements and system selection” (score 3.3 + 1.0) as the topics they were least knowledgeable
about. In contrast, these nurse leaders identified “Organizational integrity: stewardship, ethics and accountability” (score 4.1 + 0.9) and “Financial
management & budget development” (score 4.0 + 1.0) as the topics where they had the greatest knowledge. The remaining item mean scores all
fell between 3.5 and 3.9. (See Table 16 and Chart 16)
3.3
3.1
3.9
4.1
3.8 3.8
3.53.5
3.8
4.0
3.6
3.6
3.0
3.2
3.4
3.6
3.8
4.0
4.2
4.4
Chart 16: Self-perceived Knowledge in Comparison to Non-nurse Healthcare Executives
Clinical information technology clinical
requirements and system selection.
Integration of standardized nursing language(s)
into practice.
Implementation of patient safety programs.
Organizational integrity: Stewardship, Ethics,
A
ccountability.
Process Management: Principles of Analysis
and Design.
Clinical staff leadership development strategies
and issues.
Management leadership development strategies
Organizational Magnet status requirements.
Staffing: skill mix/& patient ratio issues.
Quality reporting: JCAHO, CMS, NDNQI, etc.
Financial management & budget development.
Health care policy
Clinical practice (direct care delivery)
3.9
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RQ2: How do nurse leaders perceive their influence about specific management and leadership topics in comparison to non-nurse healthcare
executives within their primary employment organization?
Respondents to this survey self reported their total influence in comparison to non-nurse healthcare executives as 47.8 + 10.0 (possible range 13
minimum – 65 maximum). Each of the specific topic items mean scores were greater than the midpoint score of 3.0. Nurse leaders, when
comparing themselves to non-nurse healthcare executives identified “Integration of standardized nursing language(s) into practice” (score 3.2 +
1.3) as the topic they were least influential about. In contrast, these nurse leaders identified “Organizational integrity: stewardship, ethics,
accountability” (score 4.0 + 0.9) and “Management leadership development strategies” (3.9 + 0.9) as the topics where they had the most influence.
The remaining item mean scores all fell between 3.5 and 3.8. (See Table 16 and Chart 17)
3.6
3.2
3.8
4.0
3.7 3.7
3.9
3.6
3.5
3.6
3.8
3.5
3.7
3.0
3.2
3.4
3.6
3.8
4.0
4.2
4.4
Chart 17: Self-perceived Influence in Comparison to Non-nurse Health Care Executives
Clinical information technology clinical
requirements and system selection.
Integration of standardized nursing language(s)
into practice.
Implementation of patient safety programs.
Organizational integrity: Stewardship, Ethics,
A
ccountability.
Process Management: Principles of Analysis
and Design.
Clinical staff leadership development strategies
and issues.
Management leadership development strategies
Organizational Magnet status requirements.
Staffing: skill mix/& patient ratio issues.
Quality reporting: JCAHO, CMS, NDNQI, etc.
Financial management & budget development.
Health care policy
Clinical practice (direct care delivery)
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RQ3: How do nurse leaders perceive their knowledge about specific management and leadership topics in comparison to fellow nurse
leaders within their primary employment organization?
Respondents to this survey self reported their total knowledge in comparison to fellow nurse leaders as 53.7 + 6.7 (possible range 13 minimum –
65 maximum). Each of the specific topic items mean scores were greater than the midpoint score of 3.0. Nurse leaders, when comparing
themselves to fellow nurse leaders identified “Health care policy” (score 3.7 + 0.9) as the topic they were least knowledgeable about. In contrast,
these nurse leaders identified “Staffing: skill mix & patient ratio issues” (score 4.4 + 0.9), “Organizational integrity: stewardship, ethics,
accountability” (score 4.4 + 0.8) and “Clinical staff leadership development strategies” (score 4.4 + 0.8) as the topics where they had the greatest
knowledge. The remaining item mean scores all fell between 3.7 and 4.3. (See Table 16 and Chart 18).
3.8
3.9
4.3
4.4
3.9
4.4
4.2 4.2
4.4
4.2
4.0
3.7
4.3
3.0
3.2
3.4
3.6
3.8
4.0
4.2
4.4
Chart 18: Self-perceived Knowledge in Comparison to Fellow Nurse Leaders
Clinical information technology clinical
requirements and system selection.
Integration of standardized nursing language(s)
into practice.
Implementation of patient safety programs.
Organizational integrity: Stewardship, Ethics,
A
ccountability.
Process Management: Principles of Analysis
and Design.
Clinical staff leadership development strategies
and issues.
Management leadership development strategies
Organizational Magnet status requirements.
Staffing: skill mix/& patient ratio issues.
Quality reporting: JCAHO, CMS, NDNQI, etc.
Financial management & budget development.
Health care policy
Clinical practice (direct care delivery)
Copyright INHL 2007
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RQ4: How do nurse leaders perceive their influence about specific management and leadership topics in comparison to fellow nurse leaders
within their primary employment organization?
Respondents to this survey self reported their total influence in comparison to fellow nurse leaders as 54.5 + 7.6 (possible range 13 minimum – 65
maximum). Each specific topic item mean scores were greater than the midpoint score of 3.0. Nurse leaders, when comparing themselves to fellow nurse
leaders identified “Health care policy” (score 3.8 + 0.9) as the topic they were least influential about. In contrast, these nurse leaders identified
“Implementation of patient safety programs” (score 4.4 + 0.7), “Clinical staff leadership development strategies” (score 4.4 + 0.7), “Clinical practice (direct
care delivery)” (score 4.4 + 0.8), “Organizational Magnet status requirements” (score 4.4 + 0.9), and “Staffing: skill mix & patient ratio issues” (score 4.4 +
0.9) as the topics where they had the greatest influence. The remaining item mean scores all fell between 3.9 and 4.3. (See Table 16 and Chart 19).
.
3.9
4.0
4.4
4.3
4.0
4.4
4.3
4.4 4.4
4.2
3.9
3.8
4.4
3.0
3.2
3.4
3.6
3.8
4.0
4.2
4.4
Chart 19: Self-perceived Influence in Comparison to Fellow Nurse Leaders
Clinical information technology clinical
requirements and system selection.
Integration of standardized nursing language(s)
into practice.
Implementation of patient safety programs.
Organizational integrity: Stewardship, Ethics,
A
ccountability.
Process Management: Principles of Analysis
and Design.
Clinical staff leadership development strategies
and issues.
Management leadership development strategies
Organizational Magnet status requirements.
Staffing: skill mix/& patient ratio issues.
Quality reporting: JCAHO, CMS, NDNQI, etc.
Financial management & budget development.
Health care policy
Clinical practice (direct care delivery)
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Discussion
The respondents to this survey identified being both more knowledgeable and influential when comparing themselves to fellow nurse leaders than when comparing
themselves to non-nurse executives within their organization. This is also supported on an item by item basis (Table 16) with the exception of the topic “Financial
management & budget development.” This suggests that the nurse leader respondents to this survey identify non-nurse healthcare executives as more
knowledgeable and influential than fellow nurse leaders on nearly every survey topic. This is somewhat concerning, and identifies opportunity and need for
knowledge, competence and influence enhancement for nurse leaders.
Another interesting finding is the identification of “Integration of standardized nursing language into practice” as the topic where nurse leaders self reported
knowledge and influence as lowest in comparison to non-nurse executives. This is somewhat of a surprising finding, as NELs perceive themselves as more
knowledgeable and influential with fellow nurses than with non-nurse executives who seemingly have less exposure to standardized nursing language. This
however is an important finding as hospitals and healthcare organizations continue to focus resources on nursing and clinical information systems. As
organizations select, design and build clinical information systems it is important to approach these projects from the well quoted perspective “If you cannot name
it, you can’t control it, finance it, research it, or put it into policy”(Lang & Clark 1997). A standardized language for nursing can aid in the articulation of nursing
clearly and efficiently conveying what clinicians do, easily tracking care across clinicians and settings, evaluating effectiveness of care and generating data to
support policies for appropriate resource allocation. This finding also leads us to the question “What is the relationship between the NELs level of topic knowledge
and influence within the non-nurse executive and nurse leader communities?”
For questions RQ5-RQ8, the data file was split and only those with primary titles of VP/CNO, Director and Manager were included in the sample making a sample
size (n=58).
TABLE 17: Total Knowledge and Influence Scores for VPs/CNOs, Directors and Managers in Comparison to Nurse and Non-nurse Leadership
V
ice President/ Chief Nursing
Officer Director Manager
N Mean (SD) N Mean (SD) N mean (SD)
Total knowledge compared to non nurse execs 20 49.0 12.0 25 47.0 9.1 1 NA NA
Total influence compared to non nurse execs 19 50.4 12.1 28 46.0 8.2 1 NA NA
Total knowledge compared to fellow nurse leaders 25 55.8 6.1 26 54.3 5.2 2 NA NA
Total influence compared to fellow nurse leaders 23 58.2 5.1 31 54.7 5.8 2 NA NA
RQ5: Do the total knowledge scores of Vice Presidents/ CNOs differ from the total knowledge scores of Directors and Managers in
comparison to non-nurse healthcare executives?
The mean self reported total knowledge score of the Vice President/ CNO (49.0) was higher than that of the Directors (47.0) when comparing
themselves to non-nurse healthcare executives. Due to a small N (N=1) Managers were not assessed when comparing themselves to non-nurse
healthcare executives. (see Chart 20 and Table 17)
RQ6: Do the total knowledge scores of Vice Presidents/ CNOs differ from the total knowledge scores of Directors and Managers in
comparison to fellow nurse leaders?
The mean self reported total knowledge score of the Vice President/ CNO (55.8) was higher than that of the Directors (54.3) when comparing
themselves to fellow nurse leaders. Due to a small N (N=2) Managers were not assessed when comparing themselves to fellow nurse leaders.
(see Chart 20 and Table 17)
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RQ7: Do the total influence scores of Vice Presidents/ CNOs differ from the total influence scores of Directors and Managers in comparison to
non-nurse healthcare executives?
The mean self reported total influence score of the Vice President/ CNO (50.4) was higher than that of the Directors (46.0) when comparing
themselves to non-nurse healthcare executives. Due to a small N (N=1) Managers were not assessed when comparing themselves to non-nurse
healthcare executives. (see Chart 20 and Table 17)
RQ8: Do the total influence scores of Vice Presidents/ CNOs differ from the total influence scores of Directors and Managers in comparison to
fellow nurse leaders?
The mean self reported total influence score of the Vice President/ CNO (58.2) was higher than that of the Directors (54.7) when comparing
themselves to fellow nurse leaders. Due to a small N (N=2) Managers were not assessed when comparing themselves to fellow nurse leaders.
(see Chart 20 and Table 17)
49 47
NA
50.4
46
NA
55.8
54.3
NA
58.2
54.7
NA
0
10
20
30
40
50
60
Total knowledge
compared to non
nurse execs
Total influence
compared to non
nurse execs
Total knowledge
compared to
fellow nurse
leaders
Total influence
compared to
fellow nurse
leaders
Chart 20: Self Perceived Total Knowledge and Influence Scores for VPs/CNOs, Directors and Managers in
Comparison to Nurse and Non-nurse Leadership
Vice President/ Chief Nursing Officer Mean
Director Mean
Manager mean
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Discussion
When the sample was split, Vice Presidents/CNOs (minimum n=19), Directors (minimum n=25) and Managers (minimum n=1) were isolated. Due
to the low number of Manager responses, this population was excluded. However within the VP/CNO relationship, it was identified that both
knowledge and influence scores followed a hierarchical trend which is again supportive of our previous findings. This means that the total
knowledge and influence scores of the Vice President/ CNO were higher than the Director scores in both 2005 and 2006 and the Manager scores in
2005 (See Table 17 & Chart 20) and (Adams, Duffy & Clifford 2006).
III. Section three of this document identifies the most pressing issues identified by survey respondents (RQ) 9-10
Two hundred twenty seven written responses to the qualitative “most challenging issue” question and one hundred seventy nine written
responses to the “most time consuming” question were reviewed and using directed content analysis (Hsieh & S. E. Shannon 2005) were
identified as relating with AONE competency skills. The most pressing and time consuming issues identified by nurse leaders are identified
in Table 18.
RQ9: What are the most challenging issues for nurse leader attendees at the 2006 INHL conference?
Nurse leader respondents most frequently identified issues within AONE competency category Business Skills as the most challenging
issues within their current roles.
RQ10: What are the most time consuming issues for nurse leader attendees at the 2006 INHL conference?
Nurse leader respondents most frequently identified issues within AONE competency category Business Skills as the most time consuming
issues within their current roles.
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Table 18: Issues Identified as Most Pressing and Requiring Greatest Amount of Nurse Executive Leaders (NEL) Time
Pressing Issues for NEL
Competency Skill
Total
Responses
NEL spends most time
Competency Skill
Total
Responses
AONE Core Competencies Group Total AONE Core Competencies Group Total
Communication and relationship-building
competencies
27 Communication and relationship-building
competencies
15
x Academic faculty partnerships; curriculum development; placements
x Physician-Practice collaboration
x Union Environments/Union Partnerships
x
Academic affiliations and partnerships; clinical site access
(competition); alliances with other hospitals
x Union relationships; communicating effectively with all partners
x Nursing voice within the organization/role clarity
Knowledge of the healthcare environment 47 Knowledge of the healthcare environment
21
x Implementing and promoting patient quality, safety and satisfaction
x Using and measuring evidence for practice
x Advancing professional practice with knowledge; patient education; impact of
curriculum education
x
Quality Improvement; promoting evidenced based practice; safety
x Increased work intensity
x Educational networking; integration of clinical information technology
Leadership skills 47 Leadership skills
35
x Promoting change; reframe thinking to implement innovative practice models;
“ raising the bar”.
x Leadership development- recruit and retain a leadership team
x Preparing leaders for the future
x
Promoting change; communicating the vision; developing “centers of
excellence”; staff satisfaction
x Leadership development of nurses, associate
x Chiefs, nurse managers; current and future
x Creating leadership team
x Personnel problems and issues
Professionalism
11 Professionalism 21
x Increased accountability; care coordination
x Professional commitment to standards; magnet status
x Impact of Technology and documentation
x
Implementing a professional practice model; patient care delivery
redesign
x Staff Competency ; achieving and maintaining Magnet status
x
Implementing research /evidenced based practice
Business skills
89 Business skills 87
x Resources: allocation (staffing), growth recruitment (shortage), retention,
development
x Resources: allocation (staffing), growth recruitment (shortage), retention,
development
x Strategic Planning – vision; innovation, “doing more with less”.
x Fiscal balancing – financial growth
x
Resource - adequacy and workforce supply faculty; Capacity
Management; nurse recruitment
x Resource - adequacy and workforce supply faculty; Capacity
Management; nurse recruitment
x Generating new revenue streams (e.g. Grants and innovative projects);
allocation of resources
x Budget constraints and fiscal management/ variance
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Discussion
Findings from the two questions that asked nurse leaders to describe what issues are currently dealing with and those issues that consume “ the
greatest amount of their time” seem to yield similar responses although in some cases the frequency with which they were noted varied. The issue
which most leaders identified as most pressing and the one they spent the most time with focused on the AONE Core Competency of Business
Skills. Within this competency financial balancing of the budget; recruitment and retention of a stable workforce and the impact of the faculty
shortage were often noted. In addition, issues related to the identification of new revenue sources; and strategic planning were noted often. The
impact of information management and technology were also cited frequently. Leaders were not only concerned with adequacy of the workforce but
preparation, staffing and ratios.
Competencies associated with Knowledge of the Health Care Environment and Leadership Skills were often noted as very important and of
areas concern to nurse leaders. Of note was the need for continued development of the current work force; advancing new opportunities to promote
career mobility and fostering change were essential. Leaders often noted the challenges currently and in the future, around succession planning
and role development of potential leaders.
Changes in academic curriculum, along with the inadequate number of faculty and nurses prepared at advanced levels to fill future leadership roles
were seen as important areas for consideration and future planning. Links to introducing changes in professional practice models while attending to
quality and safety, were noted as potential areas for vision and growth. The AONE core competencies related to Professionalism was less cited by
nurse leaders as a as critical concern by nurse leaders, but when mentioned addressed issues around orientation, mentoring and competency
development. Communication and Relationship Building Competencies were seen as important especially around establishing academic
faculty partnerships, physician recruitment and relating with the Union. Many nurse leaders believed it was important to cultivate an environment
where nursing’s voice could be heard and active participation in organizational decision making was supported.
Summary and Future Direction
The results of this survey mirror the 2006 INHL Knowledge and Influence Report (Adams, Duffy & Clifford 2006). Thus, it is not tremendously surprising
that issues concerning Business Skills are the most concerning and time consuming for nurse executive leaders. It is also supportive of the concept that
organizational hierarchical position impacts ones ability to be influential. This inevitable leads us to question the role of Business Skills in Nurse Executive
practice and the value of defining nurse executive practice as a means to promote professional influence within the organization. This study provides an
interesting launching point for continued research toward defining Nurse Executive Leader practice and her/ his influence on work environments and
patient outcomes. Follow-up INHL research will aim to understand
A) other factors (in addition to knowledge), that can aid in one being influential.
B) nurse executive leaders knowledge, influence and the relationship to work environments
C) additional confounding factor(s) such as education level or specialization of work that causes one to self report higher or
lower knowledge scores.
D) NELs level of specific topic knowledge and influence within the non-nurse executive and nurse leader communities
E) psychometric evaluation of the nurse executive leader knowledge and influence tool.
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References
Advisory Board Company (2003). Innovations in Nursing Leadership: Best Practices for Heightening
Senior Leadership Focus on Strategy. Washington, DC.
Adams, J. M., M. E. Duffy, and J.C. Clifford. (2006). Knowledge and Influence of the Nurse Leader: A
Survey of Participants from the 2005 Conference. Boston, MA, Institute for Nursing Healthcare
Leadership: 27.
American Organization of Nurse Executives (2005). "AONE Nurse Executive Competencies." Nurse
Leader: 50-56.
Health Forum (2006). AHA Guide to the Health Care Field. Chicago, IL, Health Forum LLC.
Hsieh, H.-F. and S. E. Shannon (2005). "Three approaches to qualitative content analysis."
Qualitative Health Research 15,: 1277-1288.
Lang, N. M. and J. Clark (1997). "The international classification for nursing practice: Classification of
nursing outcomes." International Nursing Review 44(4): 121-124.
U.S. Department of Labor - Bureau of Labor Statistics (2007). Occupational Outlook Handbook -
Registered Nurses, U.S. Department of Labor. 2007.
