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British Columbia Nursing Leadership Institute: program evaluation report MacPhee, Maura 2011

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  British Columbia Nursing Leadership Institute Program Evaluation Report                           January 2011   Authors  Maura MacPhee, RN, PhD University of British Columbia Academic Lead, BC Nursing Leadership Institute  Nitya Suryaprakash, PhD University of British Columbia Coordinator, BC Nursing Leadership Institute          January 2011      Acknowledgements   This report would not have been possible without the support of many organizations and individuals.  The authors wish to thank:  Dr. France Bouthillette for her contribution as the Administrative Lead of the BC NLI.  The nurse leader participants and mentors who attended the BC NLI.  The Ministry of Health Nursing Directorate  The BC Chief Nursing Officers 1. Barbara Mildon, Fraser Health Authority (2007-2009). 2. Tom Fulton, Interior Health Authority. 3. Suzanne Johnston, Northern Health Authority. 4. David Byres, Providence Health Care. 5. Sherry Hamilton, Provincial Health Services Authority. 6. Amy McCutcheon, Vancouver Coastal Health Authority (2005-2009). 7. Dr. Lynn Stevenson, Vancouver Island Health Authority.  The University of British Columbia, School of Nursing 1. Dr. Sally Thorne, Director. 2. Alex Etesami, Manager, Information Technology. 3. Mary Sun, Administrator. 4. Joy Franklin, Senior Secretary/Office Manager. 5. Cindy Lee, Administrative Clerk.                  Table of Contents   List of Tables..................................................................................................................... List of Figures.................................................................................................................... I. Executive Summary……………………………………………………………………                1-2 II. Introduction..................................................................................................................           3-11 2.1 Background............................................................................................................                3 2.2 The BC NLI Theoretical Empowerment Framework............................................                5 2.3 The BC NLI Design......................................................................................................     6 2.4 The Online Knowledge Network.....................................................................................     7 2.5 Other BC NLI Learning Resources..................................................................................     8 2.6 BC NLI Celebration Days................................................................................................     8 2.7 The BC NLI Participant Profile.......................................................................................     9 III. Evaluation Strategy.....................................................................................................         12-13 3.1 Evaluation Goals and Methods/Data Sources……………………………….......              12 3.2 Analysis of Evaluation Data.................................................................................              13 IV. Evaluation Findings....................................................................................................             14-29 4.1 The End-of -Workshop Evaluation Survey..........................................................                  14 4.2 Online Knowledge Network Usage.....................................................................                  22 4.3 Project Work........................................................................................................                  23 4.4 Career Tracking Survey......................................................................................   29 V. Conclusions and Recommendations.......................................................................................                 41-44 References...................................................................................................................................                  45-46 Appendices..................................................................................................................................                 47-53 Appendix A: Web Shot of the BC NLI Discussion Page....................................................                       47 Appendix B:  Workshop Evaluation Questions..................................................................                48 Appendix C: Healthcare Leader Position Titles.................................................................                        49 Appendix D: Project Details..............................................................................................   50 Appendix E: Career Tracking Survey................................................................................   51    List of Tables and Figures   Tables: Table 1:   Overview of essential nurse competencies within the BC NLI curriculum Table 2:   Number of Nurse Leaders trained Table 3:   Demographic Variables by Total Numbers/Percentages Table 4:   Evaluation Strategy Table 5:   Sample Topics on the Resource Forum Table 6:   Project Priority Areas Table 7:   Leadership Learning Goals Table 8:   Career Tracking Data Table 9:    Participants in Nursing Leadership Roles Table 10:  Management positions by year for 6 cohorts of NLI participants Table 11:  Movement among Leadership Levels Table 12:  Healthcare Sector Changes Table 13:  Span of Control  Figures: Figure 1:  The BC NLI Theoretical Empowerment Framework Figure 2:  The BC NLI Design Figure 3:  Project Locations Figure 4:  BC NLI Project Completion Figure 5:  Participant Responses to Likert Scale Items Figure 6:  BC NLI Components and Leadership Skills Acquisition      1  I. Executive Summary   This report covers the BC Nursing Leadership Institute (BC NLI) operational time period from March 2005 through June 2010. Over this period of time, 14 cohorts (35-40 participants per cohort) participated in BC NLI activities. Total attendance was 451 first-line nurse leaders representing every health sector (e.g., acute care, community, mental health) and every health authority within the province.  This evaluative report is based upon the four major components of the BC NLI: a) a 4-day residential workshop, b) mentoring supports at practice sites, c) year-long leadership projects at practice sites, and d) an online knowledge network with a discussion forum, resources, and a facilitator or knowledge broker (KB).  Key Outcomes:  The BC NLI provided opportunities for nurse leaders to network with each other: to talk and share experiences with peers from across BC.  The BC NLI validated nurse leaders’ appreciation for the importance of competent leadership.  The BC NLI advanced and solidified participants’ leadership competencies as evidenced by:  BC NLI participants stated that they feel empowered and better equipped to lead/manage in complex healthcare environments.  BC NLI participants are employing evidence-based empowerment strategies. In the research literature, empowerment strategies are associated with increased staff job satisfaction and intent to stay.  BC NLI participants’ project work illustrates how they are successfully using change management tools and strategies.  BC NLI participants are more self-aware: able to develop, implement and evaluate their own leadership learning goals.   2  BC NLI participants are recognizing positive changes in their leadership styles and behaviours (e.g., participative decision-making). They believe their staff members are also aware of these stylistic changes.  Notable Findings and Implications:  The majority of participants (68%) were over 40 years of age: a concern with respect to new leader recruitment and succession planning.  The titles and roles/responsibilities of nurse leaders vary widely. Although flexibility/adaptability is important to meet context-specific challenges, some standardization would improve communications and sharing within and across sectors and health authorities.  The majority of BC NLI participants are staying in leadership positions. Career tracking surveys demonstrate that there is limited movement between practice sites or regions, but there is advancement from first level to mid-level positions. Career movement upwards requires succession planning and professional development supports.  Key Recommendations:  First-line nurse leaders benefit from nurse-specific leadership development programs.  Mentoring support (e.g., mid-level or executive level leaders) and organizational supports (e.g., release time for project work) are necessary ingredients for participant success.  Nurse leaders require time for reflection, particularly to build essential components of emotional intelligence: self-awareness, other-awareness, and social/interpersonal competencies.          3 II. Introduction   2.1 Background The Canadian Nursing Advisory Committee (CNAC) (2002) recommended that formal leadership development programs should be in place to train and support first-line nurse leaders. Nursing research evidence demonstrates that effective nurse leadership is an essential component of quality, safe practice environments (Estabrooks et al., 2002; Pearson et al., 2007). First-line leaders, in particular, act as critical buffers between direct care staff and practice environment stressors (Aiken et al., 2001; Ginsburg et al., 2005).  Based on the CNAC report, the BC Ministry of Health Nursing Directorate collaborated with the BC health authorities’ Chief Nursing Officers (CNOs) and faculty from the University of British Columbia (UBC) School of Nursing to initiate, implement and evaluate a leadership development program for first-line nurse leaders across the province. The primary goals of the BC NLI were to: a) prepare effective first-line nurse leaders to meet practice environment challenges across BC; b) provide necessary supports/resources to promote new leader retention; and c) pave the way for ongoing leadership development (i.e., first-level to mid-level transitions).  The program curriculum was based upon a leadership needs assessment survey conducted across BC (Arcand, 2003) and a literature review of published leadership development programs within the nursing, management science and organizational behaviour literature (MacPhee & Bouthillette, 2008). Table 1 is an overview of essential nurse competencies (knowledge components) within the BC NLI curriculum that were identified/derived through the needs assessment survey and the literature review.  The first BC NLI pilot was conducted in March 2005 with 25 first-line nurse leaders. Successful evaluation outcomes resulted in 13 additional sessions between March 2006 and March 2010: three sessions annually with an average of 35-40 first-line nurse leaders in attendance. Participants were nominated by their mid-level or executive level directors to attend the NLI, and formal selections were done by each health authority’s CNO. Each health authority (Fraser Health, Interior Health, Northern  4 Health, Providence Health, Provincial Health Services, Vancouver Coastal Health and Vancouver Island Health) was allotted five seats per session. Nominating criteria included: a) novice first-line leader with less than or equal to 3 years’ of leadership experience; and b) leadership potential (succession planning) as evidenced by enthusiasm and interest in leadership/management roles and responsibilities.  An Advisory committee comprised of UBC School of Nursing faculty, a CNO representative and a Ministry of Health Nursing Directorate representative was established to provide guidance with respect to BC NLI operations and sustainability.  Table 1 Key BC NLI Competencies (knowledge) * Knowledge  1. Leadership theory 2. Leadership styles 3. Quality practice environments 4. Power dynamics 5. Business charters/cases 6. Human resource allocation 7. Communications 8. Teamwork 9. Quality and safety 10. Accreditation 11. Time Management 12. Networking   13. Organizational structures/processes/outcomes 14. Empowerment theories/strategies 15. Emotional intelligence 16. Change management 17. Project planning/implementation/evaluation 18. Innovation theory/diffusion theory 19. Complexity science principles 20. Conflict resolution 21. Finance/budgeting *Some of these competencies, such as finance/budgeting are more characteristic of mid-level leader positions, but they were included on advice of executive nurse leaders within BC to better prepare first-line leaders for eventually moving into mid-level leader roles.   5 2.2 The BC NLI Theoretical Empowerment Framework A unique feature of the BC NLI was its over-arching theoretical empowerment framework that is based on nurse empowerment research (Laschinger et al., 2008a) and structural empowerment theory (management sciences) and psychological empowerment theory (social-psychological sciences). The theoretical framework serves as a mechanism for unifying nurse empowerment concepts and strategies. See Figure 1 for a diagram of the BC NLI theoretical empowerment framework. Laschinger and colleagues have shown that effective nurse leaders can empower staff by providing staff with access to organizational empowerment structures (structural empowerment) and by building self-confidence through psychological empowerment strategies (Faulkner & Laschinger, 2008; Laschinger et al., 2004) Both theories/associated strategies have been shown to lead to better outcomes for nurses and nurse leaders, such as increased job satisfaction, organizational commitment and intent to stay and decreased emotional exhaustion and turnover (Laschinger et al., 2007; Laschinger, 2008b).  Figure 1.  The BC NLI Theoretical Empowerment Framework      BC NLI  Leader and Staff Job Satisfaction Leader and Staff Organizational Commitment Staff Structural and Psychological Empowerment Leader Structural and Psychological Empowerment  6 2.3 The BC NLI Design The BC NLI four-component design (i.e., residential workshop, mentoring, project work, networking) was modeled after similar nurse leader development programs (Simpson et al., 2002; Sullivan et al., 2003), although the online knowledge networking component was a unique feature of the BC NLI (MacPhee et al./, 2009). See Figure 2 for a diagram of the inter-related BC NLI components.  Figure 2. The BC NLI Design    Participation in the BC NLI entailed a year-long commitment, beginning with a 4-day residential workshop.  Nurse leaders were asked to arrive on a Monday evening for a ―Meet and Greet‖ and program overview. Over the following three days, faculty and guest experts covered the key knowledge components (See Table 1) with time allotted for peer discussions, networking and interactive exercises. On the evening of the third day (Thursday evening), participants’ mentors were invited to attend a buffet dinner, and the final, fourth day was dedicated to mentor-mentee work. Mentor-mentee dyads were expected to develop a year-long working agreement, identify realistic leadership learning goals and activities, and begin work on a leadership project plan. Faculty were available to assist with project planning and the development of realistic leadership learning goals.  British Columbia Nursing Leadership Institute  7 During the remainder of the year, mentors and mentees were asked to commit regular time to project work and assessment of leadership goals and activities. Participants were asked to post electronic project reports on the BC NLI website one week post-workshop attendance, at 6 months and at year’s end (or the completion of their project work). Participants also were asked to complete annual career tracking surveys.  2.4 The Online Knowledge Network A unique feature of the BC NLI is its online knowledge network (KN). Details of the BC NLI KN are described in MacPhee et al. (2009). Knowledge networks are ways to build online communities of practice: a virtual community of individuals with like interests who can share ideas and resources with each other. The BC NLI KN is housed at the UBC School of Nursing, and it is maintained through in- kind supports from the School of Nursing. Although the BC NLI funding has officially ended, the online KN will remain open to BC NLI leaders and mentors through September 2011.  There are public and private components of the KN. The public website is at: http://www.nli.nursing.ubc.ca. There are links to BC NLI background and description pages, the faculty, and resources used by BC NLI faculty, such as textbooks and articles. The Project Page site provides an overview of BC NLI participants’ projects, and searches can be done by cohort attendance date, health authority, or key words (although this function is not well developed). Participants have control over content on the Project Page. Participants, for instance, determine whether their contact information is publically available, and they also control public access to detailed project information: a magnifying glass next to the project title indicates public access to project details.  The Discussion Forum is a private site for BC NLI participants and mentors. A web shot of the Discussion Forum can be found in Appendix A. This site includes a General Discussion page for discussion threads on any topic.  To maximize the effectiveness of KNs, it is important to use a skilled facilitator or Knowledge Broker (KB) to connect online members with each other and with available resources (MacPhee et al., 2009). Knowledge brokers can also act as gate keepers to regulate information quality and quantity.  8 The BC NLI KN has been employing skilled nurse educators to act as KBs on a part-time basis, and a KB will be available to BC NLI online members through September 2011. Note: The KBs have been funded through a Canadian Health Services Research Foundation grant.  The Special Monthly Discussion page is no longer operable. The BC NLI used to host online conversations with subject matter experts via this Discussion page. In the past, some hosted conversations included the following topics: patient flow in Emergency Departments, shared governance models, SBAR and other communications tools, team-building. For each Special Monthly Discussion, an e-notice was sent out to BC NLI members, encouraging them to post questions for experts during a specific time period. Experts were available in real time to answer online questions, and they also checked in regularly to address additional questions/postings. Transcripts of these online conversations are still available to members at this private site.  Other private components of the Discussion Forum include a Resource Forum where participants and the KB can share relevant resources with each other, and a Picture Gallery for posting BC NLI photographs.  2.5 Other BC NLI Learning Resources At the time of workshop attendance, each participant received a binder with powerpoint handouts and notes pages accompanying each knowledge session (i.e., lecture with accompanying discussion and activities on a related topic, such as teamwork). Participants also received a copy of Becoming Influential: A Guide for Nurses by Sullivan (2004). This book covers power dynamics, ―rules of the game‖ within organizations, influence strategies, and strategies for dealing with difficult people and challenging situations. The book complemented several knowledge sessions in the 4-day residential workshop.  2.6 BC NLI Celebration Days Certificates of completion (at the end of the year or project work completion) were formally awarded on BC NLI Celebration Days. These events typically consisted of 1-2 days of nurse leader project presentations (podium or poster) and in-person networking activities. Celebration Days were held at the  9 UBC Vancouver campus in June 2008, 2009 and in Harrison Hot Springs June 2010. Nurse leader graduates’ and their mentors were invited to attend.  Participants were encouraged to share project information and leadership insights related to their year-long learning activities. The BC NLI produced Celebration Day booklets with participants’ project summaries and contact information to promote networking beyond the BC NLI, such as continued engagement with the online KN.   Patterned after the Canadian Institute of Health Research (CIHR) Café Scientifique model (http://www.cihr.ca/e/35087.html), participants also were invited to discuss topics such as: How can knowledge networking be effectively used by leaders to make a practice difference?  What are some ways to enhance care delivery during times of economic constraint?  2.7 The BC NLI Participant Profile We defined first-line nurse leaders as union members in roles to support day-to-day nursing activities. First-line leaders were not involved in disciplinary actions (e.g., hiring, firing) or budgeting. Table 2 provides an overview of the number of nurse leaders trained per BC NLI session.                10 Table 2 Number of nurse leaders trained  Session  N Session 1:    March 2005 25 Session 2:    March 2006 28 Session 3:    November 2006 35 Session 4:    March 2007 (5 th -9 th ) 34 Session 5:    March 2007 (26 th -30 th ) 34 Session 6:    October 2007 31 Session 7:     November 2007 30 Session 8:     March 2008 35 Session 9:     October 2008 32 Session 10:   November 2008 32 Session 11:   March 2009 34 Session 12:   October 2009 33 Session 13:   November 2009 30 Session 14:   March 2010 38 Total 451  Although 451 nurse leaders attended the BC NLI, we did not develop a formal online registration system until October 2007 that was able to accurately record participants’ demographic information. Table 3 is a demographic overview of BC NLI leaders from cohorts October 2007 through March 2010.  More than half the nurse leaders were over 40 years of age (68%), female (91%), with less than 3 years of nursing experience in their current position (77%). Five major employment settings were identified: acute care (68%), residential/long term care (9%), public health (6%), mental health (4%), and community and home health care (7%). Nearly half the participants had completed their Bachelor’s in Nursing (BSN) (49%), while 38% of participants held diplomas in nursing.    11 Table 3 Demographic Variables by Total Numbers/Percentages (October 2007- March 2010 cohorts) N=295 Variable n % Variable n % Age Range   Sex 20-29 12   4.1 Female 267 90.5 30-39 79 26.8 Male 28  9.5 40-49 117 39.6 Educational Level 50-60 84 28.5 Bachelor 145 49.2 Not Given 3   1.0 Diploma 112 38.0 Organization    Masters 19   6.4 Fraser Health 43 14.6 Other  13   4.4 Interior Health 38 12.9 Not Given 6   2.0 Northern Health 40 13.5 Experience in current position Providence Health Care 51 17.3 < 1 year 93 31.5 PHSA* 40 13.5 < 3 years 134 45.4 VCH** 45 15.3 > 3 years 63 21.4 VIHA*** 38 12.9 Not given 5 1.7 Employment Setting Acute Care 202 68.4 Residential Care/LTC 26  8.8 Public Health 17  5.8 Home Health and Community Care 21  7.1  Mental Health and Addictions 12  4.1 Others 17  5.8 Notes: * Provincial Health Services Authority; **Vancouver Coastal Health Authority; ***Vancouver Island Health Authority.  The majority of data reported in the following sections correspond to the cohorts attending session 6 (October 2007) to session 11 (March 2009). Data from cohorts (12-13) are still being analyzed, and data from the final session (14) still needs to be collected in March 2011.    12 III. Evaluation Strategy   3.1 Evaluation Goals and Methods/Data Sources Evaluation strategies were designed to: a) assess the effectiveness of the four BC NLI components from the perspective of participants; b) produce evidence of nurse leader effectiveness; c) produce evidence of new leader retention in their first-line leadership roles; d) produce evidence of leadership development/transitions with respect to movement from first-level to mid-level leadership roles.  Our key evaluation data sources/data collection methods were: a) an end-of-workshop survey to assess participants’ perceptions of content/delivery of the 4-day residential workshop; b) online KN user statistics to determine types and frequencies of online member communications; c) participants’ Project Page information to assess leadership goals at the end of the workshop and project goals/work at the end of the workshop, 6 months and at 1 year from workshop attendance;  and d) an online career tracking survey administered annually from workshop attendance to determine participants’ status with respect to leadership position and location (e.g., practice setting, health authority). Table 4 summarizes the BC NLI evaluation goals and evaluation data sources/data collection methods.             13 Table 4 Evaluation Strategy Evaluation Goal Evaluation Sources/Methods  BC NLI Effectiveness  End-of-Workshop Participant Survey (Appendix B)  Online KN user report/statistics  Nurse Leader Effectiveness  Participant Member Pages (Online Project Page)        http://www.nli.nursing.ubc.ca/Projects.aspx o Leadership goals, activities (end of workshop) o Project work (one week post-workshop attendance, 6 months, 1 year) Nurse Leader Retention  Electronic career tracking survey administered at annual anniversary dates from workshop completion: o 2007 cohorts (2008,2009,2010) data o 2008 cohorts (2009, 2010) data o 2009 cohorts (2010) data  3.2 Analysis of Evaluation Data Evaluation data were primarily descriptive—either numbers or narrative statements. For the numeric data, we will report number totals and frequencies (i.e., proportion of responses/total responses). For narrative data, such as participants’ responses to open-ended survey questions and their descriptions of leadership goals and project work, we used content analysis (Graneheim & Lundman, 2004) to identify common themes, and we also identified quotations or exemplars representing common themes.           14 IV. Evaluation Findings   4.1 The End-of-Workshop Evaluation Survey These survey data are based upon 12 sessions/cohorts from November 2006 to March 2010. Out of 398 evaluation forms distributed, 295 were returned (74% return rate). See Appendix B for a copy of the questionnaire. The common themes (highlighted in red) are embedded within key italicized quotes. Additional quotes are provided per question with accompanying conclusions.  Question 1: I really liked   Networking with other nurse managers from different parts of BC. Being with other nurses. To share stories and perspectives with nurse peers who understand me.   To be able to understand clearly the issues in leadership, and leadership roles and responsibilities. To be able to put faces to positions and understand organizational structures.   A workshop content that is transferable to the workplace, evidence-based, and practical. Learning different strategies which I can incorporate in my workplace. To be able to take all the tools/ materials and apply it directly to daily practice.   Being taught by nurse leaders and faculty with expertise in the real world.   That I was inspired to do a better job.   That I was able to acknowledge my accomplishments, personally and professionally   A chance to reflect on what I had learnt everyday.   Having time to connect with my mentor.  Additional Supporting Quotations: Networking: "I have been able to see more clearly the issues that exist for me in this new stage of my career and for my staff as they are commonalities that exist for other nurse leaders and teams.” ―Realising that I am not alone” and ―Recognizing how even though we manage different areas, we face similar challenges.”  15 Issues in Leadership: "As a new leader of XX, it (the workshop) helped to explain processes that I have been doing already with more evidence.” (The program) "validated and enhanced my vocabulary and understanding of what I currently do in my role.” "The content gave me an insight into my roles and responsibilities.” Transferable/Expertise in the Real World: "All the presenters were people who could really relate to the real issues in nursing. They were real and didn't mince words. The information was straight forward to the point and meaningful to my career.”  "All the sessions were presented in a very informative and helpful way and was pertinent to what I am doing.” “I really appreciated the binder and handouts as it gave me time to listen and not be worried about writing down the content. It had some very practical and useful tools that I will be using when I return.” Inspired/Acknowledge My Accomplishments/Reflect: (The program) “ changed my perceptions of how we should be feeling and acknowledging our accomplishments in our work and personal lives.” "My batteries have been recharged and I remember why I became a manager.” “I really appreciated time to listen and reflect.” Mentor: ―I was able to connect with my mentor to get a baseline understanding of the project.” “The ability to have one-on-one time with my mentor.”  A number of participants felt that everything about the workshop was great: " From the great speakers, great learning tools, great environment… All make for a good learning experience.” ―I liked everything in this BC NLI course- it is very unique, it is a big chance of a lifetime. I learnt a lot and this hopefully will inspire me more to fulfil my position.”  Conclusions:  Connecting with other nurse leaders was a learning experience and a validation process for participants.  The curriculum content was comprehensive and practical, and the delivery modes included action learning strategies that are known to appeal to adult learners (Allen & Hartman, 2008).  Faculty expertise with practice-based organizational/leadership challenges enhanced participants’ ability to make connections between theoretical knowledge and practice.  Reflection time was essential for participants to evaluate their leadership strengths and challenges.  16 Question 2:  I would change   The format to end the day earlier, less volume of information given, more group work, and longer breaks.   Some of the presentations to have more interactive time for questions, small group discussions and for sharing of experiences and storytelling.   Additional Supporting Quotations: Volume of Information: "For a complete newbie like myself, it was a lot to take in 4 days. I fear that I won't remember all those wonderful things I learned.‖ “It was hard to focus due to the information overload during the day.‖ More Interactive Time: “At times it is difficult to focus on lectures. I would have liked more small group work so that others would share their experiences and expertise.” “I would have liked the ability to practice some of the techniques on how to be an effective leader through small group work.”  Conclusions:  A great deal of new information was covered in the 4-day workshop. Although time was allotted for discussion and group work during the workshop, the faculty recognized the need for additional reinforcement, hence, the additional BC NLI components (i.e., online networking, leadership projects, mentor support).  Question 3: A new idea for me was   Many of the topics and concepts presented like developing a project plan, different leadership styles, reflective journaling, innovation theory, leading from the middle, complexity science, emotional intelligence which were useful, practical and applicable to daily practice. Importance of business language. I have to use the right language depending on the target person and organization. How big trust is in the workplace. Frameworks and models made more sense. The importance of organizational structures and chain of command in order to present cases.   That there are tools easily available that I have access to if required.   Looking at my leadership values with respect to the mission/vision of the organization. Matching values/accountability- to myself, my team and organization.   17 Additional Supporting Quotations: Topics/Tools: Every returned survey specified 1-2 new topics, often linked to accompanying tools/resources introduced to participants during the workshop.  The topic/tools most commonly cited pertained to project management. “Project management concepts and tools will be valuable to me during my project work.”  ―The knowledge that there are formal tools for planning and communicating plans.‖ Another common topic was empowerment/power. “Knowing that as a leader, you are in charge, in a position of power and ultimately responsible for that was an eye opener.”  ―Power and influence… I never gave this a thought, or playing the game… always need to be aware of playing the game.”  For a few participants “Almost everything were new ideas for me.”  “It was like the light bulb went on.” Leadership Values: “One of the things that stands out for me is trying to do everything with the vision/mission in mind.” “Not only do I have a profound responsibility to the patients and my staff but to myself and my employer.”  Conclusions:  Participants benefited from having an array of tools/resources associated with theory content.  Empowerment theory with accompanying strategies (our theoretical framework for the BC NLI) was valued by many participants.  Values (e.g., leadership values, organizational values, staff values) need to be emphasized in leadership development programs. Nursing research evidence supports the importance of values. When organizational values are in synchrony with staff values, there is less dysfunction in the work environment (Gifford et al., 2002). Leaders often fulfill the role of connecting organizational values (e.g., vision/mission statements) to practice (Force, 2005, MacPhee, 2007).           18 Question 4: The most beneficial part of the Institute for me was   Networking with nurse managers in similar positions across BC. Acknowledgement that everyone has major challenges in their work environment. The ability to explore leadership issues and problem solve these with professionals in other areas/specializations. Knowing that I am not alone.   Ideas, topics covered and tools to do the job. Overall frameworks relating practice to research. Learning the business language. Learning ways and strategies on how to empower my staff.    Having time out to reflect and self-assess my leadership areas. Identifying my leadership style and learning what kind of leader I strive to be.   Inspiring and energizing me and helping me value what I can do as a leader.   Connecting with my mentor in a very meaningful and positive way.  Additional Supporting Quotations: Responses to this question reinforced participants’ answers to Questions #1 and #3. Networking: ―To hear from individuals who are creatively addressing issues in nursing and health care regardless of the current climate and difficulties.” “I liked networking and the support I know I will have when I go back home.” “I also learnt just how vast the expertise in the province is of frontline leaders-- sharing experiences, insights and ideas was invaluable.” “I found the group was most engaged when we were sharing situations and hearing solutions/practical applications from the group.” Ideas/Topics/Tools: “The tools to get the job done.” “ The business case presentation illustrated the importance of presenting a solid plan when introducing new project ideas. This information will help me greatly when planning new projects.” “The operational finance was beneficial, as I have no experience coming to this leadership position from the bedside.” Reflect/Inspiring: “I became aware of exactly where I am professionally, identified specific gaps in my leadership styles/strengths.”  ―I needed the time to re-energize my interests in my position as a leader within the team…prior to this week I was at a point of thinking I needed to move on or move  back to the frontlines due to the feelings of exhaustion and isolation. At the end of the week, I feel excited, invigorated to lead the team.‖ ―I was feeling „ho hum‟ in my job and these 4 days has brought some enthusiasm and excitement to what I want to do.”  ―I feel more confident in my role. Being part of the institute has switched on the nurse leader in me and I feel that I have new motivation and passion.” “The realization that yes I can do this. I feel the need to be a part of the bigger picture.”  ―Being away  19 from family, work, commuting… it freed me to focus one hundred percent on the course content and critically reflect.”  “I was able to self-assess my leadership areas of improvement-- reflect on how I am as a leader and where I want to go.” Mentor: “Connecting with my mentor in a very meaningful and positive way, away from a hurried workplace.‖ “It‟s important knowing that I have mentor support.”  Conclusions:  Similar themes emerged from different questions (i.e., #1,3,4) reinforcing the importance of time away in a formal leadership program for nurse leader networking, knowledge acquisition, and critical self-evaluation and reflection.  Leadership workshops are insufficient on their own. They must be accompanied by mentor and organizational supports.  Statements made by participants (i.e., increased confidence, motivation to lead) provide evidence that attendance at the BC NLI psychologically empowered them.  Question 5: What I will do with what I have learnt   Consciously think about developing my leadership skills in my work place. Evaluate what I have learnt, prioritize what I have to accomplish as a new leader. Use some of the tools learned to enhance my leadership role. Set clear goals and objectives for my personal and professional growth plan.   I want more engagement with my staff, the team, the organization. Build trust with the staff.  Improve staff satisfaction/retention. Increase engagement within the team. Try to be more inclusive in meeting with allied groups such as finance, recruiting. Learn more about my organization and its goals and vision.  Additional Supporting Quotations: Developing My Leadership Skills:  Many comments pertained to participants’ leadership projects. “I will work on my project with new insights, information, techniques along with the tried and true ones that I have learnt along the way.”“(I have learnt) how to plan for my project and work towards the successful completion of the goals.” “I will now re-evaluate my project plan and tie it to the mission statement/values of my organization.” “I will now be able to take the lead in my project not relying so much on others to create it for me.‖ Other comments referred to participants’ desire to create quality,  20 safe work environments. “I want to create a working environment to provide quality care using best practices.” I want to take forward the concept of quality practice environments.” Engagement (Empowerment): ―I want to work to increase engagement within the team; work to change culture on the unit I am responsible for.” “I want to transfer what I know to the work place and team members to empower them.” “I want to implement the knowledge I learnt to team build and resolve conflict.” “Empowering staff to make suggestions of what they would like changed in the workplace.” “I will meet with my staff regularly to help set professional goals with them and to provide feedback through performance evaluation.”  Conclusions:  Responses provided evidence of participants’ increased awareness of themselves as leaders, their influence on others, and their place within the organization.  Responses provided additional evidence of participant empowerment: participants’ desire to try out new skills and to actively engage with others.  Question 6: I would like to learn more about   Power and politics-organizational structure- the chain of command and roles and responsibilities of management levels. What is the thinking of administration?  Political situations and its influence within nursing and interdisciplinary teams. Nursing influence- how limiting?   The practical stuff like fiscal management, conflict management, change management, team building, influencing others, leadership styles, mentoring. Communication coaching as a leader. Being persuasive and giving presentations. Dealing with union issues and grievances. The human resources aspect of leadership management-peer evaluations, disciplinary stuff.  Additional Supporting Quotations: Power and Politics: ―I need to know how to tell who to go to as a resource, what can I do and not do.” “I need more information on the organizational structure...maybe description of various job titles.”  “What are provincial health care trends/decisions and how they affect different authorities as well as inter authority communication." “As nurses, how can we influence policy and change?” Practical Stuff: Participants indicated that you can “always learn more.” There was a diversity of comments, but many of them pertained to interpersonal skills such as conflict resolution, human resource issues, and union issues.  ―Conflict resolution between staff is one of the areas I find  21 particularly challenging to deal with as a nursing unit manager- would like more on this.”  “HR processes--I would like to learn more about working with human resources with union participation.”  "I want to know more about generational gaps and differences.”  “I would like leadership strategies for working with a portfolio of geographically separated programs, each of which I have limited time on site.”  “Needing better knowledge of the collective bargaining agreement and grievance procedures.”  Conclusions:  Interpersonal skills, human resource and union issues were predominant themes. Participants also raised topics that may be region/institution-specific, such as managing across geographically disparate sites.  To accommodate continuous learning, there should be ongoing leadership development opportunities, such as mini-workshops or in-services (Allen & Hartman, 2008). The BC NLI addressed some of the common topics identified through this survey question via the online Special Monthly Discussions site.  Question 7:  If I was organizing this leadership course I would   Make sure there is follow-up. Have a “part II" face-to-face in 6 months. Have alumni meet yearly to present projects.   Provide continuing education opportunities. Take what we have learned and expand to the next levels.   Look for continued funding to ensure sustainability. Nurses in BC have been waiting a long time for these types of opportunities!   Additional Supporting Quotations: Follow-up/Continuing Education Opportunities: “The program was well-developed with the right focus on nurse leaders. We need more of this to keep up the learning.” “Have a part II face-to-face in 6 months.” “Have alumni meet yearly to present projects.” Sustainability: “I would change nothing. I would look for more funding to keep it going….there are so many others that would benefit from this.” “Look for continued funding for the face to face leadership forums.” “Ensure all new leaders receive an opportunity to attend- invaluable as a new leader.” “Require all managers to take the course.”  22 Conclusions:  Participants particularly valued face-to-face interactions with their peers.  Participants recognized the importance of continuing education (to maintain/build competencies), and the importance of the BC NLI as a means to develop future nurse leaders across the province.  4.2 Online Knowledge Network Usage The BC NLI faculty are tracking statistical reports related to the online KN usage. Funded through the Canadian Health Services Research Foundation and in-kind supports through the UBC School of Nursing, this component of the BC NLI will continue through September 2011. The statistics in this report cover August 2008 through December 2010.  The BC NLI KN currently has 418 members including nurse leaders, their mentors, and some guest members (e.g., UBC School of Nursing faculty and students). There have been over 332 posts on 90 different topics.  Within the Special Monthly Discussions forum, we are tracking ―number of views‖ or ―hits‖ to determine the popularity of specific topics. The most popular topics have been: a) team-building (160 hits); b) business cases (146 hits); c) SBAR communications (144 hits); d) patient flow in Emergency Departments (115 hits); and e) accreditation (87 hits).  In a similar fashion, we are tracking the types of postings in the Resource forum and the number of views per topic. The KB and online members generally post 3-4 new resources monthly. Table 5 provides a sample of posted topics with their corresponding number of views.        23 Table 5 Sample Topics on the Resource Forum Topic Number of Views  Business case templates and ―how-tos‖ 83 Examples of patient flow algorithms 56 Shared governance models/guidelines 47 Performance appraisal materials 46 SBAR templates 34 Regional patient safety initiatives 14 Nursing workload articles 20 Mentoring resources 20 Web links for emotional intelligence tests 14 Work-life balance articles 12 Quality practice environment survey 10  Conclusions: The online KN has been the least used component of the BC NLI. A considerable investment of 3 to 5 years of effort and money are often required to establish active online communities of practice (MacPhee et al., 2009). Participants were more engaged with the KN during the BC NLI funding period, and since the last workshop was held in March 2010, online activity has waned. To enhance KN usage while its funding lasts, the KB and BC NLI faculty send out e-mail newsletters with links to the KN Resource forum at regular, 2-week intervals.  4.3 Project work Nurse leaders were asked to upload information in their BC NLI online member pages on the Project Page website (Public access at: http://www.nli.nursing.ubc.ca/Projects.aspx. ). At one week post- workshop attendance, an electronic notice reminded participants to upload their initial project description and leadership learning goals. At 6 months from workshop attendance, an electronic notice requested that participants upload formative project reports, and at 1 year from workshop attendance, an electronic notice asked participants to: a) indicate the status of their project, b) submit a final project  24 report, and c) briefly indicate how BC NLI attendance had furthered their leadership career. Refer Appendix D.  The BC NLI faculty conducted content analyses on members’ project pages for the October 2007 to March 2009 cohorts. Faculty received assistance from a UBC School of Nursing undergraduate student funded through a Canadian Institute of Health Research (CIHR) student award. A UBC School of Nursing graduate student is conducting thesis work on cohort data from October 2007 through November 2009.  Based upon 194 participants (October 2007-March 2009 cohorts), we received 153 project descriptions with leadership goals post-workshop attendance (response rate=79%).  We content analyzed these project descriptions and leadership goals to establish priority project areas and major leadership learning goals, respectively. We also determined the settings/sectors for the projects.  Most of the 153 submitted projects (October 2007-March 2009) were conducted within the home institutions of the participants (68.6%), although some projects were regionally based (26.8%), a few projects were between health authorities/regions (2%), and 2.6% were provincially based. See Figure 3 for a breakdown of project locations.  Figure 3.  Project Locations   25 Table 6 provides an overview of project priority areas. These priority areas are arranged from highest to lowest overall number of corresponding projects across the 6 cohorts. Note that the ranking of priority areas varied slightly by year. The actual titles of leadership projects can be publically viewed at: http://www.nli.nursing.ubc.ca/Projects.aspx.  Table 6 Project Priority Areas  2007 (N=48) 2008 (N=78) 2009 (N=27) Total (N=153) Project Areas (Highest to lowest total #s) n (%) n (%) n (%) n Staff Retention/Job Satisfaction    5 (10.4)      12 (15.4)      5 (18.5) 22 Staff Professional Development   8 (16.7)       8  (10.1)      6 (22.3) 22 Communication and Collaboration   8 (16.7)      12 (15.4)    1 (3.7) 21 Improving Care Delivery      2 (4.2)      10 (12.8)      5 (18.5) 17 Staff Mix   8 (16.7)        4 (5.1)      3 (11.1) 15 Staff Orientation      3 (6.2)        9 (11.5)      3 (11.1) 15 Community Care      2 (4.1)        4 (5.1)       0 6 Geriatric/LTC Care      4 (8.3)        2 (2.6)       0 6 Mentoring      2 (4.1)        1 (1.3)    1 (3.7) 4 Use of Technology      1 (2.1)        2 (2.6)    1 (3.7) 4 Surgical Care      1 (2.1)        3 (3.8)       0 4 Palliative Care      1 (2.1)        1 (1.3)    1 (3.7) 3 Prenatal/Perinatal Care      1 (2.1)        2 (2.6)       0 3 No specific priority  area      1 (2.1)        2 (2.6)       0 3 Paediatric Care      1 (2.1)        1 (1.3)       0 2 Mental Health Care      0        2 (2.6)       0 2 Emergency Services Care      0        1 (1.3)    1 (3.7) 2 Quality/Safety       0           2 (2.6)       0 2  Leadership goals from the 153 submissions (October 2007-March 2009 cohorts) are ordered from highest to lowest numbers in Table 6. Some participants had more than one major learning goal.  26 Table 7 Leadership Learning Goals Leadership Goals: Highest to Lowest  n Develop leadership skills (e.g., project management, human resource management) 70 Empower/support staff 64 Cultivate a more effective leadership style (e.g., participative, transformational) 24 Facilitate communications, collaboration (e.g., staff, interdisciplinary) 19 Network with others 16 Improve efficiency/proficiency 14 Maintain work-life balance 9  At the end of 1 year from workshop attendance, we used participants’ status reports to determine successful completion of leadership projects. Figure 4 provides a diagram of leadership project completion for October 2007 through March 2009 cohorts at 1 year from workshop attendance.  Forty- six percent (n=71) of participants successfully completed their projects while 18% (n=27) stated that their project work was still ongoing due to delays, et cetera. Twenty percent (n=30) of the participants did not complete their project work for a variety of reasons including workload issues, different organizational priorities, and lack of mentoring support. A few of these  individuals (n=7) stated that they had switched leadership positions due to organizational restructuring and could no longer continue to participate in BC NLI activities. Our non-response rate was 16% (n=25).           27 Figure 4.  BC NLI Project Completion   At the 1 year anniversary from workshop attendance, we asked participants to briefly indicate how BC NLI attendance had furthered their leadership career. The majority of comments focused upon the importance of project work: having an opportunity to use newly acquired leadership competencies to conduct a leadership project of relevance to their practice settings.  One participant stated: "The biggest thing that I got from the BCNLI was to take on a project and see it to completion. Now that is it completed, there is actually still more that I want to do! It was good because it gave me the structure on how to do a project. And how to get people excited about it and involved in it, so I can see myself doing further projects in the future.”  Participants were able to learn more about their organizations’ management structures and the processes necessary to obtain project ―buy-in‖ from key stakeholder groups. ―The information, project proposal guidelines were so valuable in getting me started with my project. I was able to look at the big picture and align my vision with the organization's vision. This was important in dealing with the key stakeholders." "I was able to get the Director's attention to the issues and we got fourteen thousand dollars dedicated to making the project happen.”  "I created a project charter which actually received a lot of positive feedback from senior management like the directorship and the health authority. The flip side is that we just never got the funding to hire somebody to trial out the project due to lack of clinician  28 buy-in and FTE support.”  "I helped build a brand new emergency department and part of my project actually was assisting staff through clear communication to embrace the changes.  And we changed our entrance to the hospital, we changed how we do triage and then we moved to a new department all within the last year.  So all those skills that the NLI supports and assisted with I‟ve been able to use every day.”  " I learned how to run a focus group—I‟ve never done that before. It was really, really good. I think it really created excitement among the staff sort of feeling there was some change coming— thinking of how to make the clinic better… I had really good representation from all our groups, and it was really effective in getting communication happening.”  Through project work, participants were able to empower themselves and staff.  One participant wrote: “I‟ve done little things, but I‟ve never set up anything as big as this one or nothing totally generated by myself. I thought of it and put it together from scratch—I‟ve done projects, but they‟ve been delegated…and mine made a huge difference to the workplace… I enrolled others and got people excited about things. It‟s given me so much more self confidence.”  Another participant stated: ―I have an improved and broader understanding about facilitating change and collaborative leadership. I feel I am taking a more confident leadership role.”  Other participants commented: "Project work helped me work towards meeting my goal of establishing a more cohesive and effective team.” "It (project work) enabled me to empower the staff nurses and increase their job satisfaction and increase staff morale. I am hoping that they will feel connected to management and that they feel that they are being heard and that they are effecting change.‖ “I was able to communicate and engage staff in the decision making process by providing them with tools to problem solve and guidance to achieve positive outcomes." “I helped the staff choose an evaluation tool.  I have had several staff comment on how great this experience was and that they had not had a formal evaluation done for more than 10 years. I am seeing more engaged staff who seem to smile more and enjoy their work. I make a special effort to do my best to thank them and fan good work whenever I can. This seems to be creating a more positive work environment.‖   29 For those participants who were unable to successfully complete their projects, the project work was still deemed the most beneficial aspect of the BC NLI. One participant stated: “Although I didn‟t finish, this was an invaluable lesson on dealing with resistance to change from staff.”  The second most-cited benefit of the BC NLI pertained to formal mentoring support, particularly in relation to project work. Participants wrote: “Having a mentor with dedicated time to meet throughout the project was crucial to the ongoing work." “Mentors are the key to the ongoing success of my leadership and the formal mentorship relationship recommended by the institute enabled me to balance a spirit of advocacy with a spirit of inquiry.”  I think the project would have failed without a mentor that‟s really committed to the project. I had quite a good one where the sense is that he did put me into the calendar so I was always there.  But If I didn‟t have that I don‟t think I would have finished my project.”  Conclusions: Project work and mentorship time were the two most valued components of the BC NLI, although participants’ statements reflected the utility of the workshop content, tools and resources with respect to successful project planning and implementation. Projects ranged from the unit/facility level to the provincial level, although the majority of projects took place within participants’ respective practice settings. The majority of projects dealt with staff issues, such as retention, staff development, communications and collaboration. The key leadership learning goals reflected participants’ determination to enhance their skills and styles, and to make good use of newly acquired knowledge and tools. A significant leadership goal was empowerment of staff, emphasizing participants’ awareness of others’ needs to have a greater voice in practice environment issues.  4.4 Career Tracking Survey Participants were asked to complete online career tracking surveys at annual anniversary dates from their BC NLI workshop attendance. To facilitate survey completion, the questions had drop-down response menus with the opportunity to write in details. The survey questions were: 1) Are you currently working in nursing?  2) Are you in a leadership role?  3) What is your current management position?  4) What is your current health authority?  5) What is your current health sector?  6) What is your current  30 span of control? These questions allowed us to ascertain participant movement with respect to nursing leadership roles and responsibilities, healthcare sectors and practice regions.  For the 1 year career tracking survey (Appendix E), we included additional questions to better evaluate benefits derived from the BC NLI. The survey included nine Likert scale questions ranging from 1 (strongly disagree) to 7 (strongly agree). These questions were designed by the BC NLI faculty to determine BC NLI goal effectiveness. The questions asked participants to choose the best numerical response with respect to how the BC NLI had: a) increased self-awareness of strengths and weaknesses as a leader; b) provided a clear leadership development path; c) allowed the participant to gain experience in change management; d) facilitated the experience of success through the development and implementation of a work project; e) provided a means to connect and network with other leaders; f) provided important knowledge and tools to develop skills and knowledge as a leader; g) showed participants that they were not alone with their leadership struggles; h) helped participants recognize they were not in leadership positions where they wanted to be; and i) not assisted with leadership career development in any way. The latter two questions were included to prevent response bias with respect to only positively worded questions.  A final survey question asked participants to indicate what percentage of their leadership skills had been acquired from each of the four BC NLI components: the workshop, mentoring, project work and online networking. This additional question helped to validate information obtained from other evaluation sources, such as the end-of-workshop evaluation survey and the project work.  As of December 2010, we have collected 3 years of career data (2008, 2009, 2010) for the October- November 2007 cohorts. We have 2 years of career data (2009, 2010) for the March 2008, October 2008 and November 2008 cohorts, and we have 1 year of data (2010) for the March 2009 cohort. All 6 cohorts (N=194) received the 1-year career tracking survey, and we received 158 completed surveys (response rate=81.4%). Five cohorts (N=160) received the 2-year career tracking survey, and we received 140 completed surveys (response rate=87.5%). Two cohorts (N=61) received the 3-year career tracking survey, and we received 52 completed surveys (response rate=85.2%).  Table 8 depicts cohort numbers and returned career tracking surveys.   31 Table 8 Career Tracking Data Time/cohort N Respondents (%)      Year 1 ( 6 cohorts) 194 158 (81.4%) Year 2( 5 cohorts) 160 140 (87.5%) Year 3 ( 2 cohorts)  61  52 (85.2%)  The following sections present the evaluation data according to the order of the questions on the career tracking survey.  Question 1: Are you currently working in Nursing?  Over the 3-year period of survey administration, all the respondents remained in nursing.  Question 2: Are you in a Nursing Leadership role?  Table 9 depicts the number of respondents holding nursing leadership positions at Years 1, 2, 3.  Table 9 Respondents in Nursing Leadership Roles Time N Yes (%)   Year 1  158 141 (89.2%)   Year 2 140 129 (92.1%)   Year 3  52 48 (92.3%)  The majority of BC NLI participants remained in nursing leadership roles, although there were small numbers of individuals who exited leadership roles each year—shifting to non-leadership positions, such as direct care positions. The primary explanations for movement out of leadership roles included: “lack of organizational support,” “burnout,” “extremely heavy workload,” “unrealistic staff expectations.”   32 Question 3: What is your current Management position?  A notable finding is that several respondents were confused by their level of formal authority. We defined front-line/first-level as non-union positions related to management of day-to-day unit/facility activities. We defined mid-level positions as exempted or non-union positions associated with disciplinary actions (e.g., hiring, firing) and budgeting. We defined executive-level positions as associated with higher-level organizational planning and strategy: a member of the executive decision- making team.  Many respondents, however, wrote in their actual titles, because they were not sure of their management positions within their organizations, particularly during ongoing restructuring/redesign in many of the health authorities. We conducted follow-up phone calls with respondents to help determine their positions within their organizations. Appendix C is a sample of the plethora of titles being used throughout the province with respect to different levels of healthcare leadership. Faculty noted similar confusion during the residential workshops. At the beginning of each workshop, we asked participants to state their titles and provide brief job descriptions. During these introductory sessions, we often needed to ask questions and clarify job positions because of a myriad of titles in use across the province.  Table 10 provides the overall numbers and frequencies of leadership positions at the time of workshop attendance and the Year 1, 2 and 3 career tracking surveys. The frequencies more accurately depict participants’ movement among leadership roles, because the total numbers varied due to the number of cohorts tracked over the 3-year period. Based on 6 cohorts from October 2007 through March 2009 (N=194),  at the time of workshop attendance, 133 individuals (69%) were in front-line leader positions; 53 individuals (27%) were in mid-level positions; 2 individuals (1%) were in executive-level positions; and 6 individuals (3%) were in non-management positions. Individuals in the non-management positions stated that they were being groomed for front-line leader positions. Over-all, from Year 1 to Year 3, the frequencies of front-line leaders went down while the frequencies of mid-level positions and non- management positions increased. We have not conducted statistical tests to determine the significance of these trends.     33 Table 10 Management positions by year for 6 cohorts of NLI participants Time N Front line n (%) Mid-level n (%) Executive n (%) Non-Management n (%)    Workshop 194 133 (68.6%) 53 (27.3%) 2 (1.0%) 6 (3.1%)    Year 1 158  84 (53.2%) 53 (33.5%) 3 (1.9%) 18 (11.4%)    Year 2 140  74 (52.9%) 53 (37.8%) 0        13 (9.3%)    Year 3 52  28 (53.8%) 20 (38.5%) 0 4 (7.7%)   Table 11 depicts the movement among levels in more detail. The most notable level changes were:  a) Increased frequencies in mid-level positions due to movement from front-line leader positions; and b) Increased frequencies in non-management positions due to movement from front-line leader positions. The front-line leaders seemed to either advance quickly into mid-level positions or return to non- management positions, such as direct care nursing.  Table 11 Movement among Leadership Levels Leadership Level Year 1 n Year 2 n Year 3 n Moved from front-line to mid-level 10 4 1 Moved from front-line to non-management 11 3 2 Moved from mid-level to executive level 1 Moved from mid-level to front-line 1  1 Moved from executive to mid-level  2 Moved from executive to non-management  1 Moved from non-management to front-line   1 Moved from non-management to mid-level  1  Question 4: What is your current Health Authority?  There was no movement among health authorities over the 3-year survey period.  34 Question 5: What is your current Health Sector?  Table 12 depicts the number of participants that changed healthcare sectors over the 3-year survey period. Except for one individual who moved from acute care to Human Resources, all the other changes represented movement from mental health, long-term care and community care to acute care settings.  Table 12 Healthcare Sector Changes Changes in the Health Sector Number of participants Workshop --> Year 1 2 Year 1 --> Year 2 3 Year 2 --> Year 3 2   Question 6: What is your current Span of Control?  There were wide ranges for leaders’ span of control (e.g., 0-200). The average number of direct care reports for front-line leaders was 32-43 reports; mid-level leaders had averages of 59 to 76 direct reports; and executive level leaders had averages of 53-60 direct reports.  Table 13 Span of Control Time Front-line Mid-level Executive  n M Range n M Range n M Range Workshop 133 35.5 0-200 53 58.7 0-200 2 52.5 30-75 Year 1 84 31.8 0-250 53 75.8 0-250 3 60 0-110 Year 2 74 40.6 0-250 53 61.8 0-200 0 Year 3 28 42.8 0-250 20 69.7 0-275 0   35 The following portion of the career tracking survey pertained to BC NLI attendance. These questions were part of the 1-Year survey data, Out of 158 career tracking survey respondents at Year 1, 149 completed the survey (response rate=94%). We have pasted the survey responses to the 9 Likert scale items below. The Likert scale (1-7) represents the Y axis and the X-axis represents the number of responses for each numerical Likert scale item.  The primary question stem was: How did the BC NLI assist in your leadership development with respect to ( Figure 5) :  Figure 5.  Participant Responses to Likert Scale Items    36         37         38          39   We calculated the frequencies of ―agree‖ (6) to ―strongly agree‖ (7) responses for all the nine questions: 1. Increased self-awareness of strengths and weaknesses as a leader (57.0%) 2. Provided clear leadership development path (36.2%) 3. Allowed me to gain experience in change management (46.3%) 4. Facilitated the experience of success through the development and implementation of a work project (47%) 5. Provided a means to connect and network with other leaders (58.4%) 6. Gave me important knowledge and tools to develop leadership skills (69.8%) 7. Showed me that I was not alone in my struggles (72.5%)  40 8. Helped me realize that leadership positions were not where I wanted to be (4%) 9. Did not assist my leadership development nor career in any way (2%) The final survey question asked respondents to indicate what proportion (of 100%) of their leadership skills were acquired from each of the 4 BC NLI components. The pie chart below (Figure 6) is a graphic representation based on 149 responses. With respect to this question, respondents attributed 41% of skills acquisition to the 4-day residential workshop; 30% of skills acquisition to mentoring; 26% of skills acquisition to project work; and 3% of skills acquisition to online networking.  Figure 6.  BC NLI Components and Leadership Skills Acquisition   Conclusions: The career tracking survey data showed that over the 3-year survey period, all the respondents were in nursing positions, and the majority of respondents were still in leadership positions. There was no career movement across regions and minimal movement across sectors. The majority of movement from front- line positions to mid-level positions or non-management positions occurred in the first year from workshop attendance.  The majority of respondents perceived that the BC NLI had assisted them with their leadership journey, particularly with respect to raising awareness of individual leadership strengths and weaknesses and the opportunity to network with others. The final question indicated that except for online networking, the other 3 components were perceived as making similar contributions to leadership skill development.  41 V. Conclusion and Recommendations  Well-designed leadership development programs make a difference with respect to leader preparation and advancement (Boaden, 2006). Leadership program design considerations include the theoretical frameworks or models that are used to unify key concepts of importance to the leader population, curricular content, and the teaching/learning strategies and delivery modes (e.g., online, face-to-face) (Allen & Hartman, 2008; Yukl, 2006).  The BC NLI faculty chose a theoretical empowerment framework to guide curriculum content and delivery, because nursing research evidence has shown that empowered leaders can empower staff, resulting in positive outcomes for leaders and staff (Laschinger, 2008a).  The BC NLI curriculum content was based upon universal leadership competencies reported in the nursing, management science and organizational behaviour literature. Other content originated from a needs assessment survey that was conducted with nurse leaders across the province. The BC NLI teaching strategies included a variety of adult learner, action-oriented learning strategies (Allen & Hartman, 2008). Each knowledge session was designed to include some lecture time, some application time, and some reflection time. In addition to workshop content, other components of the program, such as project work and mentoring, promoted knowledge transfer to practice settings. Successful leadership programs (Skelton-Green et al., 2007) have similar components that support and sustain knowledge uptake beyond classroom time. The BC NLI curriculum package, therefore, is an example of a carefully designed, evidence-based leadership development program.  The BC NLI curriculum was designed primarily for front-line nurse leaders, although content was included for mid-level leaders to promote preparation of front-line leaders for the transition to higher- level leadership positions. The BC NLI is a stepping stone for nurse leader development.  Because of its academic roots and its affiliation with the UBC School of Nursing, curricular content and project work can be granted graduate-level credits in lieu of graduate-level leadership course work or as directed or independent study. The BC NLI curriculum links nicely to academic programs, and academic programs can be sources for new nurse leaders.  42 With respect to new nurse leader development and leader succession planning, the BC NLI curriculum provides a sound foundation for both. There is a nursing shortage, and there is a nurse leader shortage (Laschinger et al., 2010; Canadian Nurse Association, 2009).  This province needs a systematic plan to proactively position itself with respect to a health human resources shortage: the province needs wise leaders to manage the challenges associated with such things as nurse shortages, complex patients, and economic efficiencies.  Identification of future leaders is a critical first step and education and supports is the critical next step. British Columbia should have a human resource proposal in place to recruit and educate/support new leaders. The BC NLI curriculum is a ready-made package that has worked well for over 400 new nurse leaders.  This evaluation report includes evidence from a variety of sources: an end-of-workshop survey; descriptive data and content analyses of participants’ project work and leadership learning goals; and career tracking survey data. These different sources of evaluation data have demonstrated that the BC NLI is an effective leadership development program. There is evidence that the program empowered nurse leaders who in turn empowered their staff.  What is empowerment? In the social-psychological literature, empowerment is synonymous with increased self-confidence and motivation to succeed (Spreitzer et al., 1999). In the management science literature, empowerment means access to information, resources, supports and opportunities (Kanter, 1993). These different types of empowerment augment or synergize each other ( Faulkner & Laschinger, 2008).  Our evaluation data showed that BC NLI participants were psychologically empowered (e.g., inspired, re-energized, self-confident), and they were structurally empowered (e.g., the tools and resources to get the job done; mentoring and organizational supports). In turn, their statements indicated that they were using empowerment strategies learned through the BC NLI to psychologically empower staff (e.g., giving meaning to staff work; tying staff values to organizational values), and they were providing staff with access to important organizational empowerment structures (e.g., participation in work environment decision-making). Although we cannot make direct associations between BC NLI attendance and empowerment outcomes such as retention and job satisfaction, the career tracking data show that the majority of participants have stayed in leadership roles within their health authorities.  43 Those individuals who have exited from leadership positions stated that they did so because of dis- empowering conditions, such as lack of sufficient supports to manage stressful work environments.  Our evaluation data demonstrate that the BC NLI made a significant, positive difference for the majority of nurse leaders who participated in the program. The following recommendations are based upon key findings in this report and our perceptions of what has worked most effectively during the course of time (2005 pilot to last June 2010 Celebration Day) that we have served as the designers, deliverers and evaluators of the BC NLI.  Recommendations  1. We recommend using the BC NLI curriculum for front-line leaders. Although the content was adapted to suit some of the knowledge needs of mid-level leaders, the knowledge sessions work particularly well for front-line leaders. 2 Although there are different ways to deliver knowledge content (e.g., online, face-to-face), we recommend that project work with mentoring supports be included as vital components of leadership development. The project work should not be an ―add-on.‖ Projects should be relevant to the organization and include opportunities for leaders to practice knowledge applications. 3.   Project work should be systematic—taking participants through the different phases of project development, implementation and evaluation. The BC NLI curriculum includes a project management toolkit with publicly accessible tools/weblinks that helped participants go step-by- step through the change management process. 4.   Nurse leaders need networking time to connect with each other and share stories and concerns from a nursing perspective. Although a variety of excellent inter-professional leadership workshops and programs are available, nurse leaders, particularly front-line nurse leaders, need time to acclimate to the unique language and issues associated with leadership and management. Power dynamics/differentials have always been present in professional nursing (Udod, 2008), and front-line leaders seem to benefit from openly vetting their concerns among each other. Within practice settings, networking opportunities should be provided for nurse leaders, such as nurse leader support groups.  44 5.   Nurse leaders need critical reflection time. The BC NLI provided reflection time for participants to assess their leadership strengths and weaknesses, and to plan for what they would do with their newly acquired knowledge. Organizations should provide reflection time for nurse leaders by supporting protected time for leaders to discuss leadership goals and activities with an experienced mentor-leader. 6.  Leadership development is not static: Continuing education opportunities need to be provided, particularly in practice contexts. The BC NLI provided a solid, substantial overview of most leadership competencies, but ongoing professional development will require participants’ organizations to hone and refine those competencies through context-specific education. 7. The BC NLI curriculum package is adaptable. The BC NLI faculty and educators from the Victoria Order of Nursing (VON) adapted the BC NLI curriculum to educate VON front-line leaders (nurse and non-nurse leaders). The curriculum, therefore, should be used in different contexts and for different leader populations to promote leadership development. 8.  The BC NLI is a provincial resource: it was funded through a collaboration between the Ministry of Health Nursing Directorate, the health authorities and the UBC School of Nursing. The BC NLI is a successful curriculum package that should be used for the development of our province’s future nurse leaders.   45 References Aiken, L. H., Clarke, S.P., Sloane, D. M., Sochalski, J.A., Busse, R., et al. (2001). Nurses’ reports on hospital care in five countries. Health Affairs, 20(3):43-53.  Allen, S., and Hartman, N. (2008). Leadership Development: An exploration of sources of learning. S.A.M. Advanced Management Journal, 73(1):10-19, 62.  Arcand, R. 2003. First Line Nursing Leadership Development of an Education Program: Phase I. Unpublished report. Vancouver: University of British Columbia.  Boaden, R. (2006). Leadership development: Does it make a difference? Leadership and Organization Development Journal, 27(12):1-27.  Canadian Nursing Advisory Committee. (2002). Our health, our future: Creating quality workplaces for Canadian nurses. Retrieved December 6, 2010 from http://www.hc-sc.gc.ca/hcs-sss/alt_formats/hpb-dgps/pdf/pubs/2002-cnac-cccsi-final/2002-cnac-cccsi- final-eng.pdf  Canadian Nurses Association. (2009). The next decade: CNA‟s vision for nursing and health. Retrieved December 24, 2010 from http://www.cna-aiic.ca/CNA/documents/pdf/publications/Next_Decade_2009_e.pdf  Estabrooks, C. A., Tourangeau, A. E., Humphrey, C. K., Hesketh, K. L., Giovannetti, P., Thomson, D., et al. (2002). Measuring the hospital practice environment: A Canadian context. Research in Nursing & Health, 25(4):256–268.  Faulkner, J., & Laschinger, H. (2008). Effects of structural and psychological empowerment on perceived respect in acute care nurses. Journal of Nursing Management, 16(2): 214-221.  Force, M.V. (2005). The relationship between effective nurse managers and nursing retention. The Journal of Nursing Administration, 35(7-8):336-341.  Gifford, B., Zammuto, R., Goodman, E. (2002). Silence, power and communication in the operating room. Journal of Healthcare Management, 47(1):13-25.  Ginsburg, L., Norton, P.G., Casebeer, A. and Lewis, S. (2005). An educational intervention to enhance nurse leaders’ perceptions of patient safety culture. Health Services Research, 40(4):997-1020.  Graneheim, U., and Lundman,B. (2004). Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness. Nurse Education Today, 24:105-112.  Kanter, R. (1993). Men and women of the Corporation (2nd ed.). New York: Basic Books.  Laschinger, H. (2010). New leader study. Available at:http://publish.uwo.ca/~hkl/nls/nls.html. Accessed on December 21, 2010.   46 Laschinger, H.K. (2008a). University of Western Ontario Workplace Empowerment Program. Retrieved December 6, 2010 from http://publish.uwo.ca/~hkl/  Laschinger, H.K. (2008b). Effect of empowerment on professional practice environments, work satisfaction, and patient care quality: further testing the nursing worklife model.  Journal of Nursing Care Quality, 23(4): 322-330.  Laschinger, H. K., Nancy, P., and Joan, A. ( 2007). The impact of leader-member exchange quality, empowerment, and core self-evaluation on nurse manager’s job satisfaction. The Journal of Nursing Administration, 37(5):221-229.  Laschinger, H.K., Finegan, J.E., Shamian, J., and  Wilk, P. ( 2004). A longitudinal analysis of the impact of workplace empowerment on work satisfaction.  Journal of Organizational Behaviour, 25:527–545.  MacPhee, M., Suryaprakash, N., and Jackson, C. (2009). Online knowledge networking: What leaders need to know. The Journal of Nursing Administration, 39(10): 415-422.  MacPhee, M., and Bouthillette, F. (2008). Developing leadership in nurse managers: the British Columbia Nursing Leadership Institute. Canadian Journal of Nursing Leadership, 221(3):64-75.  MacPhee, M. (2007). Strategies and tools for managing change, The Journal of Nursing Administration, 37: 405–414.  Pearson, A., Laschinger, H., Porritt, K., Jordan, Z., Tucker, D. and Long, L. (2007).  Comprehensive systematic review of evidence on developing and sustaining nursing leadership that fosters a healthy work environment in healthcare. International Journal of Evidence-Based Healthcare, 5(2): 208–253.  Simpson, B., Skelton-Green, J., Scott, J., and O’Brien-Pallas, L. (2002). Building capacity in nursing: Creating a leadership institute. Canadian Journal of Nursing Leadership, 15(3):22-27.  Skelton-Green, J., Simpson, B., & Scott, J. (2007). An integrated approach to change leadership. Canadian Journal of Nursing Leadership, 20(online exclusive), 1-15.  Spreitzer, G., De Janasz, S., & Quinn, R. (1999). Empowered to lead: the role of psychological empowerment in leadership, Journal of Organizational Behavior, 20, 511-526.  Sullivan, J.,  Bretschneider,  J., and  McCausland,  M. (2003). Designing a leadership development program for nurse managers: An evidence-driven approach.  Journal of Nursing Administration, 33(10): 544-549.  Udod, S. (2008). The power behind empowerment for staff nurses: using Foucault’s concepts. Canadian Journal of Nursing Leadership, 21(2), 77-92.  Yukl, G. (Ed.). (2006). Leadership in organizations (6th ed.). Upper Saddle River, New Jersey: Pearson Education International.   47 Appendix A Web Shot of the BC Nursing Leadership Institute Discussion Page    48   Appendix B BC NURSING ADMINISTRATIVE LEADERSHIP INSTITUTE EVALUATION QUESTIONS   I really liked…………..   I would change………….   A new idea for me was ………………..   The most beneficial part of the institute for me was …………….   What I will do with what I have learned is……………….   I would like to learn more about …………….   If I was organizing this leadership Institute I would ……………..    49 Appendix C Healthcare Leader Position Titles    Frontline   Mid-Level   Executive Level Case Manager Clinical Coordinator  Department Leader Clinical Nurse Coordinator  Clinical Educator Operations Leader Clinical Nurse Educator Clinical Manager  Services Manager Clinical Nurse Leader Clinical Nurse Leader Clinical Practice Coordinator Clinical Nursing Supervisor Clinical Resource Nurse Clinical Practice Leader Clinical Services Coordinator XX Program Consultant Clinical Supervisor Community Manager Clinical Team Leader Community Services Coordinator Community Care Coordinator Manager Head Nurse Operations Leader Nurse Manager Patient Care Coordinator Nursing Care Coordinator Program Coordinator Nursing Supervisor Program Leader Patient Care Coordinator Program Manager Patient Service Coordinator Team Leader Program Coordinator Program Manager Area Leader Resident Care Coordinator Service Co-ordinator Staff Support Coordinator Team Leader          50 Appendix D Project Reports One week post workshop Attendance:  Mentor:  Mentor Contact:  Title of the Project:  Care Areas:  Key Issue(s):    General Background:  Project Goals:  Brief Overview:         Leadership Goals:  Project Update   Project Goals Update:   Learning Goals Update: Project Summary   Brief description of your project   Were you able to successfully complete your project? Why or why not?    Lessons learnt- What went well/ challenges  Do you believe that BC-NLI participation enhanced your leadership skills and abilities? Why or why not?     51 Appendix E Career Tracking Survey 1. I am currently working in nursing   Yes   No (If “Yes” please answer questions 2-5) If No, 1) Please provide a brief explanation for leaving the nursing profession.    2) Has attending the NLI been a factor in your decision?    You do not have to answer the remaining questions. Thank you for your participation 2. I am still in a leadership role. Yes   No   If Yes, Number of people directly reporting to you:   Your current Leadership position  Your leadership position at the time of NLI attendance last year  Frontline ( union)  Frontline ( union) Frontline ( excluded)  Frontline ( excluded) Middle management- operations leader  Middle management- operations leader  Executive management  Executive management  52  If No, Your current position:   Please specify the reason for not being in a leadership role any more:  ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ __________________________________________ 3. Please provide the following details: ( tick your response in the appropriate column) Health Authority: Your current Health Authority   Your Health Authority at the time of NLI attendance  Vancouver Coastal Health   Vancouver Coastal Health Providence Health Care   Providence Health Care Provincial Health Services   Provincial Health Services Northern Health   Northern Health Interior Health  Interior Health Fraser Health  Fraser Health Vancouver Island Health   Vancouver Island Health Health Sector: Your current Health Sector   Your Health Sector at the time of NLI attendance  acute care hospital  acute care hospital community care  community care long term care/residential care  long term care/residential mental health   mental health public health  public health others (please specify)  others (please specify)   53 4. How did participating in the NLI assist you in your leadership career?   1 Strongly disagree 2 3 4 5 6 7 Strongly agree Increased self-awareness of strengths and weaknesses as a leader  Provided a clear leadership development path  Allowed me to gain experience in change management  Facilitated the experience of success through the development and implementation of a work project  Provided a means to connect and network with other leaders  Gave me some important knowledge and tools to develop skills and knowledge as a leader  Showed me that I was not alone in my struggles  Helped me to realize that leadership positions were not where I wanted to be  Did not assist my leadership development nor career in any way   5. Over the past year from the date of NLI attendance, what percentage of your leadership skills has been acquired from: NLI Component  Percentage (100%) 4 day residential workshop Mentoring Project Work Online Networking   54                              


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