UBC Graduate Research

Preparing Nurse Leaders as Managers Cross, Lucy (Lucienne) Nov 8, 2013

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Preparing Nurse Leaders                                                                                                              2    Table of Contents Abstract???????????????????????????????????4Acknowledgements??????????????????????????????..5Chapter One: Introduction to Nurse Manager Leadership??????????????.?..6  Background??????????????????????????????..8  Purpose?????????????????????????????..?.?10  Approach???????????????????????????????11  Significance??????................................................................................................13 Chapter Two: The Role of the Nurse Manager???????????????????..15  Context of the Nurse Managers Environment??????????????...??16  Functional Responsibilities????????????????????????22  Significance ?????..????????????????????????25 Chapter Three: Foundational Knowledge for Nurse Managers?????????????.27  Knowledge, Competencies and Frameworks?????????????????.27  Knowledge of Context?????????????????????????...30   Knowledge of Power??????????????????????.?.31  Knowledge of Leadership Management Skills????????????????....32  Significance..........................................................................................................................35 Chapter Four: Transformation and Transformational Experience???????????.?..37  Transformational Leadership???????????????????????...38  Authentic Leadership??????????????????????????...39  Strategies???????????????????????????????..41   Reflection????????????????????????????.41 Preparing Nurse Leaders                                                                                                              3      Emotional Intelligence???????????????????????.43   Mentoring and Coaching??????????????????????.45   Collaboration???????????????????????????47  Significance??????????????????????????????..48 Chapter Five: Analysis of Graduate and Supportive Programs in Canada......................................50  Graduate Programs??????????????????????????..?51  Supportive Initiatives??..???????????????????.?????55  Organizational Support??????????????????????????56  Significance??????????????????????????????..59 Chapter Six: Analysis of Findings and Recommendations for Future Education??????...60  Discussion?????????????????????????????.?..61  Recommendations???????????????????????????...62  Conclusion??????????????????????????????...65 References??????????????????????????????????66 Appendix A: Interior Health Nurse Manager Demographics??????????????..77 Appendix B: Interior Health Manager Job Description????????????????.79 Appendix C: Interior Health Emotional Intelligent Competencies????????????.82 Appendix D: Nurse Manager Essential Knowledge Chart???????????????.87 Appendix E: Mind Map of Nurse Manager Role and Responsibilities????????..??.94 Appendix F: The LEADS Framework??????????????????????....97 Appendix G: Interior Health Management Resources????..????????????101 Appendix H: University Of BC Okanagan, Small Survey???????????????.103 Appendix I: Association of American Critical-Care Nurses e-learn module????????.123 Preparing Nurse Leaders                                                                                                              4    Abstract  Nurse managers play a key role in creating healthy work environments to ensure optimal patient outcomes.  This pivotal role responsibility within the dynamic challenges of healthcare implies that nurse managers have a complex job.  Their role is multifaceted and requires broad knowledge for leadership effectiveness.  The purpose of this paper is to investigate how a graduate program can best prepare nurse leaders, specifically for the role of nurse manager in the context of the current Canadian healthcare system.  This paper explores both the role of the nurse manager and the knowledge needed.  This paper also recommends the need for a nurse management/leadership graduate program in Canada to foster an understanding of all the precepts that impact decision making in the business of health care.  Four strategies are discussed for empowerment and personal transformation as a leader.  Then, four recommendations are provided to promote nurse manager education at the graduate level.  Accurate nursing knowledge and business knowledge is needed for the nurse manager to understand, operate and adapt in a dynamic and diverse healthcare system.  The vested interest of an innovative nurse management/leadership graduate program in Canada is vital to attract nurses into leadership roles and to fortify nurse managers to be effective and successful for a sustainable future in healthcare.        Preparing Nurse Leaders                                                                                                              5    Acknowledgements  I want to express my appreciation to my committee: Barb Pesut for her clear guidance, encouragement and insight as this paper developed and emerged; and Sheila Epp for her detailed feedback that shaped the final product.  I want to acknowledge the following people who helped enrich the paper along the way:  Thanks to Carmen Sigalet and Diane Betman - my sounding boards and constant encouragers.  Thanks to Tina Coletti for sharing her experience as a nurse in a business graduate program.  Thanks also to Deborah Austin and Christine Bailey for sharing their experiences as rural nurse managers.  Thanks to Marie Hawkins for sharing her experience as a nurse in a leadership graduate program at Royal Roads University.  Thanks to Maura MacPhee at UBC for her encouragement and informative emails.  Thanks to Barb Reece with the ARNBC for her innovative ideas to support nurse managers in BC.  Thanks to my sister Yvonne Unrau for her insightful questions as she read the paper in its development.  Last, but not least is a big thank-you to my biggest listener, supporter, encourager, voice of reason and loving husband, Rob?who is patiently looking forward to getting his wife back.  I truly enjoyed this journey of learning.  I could not have done it alone.          Preparing Nurse Leaders                                                                                                              6    Chapter One: Introduction to Nurse Manager Leadership  The context of healthcare and the systems that operate within it have become more and more complex.  Nurse managers play a key leadership role in the profession by taking on the challenges of an increasingly diverse and dynamic environment.  They are central to effectively and safely overseeing the operational needs to ensure the delivery of optimal health care (Shirey, Ebright & McDaniel, 2013; Smith, 2012) and creating a culture of excellence (Wiggins & Hyrkas, 2011).  More specifically, nurse managers play a pivotal role in shaping the practice environment to ensure quality patient care (Cathcart & Greenspan, 2012; CNA, 2009).  Key operations attended to by nurse managers include nurse recruitment and retention (Cowden, Cummings & Profetto-McGrath, 2011; Sherman & Pross, 2010; Shirey, Ebright & McDaniel, 2013; Udod & Care, 2011), two critical functions given the nursing shortage that looms over healthcare.  The reality of the nursing shortage also includes a shortage of nurse managers (Brown, Fraser, Wong, Muise & Cummings, 2013; Laschinger et al., 2013).  This raises questions about how nurse managers are prepared to embark on and fulfill this vital leadership role.  Considering the current healthcare environment and the dynamic challenges that nurse managers must tackle, relevant educational preparedness for nurse leaders, managers and executives is critical (Huston, 2008; Simpson, Skelton-Green & Scott, 2011; Yoder-Wise, Scott & Sullivan, 2013).    In this paper, I will examine the role of the nurse manager in the current context of a complex healthcare environment, and investigate how a nurse graduate program in Canada can best prepare nurse leaders specifically for this role.  The term ?management? implies planning, taking action and measuring results; whereas the term ?leadership? is about developing a vision of a desired future and motivating others.  It has been stated that managers appeal to the head and Preparing Nurse Leaders                                                                                                              7    leaders appeal to the heart (D?Cruz, 2003).  Leadership is one of the key tasks of management alongside planning, controlling and organizing (Jackson & Parry, 2011, p. 19). For the purpose of this paper, leadership and management are one and the same as a nurse manager assumes both leadership and management characteristics.  The Canadian Nurses Association (CNA) (2009) believes that nursing leadership is about critical thinking, action and advocacy; and that nurse leaders are visionary, courageous, credible and inspire others to support innovative and professional nursing practice.  CNA (2009) also states that, ?exerting good management skills is part of being a good leader, and exerting good leadership skills is necessary for good management? (cna-aiic.ca).  Leadership and management skills co-exist as interdependent skill sets and can be offered at the graduate level to best prepare and support the nurse manager in the current context of healthcare and for the foreseeable future.  Cummings et al., (2008) found in their research that, ?higher levels of education and experience led to higher levels of leadership effectiveness? (p. 245).  In the past five years, nurse researchers in Canada have identified specific leadership educational needs for nurse managers.  Nurse graduate programs have an opportunity and reason to provide advanced or specialized education for nurse managers to ensure preparedness and effectiveness in today?s healthcare system.  Nurse graduate programs not only facilitate knowledge, they inspire learning and deep personal transformation to better ensure effective leadership in the role of nurse manager.  Nurse graduate programs can foster a deeper understanding of effective foundational leadership skills to empower staff and obtain accurate healthcare business knowledge in order to understand, operate and adapt in a dynamic and diverse healthcare system.   Preparing Nurse Leaders                                                                                                              8    Background  Early nineteenth century nurse leaders provided direction and advocacy for healthcare based on their understanding of political, economic, social and clinical knowledge.  They upheld nursing as an essential profession as they vied for better education and patient care conditions to improve healthcare outcomes (Helmstadter, 2008).  In an era of hierarchical male dominant leadership that exercised a style of ?power and control?, the female nurse leaders ?worked to understand how social inequities and injustices come to be and why, what needs to change and how to go about creating the changes that are needed? (Chinn & Kramer, 2008, p. 77).  They paved the way for today?s nurse leaders who continue to advocate for an improved healthcare environment, relevant education and essential leadership preparation.  Still, political and economic power looms over healthcare.    As a result of the Canadian government healthcare reform in the early 1990?s, the nurse leadership role that supported frontline staff in the clinical environment shifted from clinical to managerial expertise.  Tighter financial accountability, economic downturn, downsizing, mergers, and other cost-effective measures in healthcare resulted in a significant reduction in the number of nurse leaders across Canada (Brown et al., 2013; CNA, 2009; Storch & Meilicke, 2006).  The position once known as the head nurse and clinical expert was deleted in favor of a more corporate role.  The nurse manager role emerged not as an integral part of the clinical environment, but as part of the administrative environment to oversee the day to day operational needs of nursing units.  This new shift in work environment prompted many diploma prepared head nurses eligible for the newly constructed nurse manager position to return to university to earn nursing baccalaureate degrees.   Preparing Nurse Leaders                                                                                                              9     The demands for advanced and specialized knowledge among nurse managers continue to increase.  Nurse managers face the realities of rising healthcare costs,  an aging population, rapid advances in technology and medical science, the upsurge of chronic conditions for all ages, and the growing population of mental health disorders, to name a few.  Healthcare resource acquisition and allocation, in general, remains a constant challenge.  It is within the dynamic context of the clinical environment, fiscal accountability and corporate structure that the nurse manager must both operate and adapt in order to be effective (Huston, 2008).  Yet, most nurse managers embark into the role from a place of clinical expertise and are unprepared for the diverse complexities they will face (Hawkins, Carter & Nugent, 2009; RNAO, 2013).  It is imperative that nurse managers are prepared to not only lead and manage within the context of the current healthcare environment, but also to understand the business of healthcare and the economic political driving forces in order to make informed, responsible and ethical decisions.  Sherman & Pross (2010) assert that, ?If nurses are unable to see the financial ramifications and costs of decisions, they will be less successful in advocating for the resources needed to successfully staff and operate units? (para. 21).  A nurse graduate program for nurse managers can augment an interest for leadership in nursing.  Since 2006 the entry to practice for all British Columbia (BC) nurses is a baccalaureate degree, and the goal for 2020 is a baccalaureate degree for 80% of nurses (CNA, 2009; Huston, 2008; IOM, 2010).  The growing number of baccalaureate prepared nurses may seek an opportunity to advance to graduate education for leadership and management preparedness.  In fact, just as advanced practice nursing specialities require graduate preparation, it has been suggested that nursing administration be an advanced practice specialty with a specific graduate curriculum to support this (Harris, Huber, Jones, Manojlovich & Reineck, 2006).  The Preparing Nurse Leaders                                                                                                              10    demographics in a recent Canadian study demonstrate that of the 128 nurse leader participants, 89% were female, 60% held a baccalaureate degree and the average age was 45 years (MacPhee et al., 2013), indicating potential prospects for a nurse graduate program.  Another Canadian study suggested that the general appeal of a nurse leadership position was low, indicating a need to develop strategies to attract nurse leaders (Laschinger et al., 2013).  The Canadian Nurses Association (2009) indicates that the average age of nurse leaders at all levels in Canada is between 47-51 years.  In BC as of 2011 there were just over 2,170 nurse managers (CIHI, 2011).  The statistics obtained for 2013 in the Interior Health organization in BC (Appendix A) reveal the majority of nurse manager positions are held by women between the ages of 50 to 60.  These numbers confirm the predicted upcoming shortage of nurse managers and indicate a serious need to develop prepared future nurse leaders.  There is room and opportunity for nurses to advance in their practice and leadership knowledge through a nurse graduate program, specifically to pursue the role of nurse manager.  Nurse graduate programs are in an optimal position to shape the future of the nursing profession by offering curricula for nurse leaders and managers through knowledge acquisition, skill development, transformation and empowerment that matches the dynamic work environment of health care tomorrow.  It is imperative that nurse graduate programs provide relevant and current education to ensure development and success in healthcare management for nurse leaders.  Purpose  A baccalaureate degree in nursing is the minimum requirement for Registered Nurse?s to enter practice in Canada (cna-aiic.ca).  These nurses will become future nurse managers and choose to enter a graduate program that will prepare them for this next career challenge (Laschinger et al., 2013; Russell & Scoble, 2003; Wong et al., 2013).  Nurse managers who Preparing Nurse Leaders                                                                                                              11    currently work in the role with an undergraduate degree may seek a graduate program to further advance their knowledge and skills to perform their role better (Udod & Care, 2011).  The purpose of this paper is to investigate how a graduate program can best prepare nurse leaders, specifically for the role of nurse manager in the context of the current Canadian healthcare system.  This will be met through the following objectives: (1) to explore the diverse, complex and contextual variables affecting the role of today?s nurse manager; (2) to explore and identify the foundational knowledge and leadership skills required for this specialized professional role; (3) to explore the notion of transformation and a transformational experience as a nurse leader; (4) to analyze which components of nurse graduate program curricula in Canada best prepare nurse managers; and (5) to provide a critical analysis of the findings and consider recommendations for future education. Approach  The purpose and objectives of this paper will be met through a focused literature review, environmental scan and critical analysis.  An environmental scan acquires and uses information about events, trends, and relationships in an organization?s external environment so that the new knowledge gathered and critically analyzed can assist in planning a future course of action (Choo, 2001).  An environmental scan is a sensemaking approach that gathers relevant information and knowledge that that can be used for making decisions or developing future research.  It identifies social, demographic, domestic trends and issues in healthcare that drive change (Fitzpatrick, 2001).  Environmental scanning is linked with planning the future of an ideal healthcare system that responds to foreseeable future contextual conditions (Arvidson, 2010).   Preparing Nurse Leaders                                                                                                              12     There are two different approaches to environmental scanning.  One approach is the macro environmental scan which is an outside-in approach that encompasses the broader influences of factors in the external environmental for an issue.  The other is a micro environmental scan which is an inside-out approach that holds a narrower view, usually within an organization and is more specific to the issue (Gillespie, Chaboyer, Nieuwenhoven & Rickard, 2012).  The broad macro environmental scan will be the approach used for this paper as it can provide a deeper understanding of the many characteristics and contexts of the nurse manager?s workplace and issues that may have implications for educational support in a nurse graduate program.    The broader macro environmental scan for this paper includes a strategic non-systematic literature search for documents relevant to the questions the paper proposes to address.  The search used general terms for: the nurse as leader, nurse as manager, the role of nurse leader/manager, the salient knowledge required for the role, and related graduate academic preparedness.  This search was conducted in nursing data bases EBSCO, CINHAL, MEDLINE and Academic Search Complete and Google Scholar.  The literature was limited between the years 2003 to 2013 and generally limited to Canada and the USA.  The macro environmental scan is useful to gain insight and information into the changing forces of healthcare that have a high probability of affecting the role of the nurse manager.  A critical analysis of relevant literature can help inform the type of graduate education preparedness necessary to enable the nurse leader to be equipped to manage a sustainable effective future in healthcare in Canada.    The environmental scan also includes a critical analysis of relevant documents, white papers and studies mostly within the timeframe of 2003 to 2013 that pertain to the current role of the nurse manager, the healthcare environment and educational preparedness.  Relevant Preparing Nurse Leaders                                                                                                              13    documents include curricula of nurse graduate programs in Canada, the Canadian Institute for Health Information (CIHI) statistics, leadership competencies and frameworks, nurse manager job descriptions and literature pertaining to the current context of healthcare.  The macro scan also includes conversations with nurse managers about their role and experience. Significance  Nurses comprise the largest group of healthcare professional care providers, are situated closest to the day-to-day experiences of patient?s lives, and have a practical understanding of both the idiosyncrasies and complexities of healthcare systems and work environments.  Nurses are generally resourceful, innovative and perpetually able to adapt to the dynamic changes within their work environment.  They critically examine each situation in order to enable best possible patient care regardless of the level of resources or funding.  Nurse leaders that emerge after some years of clinical experience within the healthcare system are situated in an optimal position to lead and advocate for healthcare in society in the role of nurse leader/manager (O?Neil, Morjikian, Cherner, Hirschkorn & West, 2008).  Nurse leaders equipped with graduate leadership knowledge and managerial skill can further benefit patient care by bringing innovative solutions and creating effective empowering work environments.  They can determine appropriate resource allocation to promote patient safety and healthcare sustainability in a way that is responsive to the driving forces of political and economic systems.  Nurse leaders with graduate academic preparedness are in a better position to value and promote health management research and can implement best evidence for success in decision making in the context of current and ensuing healthcare challenges.  Further to this, nurse leaders with graduate-level academic preparedness will be equipped to investigate the issues of nurse and nurse manager retention and implement evidence based strategies that promote retention and succession Preparing Nurse Leaders                                                                                                              14    planning for nurse managers (Brown et al., 2013, p. 470).  Nurse graduate programs have the opportunity to not only educate but socialize the nursing profession into the new era of health care by embracing the vital leadership role that nurses must play in healthcare.  The role of the nurse manager leader is challenging, diverse and pivotal.  Chapter 2 will unpack the diverse nature of the role and reflect on how a nurse graduate program can prepare and empower nurse leaders for the current and imminent challenges that managers must face in the context of a complex healthcare system.                 Preparing Nurse Leaders                                                                                                              15    Chapter Two: The Role of the Nurse Manager  The purpose of this chapter is to provide an in-depth look into the role of nurse manager to elicit the contextual knowledge and functional responsibilities, with the aim to develop an understanding of the foundational learning needs that would best prepare nurse graduate-level students in Canada for this leadership role.  This chapter presents a literature review that reveals the nurse manager role as a unique leadership role influenced by many contextual variables.  Furthermore, the perceptions of the nurse manager role are affected by two broad constructs - contextual and social - in which the position is embedded.  One common responsibility of all nurse managers is they are pivotal in creating quality practice environments.  Specifically, they play a fundamental part in the immediate lives of nurses (Germain & Cummings, 2010; Sherman & Pross, 2010; Udod, 2011) and have a significant impact on the quality of patient care (CNA, 2009).  Competent nursing leadership is essential to the delivery of excellent nursing care, to the retention of nurses, and ultimately to the health of the organization (Hawkins et al., 2009).  The insights gained from understanding the role of the nurse manager is relevant for identifying foundational graduate learning needs.  Therefore, it is important to understand how graduate level education can better prepare and strengthen the role of the nurse manager in the Canadian healthcare system.  The nurse manager is a key leadership position in an exceptionally complex healthcare system where the job is one of the most difficult, yet also one of the most important in the healthcare setting (DeCampli, Kirby & Baldwin, 2010).  In fact, healthcare organizations that are undermanaged find it harder to effectively execute change (Embertson, 2006).  Research has shown that high nurse manager turnover and lack of competent nursing leadership is associated with negative impact on the quality of the nursing practice environment, and consequently leads Preparing Nurse Leaders                                                                                                              16    to adverse patient outcomes (Warshawshy, Rayens, Stefaniak & Rahman, 2013; Wong, Cummings & Ducharme, 2013).  The nature of the work has become increasingly challenging as managers contend with the implications of an aging population, an aging workforce, generational diversity in the workplace, and an increasing awareness of cultural diversity as a result of globalization (Spinks & Moore, 2007).   The Context of the Nurse Manager Environment  The role of the nurse manager is embedded in diverse work environments.  The interplay of dynamic systems within the broader healthcare system contributes to the impact on the work environment.  The contextual nature of the manager?s role is partly why each position holds diverse, specific, and wide-ranging responsibilities, and explains why no two nurse manager roles are exactly the same.  The differences can be unit to unit in urban centres such as; Intensive Care, Emergency, Medical, Surgical, Rehabilitation, Geriatrics, Operating and Post Anaesthetic, Mental Health, Labor and Delivery; and from site to site in the rural facilities of smaller communities.  The urban nurse manager oversees many clinical or specialty areas and assumes a more administrative focus and has a lesser need for clinical expertise, as compared to their rural counterparts.  Further, the urban nurse manager is generally responsible for a larger staff portfolio of one or more units, oversees many functional resources and has a number of colleagues to collaborate with.    In contrast, the rural nurse manager is a small site manager who works in isolation within the context of a rural community.  Each site is at least two to three hours driving distance from any urban centre.  The rural manager not only oversees the day to day administrative and operational needs of the site facility, but is required to draw from his or her clinical knowledge base to support nursing staff as many are new graduate nurses or seasoned nurses with no rural Preparing Nurse Leaders                                                                                                              17    or emergency nurse experience (Bratt, Baernholdt & Pruszynski, 2012).  Rural sites have fewer resources, increased work complexity and less staff development opportunities (Baernholdt & Mark, 2009).  The rural nurse manager and nursing staff must be prepared to treat and stabilize a potpourri of healthcare issues with varying levels of severity.  Nurse managers in rural areas grapple with less reserves and delayed access to resources, high nurse turnover and geographically induced isolation and challenges (Bratt et al., 2012).  One rural manager shares her story:    The rural nurse manager is an educator, a mentor, an administrator, an  administrative assistant and a clinical nurse expert.  They are the face of the Health  Authority to the community.   In the same way the rural nurses have to be all things to all  patients, the rural nurse manager does as well.  A rural nurse manager position is not  solely an administrative office position.  They utilize clinical nursing skills and  experience to work with the limited supports the sites have (or don?t have) to ensure that  the rural community has the support it needs to have their planned and unplanned health  care needs met.  The rural nurse site manager also needs to know about the  administrative stuff; the budgets, reports, Workplace Health and Safety, Labour and HR  issues and strategies.  They need to be even more creative to find ways to make very  small FTEs and positions work.  They need to attend even more diverse meetings than the  managers of larger facilities because they are part of the perinatal committee, the  Emergency committee, the residential group and whatever committees that home and  community programs need to interface with.  They are the only manager in the site  facility so they cover all the patient populations   (personal communication, Deborah  Austin, Nurse Administrator for Golden/Invermere, BC; August 7, 2013). Preparing Nurse Leaders                                                                                                              18     The responsibilities of the nurse manager vary within the context of the specific job environment.  The rural nurse manager may have an altogether different portfolio compared to an urban nurse manager of a specialty unit in an acute care facility, or the community care nurse manager that facilitates optimal delivery of primary healthcare for the broader urban community.  Although there are differences in the role of nurse managers, graduate education would support the common knowledge required along with applicable decision making strategies for specific work environments.    The dynamic work environments that nurse managers operate within render linear leadership and traditional management styles ineffective.  The role is filled with multifactorial challenges that exist in the social and contextual healthcare environment (Udod & Care, 2011).  On any given day, the manager is presented with: ethical dilemmas, competing priorities, generational expectations, differing value systems, staff issues, organizational mandates, cultural influences, financial constraints and work interruptions.  Further, many of these situational challenges are impacted by various external systems creating complexity issues.  Raisio (2009) labels complexity issues that are messy as ?wicked problems?.  This is when the problem itself is difficult to define and the definition and the solution are in constant interaction with each other.  One example of a ?wicked problem? in healthcare that all managers contend with is the goal to increase the equality in service delivery while trying to reduce the costs (Raisio, 2009, p. 480).  Huston (2008) affirms that nurse managers ?need skills to effectively lead in an increasingly complex healthcare environment, characterized by competing demands and stakeholders, rapid change, an ever increasing reliance on technology, and wicked problems? (p.  910).  Wicked problems add a level of perplexity, uncertainty, ambiguity and instability to the role of the nurse manager as a decision maker.  Health care is recognized by scientists as a Preparing Nurse Leaders                                                                                                              19    complex adaptive system (Best, Saul & Willis, 2013; Kramer et al., 2013; Lindstrom, 2013).  Complex adaptive systems are unstable, non-linear, continually evolving, adaptable, unpredictable, and self-organizing in response to feedback about a healthcare issue; this allows for emergence of the best solution (Kramer et al., 2013; Lindstrom, 2013).  Healthcare viewed as a complex adaptive system inspires the nurse manager to ?see? wicked problems and to adopt a multidimensional way of understanding issues to employ relevant skills that lead to viable solutions.    Effective decision making for complex issues requires nurse managers to simultaneously utilize a wide-range of leadership skills and competencies.  Some specific competency skills include sound interpersonal and communication, change management and decision making skills (Smith, Klopper, Paras & Au, 2006); project management and budget skills (Sherman, Bishop, Eggenberger & Karden, 2009); business management, personal mastery and human resource skills (Senge, 2006; Sherman & Pross, 2010).  More specifically, listed on a job summary for the position of a Manager for Acute Services obtained from Interior Health, June 2013, are generalized duties and responsibilities that essentially fall into the three categories: business skills, relational skills and human resource management skills (Appendix B).  Nurse managers are expected to oversee the day-to-day operational needs of their units, empower staff, build productive work teams, maintain quality, and satisfy customers (Kleinman, 2003, p. 452). Empowering staff through communicating effectively and building trusting relationships is essential to creating positive work environments (Germain & Cummings, 2010).  The nurse manager leadership role is contextual within the social and cultural work environments of the organization, and in the situatedness of the day to day care needs of their units. Preparing Nurse Leaders                                                                                                              20     The contextual role of nurse manager is also situated within the interplay of various systems.  These include: value systems, economic systems, human resource systems, collective agreement systems, purchasing systems, technological systems, unit functional systems and social systems.  Nurse managers who adopt a systems thinking approach can raise the quality of patient care outcomes by identifying the interconnectedness of all variables needed for effective decision making.  Issues managed in the broader scope produce more effective strategic and innovative solutions (Best et al., 2013; Senge, 2006).  A systems thinking approach provides the manager with an in-depth knowledge of work processes to be able to work collaboratively with the management clinical team without laying blame, but rather looking at the broader issue of what is going on.  Systems thinking enables the nurse manager to consider the interdependencies, interactions and patterns of the organization (Senge, 2006; Smith et al., 2006).  Nurse managers who are confident in their role and employ a systems thinking approach will challenge assumptions and take action to advocate for staff, patients and the organization (Shirey et al., 2013).  The current context of nurse managers? roles and responsibilities include the day to day challenges within systems that continue to evolve and change within the greater context of the healthcare system.    As much as the role of the nurse manager is contextual within the healthcare environment and the complexity of systems, it is also socially constructed.  This social construction occurs through relationship and cultural relevance; a process based on interactions and social relations between people (Western, 2008).  Leadership values and behaviours are influenced by culture and social variations, and co-constructed in the leader and follower relationship (Jackson & Parry, 2011).  Therefore, it is important for a manager is to have outstanding communication skills; to know how to recognize their staff; and to be visible, accessible and available (Murray, Preparing Nurse Leaders                                                                                                              21    2013, p. 56).  The nurse manager is responsible to engage with front line staff effectively and be culturally aware.  Specific examples of cultural awareness include a mindfulness of group culture, organization culture, cultural paradoxes and cultural influences (Jackson & Parry, 2011).  The social relationship between the nurse manager and nursing staff shapes the meaning of leadership within the cultural context of the social healthcare environment, and is key to employee retention.  Germain & Cummings (2010) learned, ?that, nurse leaders who prioritize their staff above all in their role are rewarded with strong nurse performance, and as a result, positive patient outcomes? (p. 437).  The term ?leadership? for the nurse manager has diverse and shared meanings depending on the social context of the group (Jackson & Parry, 2011).  Most commonly leadership is referred to as an individual?s role or their traits and behaviors in how leadership is enacted (Western, 2008).  Northouse (2013) defines leadership as a social construct specifically, ?a process whereby an individual influences a group of individuals to achieve a common goal? (p.  5).  He formed this definition based on the assumptions that (a) leadership is a process,  (b) leadership involves influence, (c) leadership occurs in groups, and (d) leadership involves common goals (p. 5).  Leadership for the nurse manager occurs in relationship with clinical staff through various supportive behaviours (Germain & Cummings, 2010) such as, respectful networking, communication, negotiation, feedback, motivation, mentorship, and especially in-the-moment teaching or supervisory interactions.  The notion that effective leadership is socially constructed and relational implies that it is imperative that nurse managers develop effective relational leadership skills.   Preparing Nurse Leaders                                                                                                              22    Functional Responsibilities  The nurse manager is responsible for a long list of tasks to ensure the day to day operational needs are met.  Some of these tasks include: ensuring adequate staffing and resources, setting goals and objectives, achieving corporate objectives, maintaining a budget, managing change initiatives, planning education for staff, recruiting and interviewing potential staff, communicating and advocating for evidence based best practice, supporting accreditation, conducting staff performance evaluations, developing policy and procedures, ordering equipment and supplies, and attending meetings (Appendix E).  Over the years, nurse managers have increasingly taken on more of the responsibilities and tasks of nurse executives (Richmond, Book, Hicks, Pimpinella & Jenner, 2009).    Linking the underlying commonalities of nurse managers? skills, tasks, challenges and responsibilities can inform a nurse graduate program.  The commonalities generally fall into these categories: clinical management, recruiting, staffing and scheduling, managing current staff, unit operations, finance, staff development, quality and safety, and hospital or community wide initiatives (Baker et al., 2012).  In addition to this, Hawkins et al., (2009) add leadership and retention, coaching and mentoring, human resource management, financial management, performance improvement and promoting evidence-based practice.  Conrad & Sherrod (2011) insist that it is vital that the nurse manager be a knowledge worker and translator. They must be skillful with data collection and analysis in order to critically analyze clinical trends and patterns for effective future decision making and to decipher new information and knowledge to create innovative ways to improve care initiatives.  Wong et al., (2013) listed the skills most necessary for a nurse manager role as the following: interpersonal skills (conflict management, giving feedback, listening to understand and communication skills), intergenerational skills, mentoring Preparing Nurse Leaders                                                                                                              23    skills, leadership skills (the ability to empower staff), and technical skills (dealing with budgets and technology) (p. 235).  All nurse managers are in a middle-management position situated between the corporate administration and the front line nurses (Udod & Care, 2011).  The role is essentially a position that holds 24-hour accountability to both levels and to the consumer for the quality of patient care (Richmond et al., 2009).  The CNA (2009) believes that the quality of patient care stems from the quality of the professional practice environment, where nurses are able to practice safe, ethical and competent care (can-aiic.ca).  All nurse managers have a pivotal responsibility to ensure the quality of the practice environment to provide optimal patient care outcomes.    A healthy work environment is fundamental and requires the nurse manager to empower and support nurses on the front line within a relational leadership approach (Wong & Giallonardo, 2013).  The Registered Nurses Association of Ontario (RNAO) (2013), defines a healthy work environment as, ?a practice setting that maximizes the health and well-being of nurses, quality patient/client outcomes, and organizational and system performance, including healthier communities? (p. 7).  Nurse managers are responsible for playing a vital role in influencing the nursing practice environment by recruiting and retaining nurses, providing resources and promoting staff engagement (Wong et al., 2013).  The evidence for patient care outcomes and adverse events is directly linked to the implications of the quality of the healthcare environment (Warshawsky et al., 2013; Wong et al., 2013).    Facilitating a healthy work environment with minimal patient adverse events is rewarding, empowering and a tremendous responsibility for the nurse manager (Sherman & Pross, 2010).  The literature and Magnet hospital evidence indicate that staff retention and job satisfaction clearly affects the quality of patient care outcomes (Hartung & Miller, 2013).  The Preparing Nurse Leaders                                                                                                              24    nurse manager can promote a healthy work environment by ensuring effective staff communication and empowering staff through implementing shared governance, paying attention to the strengths of the generational differences and ensuring staff are appreciated and valued (Hartung & Miller, 2013).  According to RNAO (2013), a healthy work environment is evidenced by increased job satisfaction for nurses; improved occupational mental health; increased perception of autonomy and control over nursing practice; increased staff motivation; increased respect and appreciation for the leader; improved organizational commitment; improved work effectiveness and performance; improved retention of staff; and improved patient outcomes (p. 36).  It is essential that the nurse manager is supported by the organization and encouraged to obtain a graduate education to better ensure successful decision making strategies that are congruent with the context of healthcare and help to shape a healthy work environment.  Many nurses that move into a novice nurse manager role must learn the role while in the job (Hawkins et al., 2009).  Just as new nurses focus on accomplishing and mastering new tasks successfully to gain confidence in their practice, so the novice nurse manager will tackle managerial tasks and challenges with the same determination, to gain confidence through developed accuracy and proficiency in managing new situations.  Shirey et al., (2013) found that the novice nurse manager will try to ?do it all? until they reach a saturation point where they have had enough.  The novice nurse manager requires adequate preparedness and education to be better established for success.  Otherwise they run the risk of not being visible to their staff as all their time is taken up doing the administrative tasks; they run the risk of aggravating the nurse manager shortage by displaying an unattractive role with unreasonable workloads (cna-aiic.ca).  One hospital suffered the detrimental effects of a high nurse manager turnover that resulted in a loss of nurses and costs to the organization.  In response, an extensive orientation program was Preparing Nurse Leaders                                                                                                              25    developed to best prepare, support and sustain novice nurse managers in the role and to provide them with the new skills they required to ensure success (Hawkins et al., 2009).   Significance  The purpose of this chapter was to have an in-depth look into the role of nurse manager to understand the contextual common knowledge and functional responsibilities.  The aim is to develop an understanding of the foundational learning needs that would best prepare graduate level students of nursing in Canada for this leadership role.  Several role responsibilities, complexities, contextual variables, diverse skills, and tasks were described.  The specific role of the nurse manager is influenced by the context of the day to day work environment, the healthcare environment and the interplay of various systems.  The role is also socially constructed within the symbiotic relationship of leader and follower.  Relational leadership styles, empowerment and cultural inferences help to frame the social context.  Understandably, no two nurse managers have exactly the same functions due to the contextual and social construct of each role, but the common knowledge and responsibilities can inform graduate education.     Research has demonstrated the pivotal relationship nurse managers play in creating a healthy practice environment to ensure quality patient care.  The literature obtained describing the role and the IH manager job description (Appendix B) do not emphasize the business skills needed to do the job.  Yet, nurse managers share a discomfort with a lack of business knowledge that would enable a better understanding of their role within this broader context (Kleinmann, 2003).  Specifically, the knowledge of the business of healthcare, healthcare economics, Canadian labour laws, human resource processes, collective agreements, program planning and managing budgets is necessary for nurse managers (Hibberd & Smith, 2006).  While the Preparing Nurse Leaders                                                                                                              26    emphasis on managing human resources, staffing issues, patient satisfaction and staff empowerment is most important, managers spend a majority of their time in analyzing financial reports, in meetings, in policy review and in program planning (Baker et al., 2012).  Knowledge of the business context of healthcare would further enable a broader systems thinking approach.  Possibly, if nurse managers had a better understanding and confidence with the business aspect of their role they would be better able to apply energy to the highest priorities and resources, to empower and support the nursing staff and create healthy work environments that ensure optimal patient outcomes.                    Preparing Nurse Leaders                                                                                                              27    Chapter Three:  The Foundational Knowledge    The current healthcare challenges accentuate the need for graduate preparation for the nurse manager.  Managers need a broad education and sound leadership preparedness to lead with confidence and utilize evidence based research for healthcare improvement and sustainability.  With greater awareness, knowledge and skills nurse leaders can grapple with an unpredictable healthcare future and cope with an environment that is framed by many challenges.  Some of the challenges include a nursing shortage, an aging workforce, an increase in skill mix and a mix of generations and cultures in the work place.  Some broader challenges include the need for interprofessional collaboration, the impact of globalization and technology and the influence of healthcare economics within an indeterminate political realm.  In light of this, formal education preparation for nurse managers is critical to be able to advance patient safety and quality, and to promote innovative models of care delivery (Scott & Yoder-Wise, 2013).  The rapidly changing environment and context of healthcare make it difficult to learn management knowledge and skills solely while on the job.  The purpose of this chapter is to explore the foundational knowledge and management leadership skills that can be furthered at the graduate level to enable the nurse manager to be best prepared to create healthy work environments and navigate the future of healthcare for sustainability.   Knowledge Competencies and Frameworks  The knowledge the nurse manager requires to be competent in every aspect of the role is multifaceted.  To advance successfully in their practice, remain credible and adapt to a future healthcare climate, formal graduate education is essential.  In the absence of formal graduate preparation, competencies were developed by Canadian and American nurse academics to provide guiding frameworks for nurse managers; however the competencies vary between Preparing Nurse Leaders                                                                                                              28    organizations (Appendix D).  Competencies are statements about the knowledge, skills, attitudes and judgments required to perform safely within an individual?s nursing practice or in a designated role or setting (College of Registered Nurses BC, 2009b).  Competencies are valuable and can inform a nurse graduate program to better establish the core knowledge needed for nurse managers.  Still, many nurse managers who acquired competencies over time through on-the-job training do not see the benefit or need for graduate education (Kleinmann, 2003).  In the case of advanced educational preparedness, those who do not have it and function without it essentially may not know what they do not know.     The Institute of Medicine (IOM) 2010 in the US has suggested that the current state of healthcare requires a reformation of nursing education.  They propose that this reformation should ensure that nurses have a broad understanding of all of the aspects that impact health.  They propose that the following competencies should be incorporated into nursing education: (1) leadership, (2) health policy, (3) system improvement, (4) research and evidence-based practice, (5) teamwork and collaboration, (6) competency in specific areas such as community, public health and geriatrics, (7) master technological tools and information management systems, and (8) collaboration and coordination (p. 2).    In anticipation of preparing future nurse leaders in the US for 2020, Huston (2008) recommends the following eight competencies: (1) a global perspective or mindset regarding healthcare and professional nursing issues; (2) technology skills which facilitate mobility and portability of relationships, interactions and operational processes; (3) expert decision making skills rooted in empirical evidence; (4) the ability to create organization cultures that permeate quality healthcare and patient/worker safety; (5) understanding and appropriately intervening in political processes; (6) highly developed collaborative and team building skills; (7) the ability to Preparing Nurse Leaders                                                                                                              29    balance authenticity and performance expectation, and (8) being able to envision and proactively adapt to a healthcare system characterized by rapid change and chaos.  These same competencies were adopted by the Canadian Nurses Association (CNA, 2009) as a means to reform and promote graduate nurse leader education for the future.  Nursing leadership without adequate graduate educational preparation will have limited power and influence for future models of care (Yoder-Wise et al., 2013).  Future sustainable models of care include integrated health initiatives and interprofessional collaborative practice (Suter, Oelke, Adair & Armitage, 2010).  Scott (2007) believes that competencies are essential to guide nursing graduate programs.  Competencies set an expectation and position a standard for the nurse manager to evaluate their practice by and to develop professional goals.  However, the nurse manager and leadership competencies (Appendix D) are not standardized and hold no accountability for nurse leaders to the professional bodies in Canada.  In Canada, nurse researchers from the Dorothy M. Wylie Nursing Leadership Institute (DWNLI) in Toronto and the British Columbia Nursing Leadership Institute (BCNLI) in Vancouver, identified education and skills needed to empower nurse leaders and managers in their current role and for the future (MacPhee & Suryaprakash, 2011; Simpson, Skelton-Green & Scott, 2011).  The DWNLI developed a beginning conceptual framework that incorporates four domains: (1) competence in nursing, (2) competence in the business of healthcare, (3) competence in leadership, and (4) competence in use of self (Simpson, Skelton-Green, Scott & O?Brien-Pallas, 2002).  The BCNLI general core competencies include: (1) developing the leader, (2) leading others, (3) leading through effective planning, (4) the mentee-mentor relationship and (5) evaluative responsibilities (MacPhee & Bouthillette, 2008, p. 67).  Research conducted through the BCNLI led to more specific competencies for manager preparation Preparing Nurse Leaders                                                                                                              30    identified in the Program Evaluation Report (Macphee & Suryaprakash, 2011).  One of the intended goals for the BCNLI program in 2008 was to prepare nurse managers to enter a graduate program in Business Administration in the absence of a relevant nurse graduate program (MacPhee & Bouthillette, 2008).    Currently the BCNLI, Royal Roads University in BC, some of the five BC Health Authorities and the Registered Nurses Association of Ontario have adopted the LEADS framework that was developed in BC through research funded by the BC Government (http://leads.cchl-ccls.ca/leads-framwork, 2013).  The LEADS framework is a health leadership capabilities framework (Appendix F).  The framework focuses on three central management capabilities needed for effective nursing leadership ? caring, being, doing ? and how these can work together to sustain change in the Canadian health system (Dickson, 2008; VanDeVelde-Cook, 2010, p. 13).  The framework attempts to address the leadership needs required to effectively manage the challenges of a rapidly changing healthcare system.  The elements in this framework closely align with the Five Practices of Exemplary Leadership by Kouzes & Posner (2007).  The LEADS framework can inform a nurse graduate program to enrich nursing leadership and strengthen connections with the interprofessional team.  Leadership competencies and frameworks can help shape the knowledge needed to effectively operate within the context of healthcare. Knowledge of Context  Managing in healthcare requires knowledge of its contextual nature, social constructs, complexity and wicked problems.  The nature of healthcare stems from an external environment characterized by interdependent systems influenced by historical, social, cultural, political and economic factors.  Storch & Meilicke (2006) recognize that ?knowledge of the development of Preparing Nurse Leaders                                                                                                              31    the Canadian health delivery is critical to understanding the social, political and economic forces that have shaped the system and that will continue to influence future changes within it? (p. 23). Change in healthcare is constant, and sustainability is of major importance.  One innovative strategy is to develop integrated health services to create optimal healing environments, but this requires knowledgeable nurse leaders who can enable this transformation for a sustainable future (Personal communication, B.  Reece, August, 2013).  Nurse managers require a broad knowledge base and systems thinking approach to enable sustainability and opportunities for innovation in healthcare (Smith, 2012). Knowledge of Power  The nurse manager requires knowledge of power structures within relationships, interconnecting systems and contextual environments.  Over the years, power shifts in leadership have enabled the successful development of empowering relationships in nursing (Laschinger & Smith, 2013).  Regardless of the progress made in nursing, ever embedded in leadership and organizations is the notion of power, whether implicit or explicit.  The nurse manager must have a comprehensive understanding of the power structures and the influence of power.  Using a systems thinking approach, the nurse manager can question - where is the power, what does the power look like, who has power and how power is exercised (Jackson & Parry, 2011).  This analytical observation will address the why questions about power and power discourse.  Leadership research suggests that despite shared power and empowerment theories in nursing, the deeper organizational power structure can serve to reinforce existing power relations.  Hidden power structures are often unconsciously expressed and culturally accepted such as seating arrangements, dress, intimidating language and offensive humor (Jackson & Parry, 2011).  The nurse manager, grounded in the knowledge and the awareness of power inferences, Preparing Nurse Leaders                                                                                                              32    can be confident in informed decision making and practice a respectful flattening of hierarchies to enable the empowerment of others. Knowledge of Leadership Management Skills   Leadership, like nursing, is an art and a science that is optimized through education and experience (Sherman & Pross, 2010).  A graduate nursing program can offer insight into the diverse aspects of leadership proficiency and attract new nurses to the role.  Wong et al., (2013) argued that advanced education courses and degrees that include management education are critical to consideration of a career in management (p. 235).  The science of managing the business or the use of ?hard skills? found in the literature is listed Appendix D.  Financial responsibilities and budgeting processes have been identified by current nurse managers as a weakness in their management skills (Sherman et al., 2007; Udod & Care, 2011).  Nurse managers require knowledge and understanding about budgeting, trend and variance analysis, strategic planning, marketing, and how to best utilize available forms of information technology (Klienman, 2003).  The common knowledge fields identified from this review for consideration in a graduate program are: theory (nursing theory, leadership theory, systems theory, power systems, theories of change, ethics); legal aspects  (healthcare legal frameworks, labor laws, collective agreements); research and best evidence based practice (innovative strategies, risk management, quality improvement initiatives, benchmarking, outcome measures, policy analysis); technological skills (systems); operations (governance, organizational structures, accreditation standards, clinical operations, standards of quality and accountability, human resource processes); political and economic influences and driving forces (historical shaping of current processes, health care environment); and a working knowledge of the business of healthcare Preparing Nurse Leaders                                                                                                              33    (budgets, fiscal management, business planning, resource allocation, project management, program development).  The list is extensive and diverse; moreover each specific field of knowledge is comprehensive.  A working knowledge applicable to the current situatedness of the manager will enhance systems thinking in the context of the healthcare environment which will in turn enable collaborative and effective decision making.    The art, aesthetic or ?soft skills? are essential for the nurse manager role. These are harder to develop in a graduate program as they involve a deeper sense of an emergence of self, based on relationship and personal development.  Personal development in a graduate program instils and cultivates life-long learning and motivation to do better.  The relational skills of the nurse manager emerge from their social and clinical background and involve communication, evaluation and feedback.  The development of personal traits will further enable the manager to motivate staff, to create a safe environment, to create a culture of safety and to accurately assess the ability of the nurse to perform his or her job (RNAO, 2013).  Leading people and mastering the skills to enable this effectively requires personal reflection and action in self-development.   The common themes elicited from the literature for the ?art? knowledge fields for a graduate program are listed here as:  leadership styles (congruent, transformational, relational, distributed, authentic, shared, value based); empowerment (quality practice environments, coaching and mentoring, proactive, visionary); team building (managing complex relationships and diversity, global perspective, building trust, connectedness, collaboration); decision making skills (conflict resolution, negotiation, rapid change and chaos, change agent, optimistic, resilient, sensemaking); communication (listen, constructive feedback, relationship building, visible, accessible, networking, time management, leading and sustaining change, promote evidence based practice); human resource management (recruit, retain, motivate, organize, Preparing Nurse Leaders                                                                                                              34    empower, professionalism); and self-development (self-awareness, self-mastery, vision).  Hibberd, Valentine & Clark (2006), believe that negotiation is an essential basic survival skill for nurse managers.  Negotiation fosters collaboration, allows for sharing of power and control and is key in conflict resolution and advocacy as it intersects all of the contexts of management (Hibberd, Valentine & Clark, 2006, p. 658).  Many leaders have noted that learning the skill of negotiation was life changing and empowering for practice and personal life (personal communication T.  Coletti, July 2013).  Knowledge of leadership styles, leadership theories and related evidence based research is necessary in a graduate program.  This informs why certain leadership theories and styles work in some situations and not in others.  Regardless of a situation, Kouzes & Posner (2007) identify four most noted common characteristics of admired leaders as being honest, forward thinking, inspiring and competent (p. 31).  ?Competent? they clarify as being reliable and having the ability to get the job done, which inspires confidence in the followers (p. 35).  Although healthcare is built around relationships and most management and leadership skills are focused on relational values, it is also a business that needs to be managed (Shermann & Pross, 2010).  The words ?healthcare? and ?business? together can be perceived as a disequilibrium in thinking for a new nurse manager who lacks understanding of  the business and the political and economic underpinnings of healthcare.  Information about the business of healthcare such as finance, clinical operations, human resource management, legal and risk management and the relevance of this content for nurse manager responsibilities may clarify the need for graduate education (Kleinman, 2003, p.  455).   Preparing Nurse Leaders                                                                                                              35    Significance  A graduate nurse program specifically developed for nurse managers is essential in today?s healthcare system. Such a program will serve to promote the nursing profession within a formidable leadership framework.  Healthcare when viewed as a complex adaptive system, enables the nurse manager to see a broader perspective and consider the interconnecting systems that play a key role in shaping a situation.  The challenges of healthcare in the environmental context require the nurse manager to be prepared with a broad knowledge base that can be offered in a nurse graduate program.  The foundational knowledge of nursing research, leadership research, and evidence based decision making for nursing management; combined with an understanding of healthcare business, program development, finances, legalities and the social, political and economic influences is explored as essential for the nurse manager to sustain a healthy work environment.  A nurse manager, fortified with a graduate nursing degree, can lead and empower others, balance priorities, negotiate complex issues and operate successfully within the business of healthcare.  The science knowledge enables effective systems thinking, critical thinking, strategic planning and task mastering.  However, leading others effectively is not entirely possible until one first understands self and how one sees the world.  Personal paradigms, values and beliefs can be challenged and shaped with understanding new knowledge.  The art knowledge or soft skills fostered in a graduate program enable the nurse manager to develop effective leadership behavior and to understand and empower others from a place of self-development and transformation.  Self-development is for the most part an experiential reflective growing process that stems from life circumstances and is enhanced in relationships while paying attention to character and emotions within specific context (Cathcart et al., 2010; Preparing Nurse Leaders                                                                                                              36    D?Cruz, 2003; Johnson, 2012).  A nurse graduate program can foster this valuable leadership development.                          Preparing Nurse Leaders                                                                                                              37    Chapter Four:  Transformation and Transformational Experience   Managing within the social context of healthcare requires leadership behaviour, skills and strategies that build relationships of trust and empowerment.  Two leadership theories used in nursing leadership research, transformational and authentic, have demonstrated effectiveness in empowering nursing staff and can enhance the potential for nurse manager success.  Knowledge of these tested theories is vital as nurse managers are in a position of relational influence and are charged with empowering staff to develop optimal quality practice environments (Wong & Giallonardo, 2013).  The relational dynamics of transformational and authentic leadership must first involve a process of leader self-development so that the ensuing development of the leader within relationship can mature to empower others (Sherman & Pross, 2010: Western, 2008).  Self-development of positive leadership behaviour matters.  The purpose of this chapter is to explore how the knowledge of personal development in both the individual transformation as a leader, and the relational leadership transformation to empower others can inform a graduate nurse program.  The significance of transformational and authentic leadership theories and four common strategies for developing transformation as a leader will be discussed as foundational for leadership development in a nurse graduate program.   A critical, but often taken for granted concept, that nurse managers must know is that leadership is not an identity; it is an interdependency with followers (Jackson & Perry, 2011; Kouzes and Posner, 2006; Northouse, 2013).  Leadership and followership are two sides of the same coin, symbiotic in nature (Jackson & Parry, 2011).  Leaders cannot be leaders without followers; followers cannot be followers without a leader.  Over the years, the leadership literature and nurse management models have shifted away from the traditional hierarchal and militant ?power-over? approach, towards an empowering transformational and relational Preparing Nurse Leaders                                                                                                              38    approach (Hibberd & Smith, 2006).  The old style of ?command and control? in healthcare is perceived as confrontational and essentially blind to ensuing implications, rendering it mostly ineffective in the relational healthcare environment.  Managers must realize that even though the dual relationship between the nurse and nurse manager represents two complimentary parts, it is the followers who will determine how successful the leader will be, and leaders are most effective when they enable followers to reach their potential (DePree, 1992).  Transformational and authentic leadership approaches enhance staff engagement and empower nursing staff which contributes to healthy work environments and subsequently, also empowers the nurse manager as leader (MacPhee et al., 2013).   Transformational Leadership  Transformational leadership started in the 1980?s with an emphasis on intrinsic motivation and follower development through empowerment.  Transformational theory is based on relationship and driven by morals, values and standards (Western, 2008).  Transformational leaders are recognized as change agents and role models who can clearly articulate a vision to empower and transform the organization to reach its potential (Jackson & Parry, 2011).  The belief behind transformational leadership is that followers who are valued and respected become motivated, empowered and perform well.  Transformational leadership theory is the success behind the esteemed Magnet Hospitals, which are facilities that are recognized for offering excellent nursing care and successful in recruiting and retaining nurses (Shirey, 2006).  Retention and empowerment of competent nurses is vital for healthy work environments and healthcare sustainability.  With further development of leadership theories, the most recent approach studied in nursing literature that accentuates the positive traits of empowerment and the relational value of transformational leadership is authentic leadership.   Preparing Nurse Leaders                                                                                                              39    Authentic Leadership   Authentic leadership is the most recent and noted leadership theory adopted in nursing that is equipped to augment both a personal transformation and a relational transformation aptitude.  It is a new emerging relational approach in nursing demonstrated to empower staff, contribute to job satisfaction and retention, and create healthy work environments (Bamford, Wong & Laschinger, 2013; Laschinger & Smith, 2013; Laschinger et al., 2013).  It emerged in response to a demand for trustworthy leadership and out of criticism for the charismatic style of transformational leadership (Northouse, 2013).  Authentic leadership is a matter of the heart; therefore, it holds value in endless depth and potential in relational capacity (Jackson & Parry, 2011; Johnson, 2012).  Hence, one cannot be an authentic leader if one has not first become an authentic person.  Authentic leadership is as much an intrapersonal development for leaders as an interpersonal approach (Northouse, 2013).  It fosters open interactions between leaders and followers and is linked to stronger feelings of trust, engagement and empowerment (Laschinger & Smith, 2013).  New evidence suggests that authentic leadership has a positive influence towards reducing emotional exhaustion and cynicism which can lead to reduced burnout in nurses (Laschinger et al., 2103).    Authentic leadership is follower focused; values driven; grounded in moral intentions and behaviour; and cultivates positive psychological capacities such as hope, optimism, confidence and resiliency (Wong & Cummings, 2009).  It is selfless and enlightened (Jackson & Parry, 2011) and aims to instill leadership trust and predictability, which is linked with organizational productivity and performance (Johnson, 2012).  Authentic leaders have a strong moral element, are aware of how they think and behave, know how they are perceived by others, and are ethically responsible (Johnson, 2012; Wong & Cummings, 2009).  They have a sense of purpose; Preparing Nurse Leaders                                                                                                              40    care about their work; develop strong relations and connections with others; exhibit self-discipline; and have a cool, calm and consistent demeanor (Northouse, 2013).    Central to the development of the authentic leadership are life experiences. The meanings attached to those experiences are fostered through an attitude of introspection and reflection on critical events (Jackson & Parry, 2011; Johnson, 2012; Northouse, 2013).  Further to this, authentic leaders understand their own values and behave toward others based on these values; they do not compromise values but allow situations to strengthen those values (Northouse, 2013, p. 259).  The development of authentic leadership is based on four theoretical components of self-awareness, relational transparency, internalized moral perspective and balanced information processing (Jackson & Parry, 2011; Johnson, 2012; Northouse, 2013; Wong & Cummings, 2009).  The first theoretical component of self-awareness has particular emphasis on knowing ones strengths, weaknesses, personality, emotional triggers, intentions and self-acceptance.  The second component of relational transparency emphasizes values, openness and truth, and thoughts and feelings appropriate for the relationship.   The third component of internalized moral perspective addresses the ability to self-regulate behaviour according to internal standards and values.  The final component of balanced information processing is comprised of the ability to remain unbiased, impartial and accepting, and objective when receiving information.    A nurse graduate program can foster personal transformation from a new depth of awareness by providing knowledge of the authentic leadership theoretical components and by encouraging reflection on situations, experiences and emotions.  Intrapersonal development in a graduate program will strengthen authentic leadership in nursing and empower nurse leaders to successfully build healthy work environments.  Authentic leadership can be developed in a graduate program by: (a) exploring possible consequences to leadership decisions, (b) enhancing Preparing Nurse Leaders                                                                                                              41    perspective taking through discussion and training, (c) exposing students to common moral dilemmas faced on the job, (d) building a belief in the ability to follow through on choices, (e) developing strategies for adapting and coping in new ethical challenges, and (f) pairing students with moral leaders to observe ethical behaviour in a positive mentorship (Johnson, 2012).  Further to this, research indicates that novice nurse managers gain confidence by first practicing empowering leadership behaviours in a supportive learning environment prior to engaging with staff (MacPhee et al., 2013).  Knowledge of authentic leadership theory and its practical application can validate experiences, strengthen values, fortify and empower the nurse manager as a relational leader.    Authentic nurse managers empower nurses, which is fundamental to creating and sustaining healthy work environments (Laschinger et al., 2013).   A nurse graduate program can advance the  development of authentic leadership, a form of leadership which has demonstrated a positive correlation with creating healthy work environments, reducing burnout, empowering and motivating nurses (Bamford et al., 2013; Laschinger & Smith, 2013; Laschinger et al., 2013; Shirey, 2006; Wong & Cummings, 2009).  The development of an authentic relational and transformational nurse leader can be fostered by the application of four common strategies that include: (1) reflecting, (2) developing emotional intelligence, (3) mentoring and coaching, and (4) promoting collaboration. Strategies Reflection    Leadership development is a lifelong intentional learning process of purposeful growth with passion that shapes why one behaves the way they do.  It is continual and uses reflection to enable positive change.  Reflection is a humbling and fortifying personal process that challenges Preparing Nurse Leaders                                                                                                              42    one?s beliefs and values and acknowledges personal biases.  It enables the nurse manager to become conscious of attitudes and gain a deeper understanding of others.  Leadership development is self-development (Kouzes & Posner, 2007, p. 344).  Personal mastery is the discipline of personal growth and learning (Senge, 2006. p. 131) to gain a deeper understanding of self.  Personal mastery improves ones self-confidence, one?s ability to trust and empower others and one?s ability to acknowledge, accept and learn from mistakes (Sherman et al., 2007).  It is using self-knowledge as a lifelong learner to grow in emotional intelligence, trust, courage and work-life balance, to lead others with humility and resilience (Simpson et al., 2002).    Reflection drives positive change and transformation.  It is an intentional process that is propelled from a new awareness or new knowledge about an experience or emotion.  The cognitive transformation is made evident in positive behaviour change.  Personal development within the context of  healthcare shapes the leader and refines behaviour and emotions to further leadership potential by attaining knowledge, gaining understanding and developing insight and discernment (Cathcart, Greenspan, & Quin, 2010; Jackson & Parry, 2011).  The context of the complex healthcare environment and the nature of managerial work may not be conducive to reflection (D?Cruz, 2003); however, reflection is essential for positive personal leadership development to occur.  Graduate education can foster nurse leadership growth within the academic environment and better prepare nurse managers to be resilient and reflective leaders.  The personal growth that is gained from reflection allows the leader to gradually be able to meet challenges with a winning perspective and to see problems as possibilities (Jackson & Parry, 2011).  Various on-line leadership tools can help nurture reflective self-examination to enable one to recognize blind spots, gain personal awareness and develop a deeper understanding of self and others.  Some tools include the Jung-Myers Briggs personality tests, the Keirsey Preparing Nurse Leaders                                                                                                              43    Temperament Sorter, and Emotional intelligent tests.  However, advanced education can take the learner beyond these tools and focus on the very core of the leader to facilitate a re-evaluation of values, beliefs, attitudes and judgements.  Graduate education can be the means to peel back and expose the hidden deep layers of an unconscious belief system that drives behaviour to better understand why a leader does what they do.  Still, in the same way that modern medicine cannot truly heal the body but can only situate the human body in the best position to heal itself, so education can only situate the leader in an optimal position to learn and transform oneself.  Education is powerless to transform a leader but can facilitate and inspire the process of an empowering practice in self-reflection.  The pathway to triumphant personal growth and leadership development through reflection in a nurse graduate program can be an exciting, humbling and fortifying learning experience and a powerful lifelong strategy.  A graduate program can foster reflective learning to help managers make sense of experiences.  Reflecting on emotional experiences to gain meaning and understanding is the pathway to developing emotional intelligence.  Emotional intelligence is integral to authentic leadership.   Emotional Intelligence  Since its popularity in 1995 the value of emotional intelligence has been controversial, highly criticized and yet embraced by nursing with implications for nursing students, (Smith, McGrath & Cummings, 2009), and nurse leaders (Vitello-Cicciu, 2002).  Nurses are expected to develop understanding of emotions to facilitate insight and health-giving recovery for another.  Emotional intelligence (EI) is defined as improving understanding of one?s own emotions and those of others to achieve greater self-awareness and more effective social management, especially with a diverse workforce (Wallis & Kennedy, 2013).  EI is an essential characteristic of the nurse manager and has implications for leadership success (Simpson et al., 2011).  Nurses? Preparing Nurse Leaders                                                                                                              44    perception of managers? EI leadership behaviour has a strong effect on feelings of empowerment and subsequently on organizational commitment (Young-Ritchie, Laschinger & Wong, 2009).    EI is one of the job requirements for a nurse manager position in Interior Health (IH).  The EI list of expected behaviors for a nurse manager in IH is believed to benefit the organization (Appendix C).  These EI traits describe a relational knowledge of ?soft skills? to work collaboratively with and empower others, as opposed to a technical knowledge of ?hard skills? needed to do the job for effectiveness and efficiency.  The focal elements of EI include self-awareness, emotional management, empathy and relationship management (Wong & Cummings, 2009).  Both authentic leadership and EI have a strong focus on the leader-follower relationship.  In both leadership paradigms the ability to remain optimistic and resilient during times of turbulence and change is a key ingredient to leadership success (Sherman et al., 2007).  EI enables the leader to assess situations objectively, to listen with intent to understand and to assimilate and align new knowledge with circumstances for optimal decision making.  Developing EI reflection and feedback on personal behaviours and emotions in relationships is vital to further self-development (D?Cruz, 2003).    Nurse managers that practice EI skills can motivate nurses to make high-level practice decisions, establish positive relationships, understand the context of care and acknowledge emotion within that context (Smith, et al., 2009, p. 1631).  EI enables nurse manages to be resilient leaders who can manage emotions within dynamic healthcare systems and use knowledge and research in practice to influence improvements (Smith et al., 2009).  However, D?Cruz (2003) argues that there is little if anything that the current graduate education model can contribute to the development of EI in the absence of a practitioner-based model, considering the focus of graduate education is firmly grounded in an academic research paradigm.  Yet, EI Preparing Nurse Leaders                                                                                                              45    practiced in graduate group work and scenario dialogues can foster development as these situations invite opportunity to cope with negative feelings openly and learn through socialization and self-awareness how to manage one?s feelings and behaviours in respect of others.  Practicing EI enables one to develop an understanding of others and build effective respectful communication skills.  Graduate students and nurse managers can resolve to be strengthened and encouraged by their peers and heightened by challenges and shared experiences that influence thinking and increase confidence.  The personal growth of EI through reflection transforms and changes ones behaviour, and empowers the nurse manager for practice.  EI and authentic leadership can be further strengthened by the impact of the giving and receiving of mentoring and coaching.   Mentoring and Coaching  Mentoring and coaching are powerful tools for learning leadership, developing insight and gaining aptitude from encouragement, support and reflective feedback.  Development as a nurse manager requires experience in the leadership role to test and solidify academic knowledge, because leadership knowledge accompanied with clinical experience does not always translate into expertise as a manager.  DeCampli et al., (2010) found that nurse managers benefit more from formal education if they can get help to put it into practice from an objective, supportive and encouraging coach.  A mentor is a trusted counselor or guide who is self-selected and establishes a long-term relationship with the mentee through informal learning (DeCampli et al., 2010).  Mentors provide feedback and help managers reflect on actions, outcomes and implications of decisions (D?Cruz, 2003; Mackoff & Triolo, 2008).  Mentors also provide specific advice and opinions on issues, and identify skills that need to be developed by sharing experiences and expertise (Thompson, Wolf & Sabatine, 2012).  Good mentors act as mirrors Preparing Nurse Leaders                                                                                                              46    that allow managers to see themselves in action to learn from their experiences, but mentors are not teachers (D?Cruz, 2003).  Although mentorship is highly effective, it would be a challenge for a graduate program to implement this level of support as good mentors for practice in an academic paradigm are hard to find.  Organizational support from the employer in partnership with a nurse graduate program would be imperative to ensure the continual development of the novice nurse manager.    A coach, on the other hand directs, teaches and focuses on developing new behaviour and attitudes to enhance performance and effectiveness, and is not so much focused on the minutia of work related issues (DeCampli et al., 2010).  A coach instructs, focuses on learning needs and fosters skill development by exposing the learner to new ideas, resources and sustained problem solving strategies with constructive feedback (DeCampli et al., 2010, p. 134).  The coach assists in developing and practicing leadership, communication, and interpersonal skills necessary for career success (Thompson et al., 2012, p. 538).  New managers benefit from a coach who is not their boss, peer or personal friend so that a professional expectation and non-judgemental, non-biased and expert support can ensue, which is critical to achieving positive outcomes.  This way the new manager can be confident to ask pointed questions that they may not have felt comfortable exploring otherwise (DeCampli et al., 2010).  It is important for the coach to remain objective and understand the values, goals and culture of the organization (Thompson et al., 2012).  A graduate program can support nurse manager development with a coach, either on site or accessible by Skype or phone.  A mentor or coach can be the pivotal support needed in the initial phase of the novice nurse managers? practice and can foster development through reflective questions following the application of new knowledge and skill.  This form of Preparing Nurse Leaders                                                                                                              47    collaborative learning encourages the nurse manager to be able to draw strength from knowledge and experience of others, and to value others as resources to move forward in the role.   Collaboration  Personal development as a manager is strengthened in collaboration with others.  Collaborative learning, decision making, fostering teamwork and group problem solving helps one to embrace new ways of thinking and enables others to succeed.  No nurse manager can do the job alone.  As managers aspire to enable followers to rise to their potential, they must also value the unique strengths and contributions of others.  Novice nurse managers must recognize they cannot know nor do everything.  To accept diversity and defer to the strength of others is not a leadership weakness but an empowering strength.  Collaboration is the master skill of leadership that enables the team to function effectively, to motivate others and to foster relationships in a climate of trust and mutual dependence towards a common goal and purpose (Kouzes & Posner, 2007).  Collaboration focuses on the process of decision-making (Johnson, 2012, p. 167). It is the meeting of minds to see ideas with new clarity and to shape them into insights for understanding.  Collaboration stimulates thought, not the thinker, and sharpens ideas while remaining respectful of others.  A collaborative healthcare culture that values input from front line staff requires an empowered leader who can empower others, balance innovation with risk (Regan & Rodriguez, 2011) and remain confident in certain vulnerability.  Empowered nurse managers are passionate about their role, are mission driven, are proud to empower the next generation and are self-aware, self-regulated and find meaning in their work through engagement with others (Mackoff & Triolo, 2008).  They model resilient behaviour, express agility towards change and have an optimistic attitude with positive expectations (Mackoff & Triolo, 2008).   Preparing Nurse Leaders                                                                                                              48     Leadership empowering behaviour fosters collaboration to enable productive decision making within a complex healthcare organization (Marion & Uhl-Bien, 2001).  A graduate program can foster transformational experience for personal self-development enabling the nurse manager to become an effective leader through learned critical self-reflection and academic leadership knowledge in a collaborative group experience.  Critical self-reflection enables one to identify personal biases and barriers, to be open to new ways of thinking, to explore alternatives and to collaborate with others.  It is essential that nurse managers draw strength from others, and to know that no one leader knows it all or has all the answers; but each member on the team holds a piece or form of an answer.  With education and experience, the nurse manager can trust that a solution will emerge through the mysterious fulfilling power of collaboration.   Significance  A nurse graduate program can foster strong, knowledgeable authentic and reflective nurse leaders.  Leadership is not about personality but is about behaviour, and behaviour can be learned (Kouzes & Posner, 2007).  Nurse manager preparedness can be learned in a nurse graduate program.  The art of leadership is a life-long journey of personal development in exploring the meaning of experiences and emotions while learning about self and understanding others.  This learning cannot be forced, even in a graduate program as one must be open to challenge personal values and paradigms and test alternative perspectives.  The process can feel like a cognitive wrestling match at times, but as one perseveres the outcomes will be life changing.  Other than the essential strategy of self-reflection, it is difficult to identify the salient core body of knowledge that personal transformation is rooted in so that all managers can grow from the same platform.  Personal transformation is an individual journey that is both humbling and empowering and vital to effective leadership development.    Preparing Nurse Leaders                                                                                                              49     The knowledge of personal development in both the individual transformation as a leader, and the relational leadership transformation as described in this chapter can inform a graduate nurse program.  Authentic leadership theory is a new emerging powerful transformational leadership approach linked with strong feelings of trust and engagement.  It can inform both the intrapersonal self-mastery development as well as interpersonal relational empowerment.  Authentic leadership builds confidence, hope, optimism, resilience and meaning in work (Johnson, 2012; Shirey, 2006).  Emotional intelligence is integral to authentic leadership and fundamental in nursing.  It can be developed through reflection of personal emotional experiences and can be incorporated at the graduate level to build a sincere self-awareness and respect for others.  Both authentic leadership and EI develop from self-reflection and raise the question about the close ties of personal and professional development.  In graduate education both are clearly present but only professional development is evaluated as per academic criteria.  Mentorship and coaching engages a practice-based development that encourages the nurse manager to put into practice what is learned with the safety of an advisor who can inspire reflection as learning opportunities.  Collaboration is key to effective decision making within a framework of trust, mutual goals and purpose.  The transformational and authentic leadership knowledge and strategies shared in this chapter can inform a nurse graduate program to foster personal leadership transformation and empower resilient and relational nurse managers who will create healthy and sustainable work environments.  Existing nurse graduate programs partly fulfill the requirements for nurse manager preparedness, but there are significant differences between programs and gaps in curricula.     Preparing Nurse Leaders                                                                                                              50    Chapter Five: Analysis of Graduate and Supportive Programs in Canada  A nurse graduate program can prepare nurse managers for their pivotal role responsibility to create healthy work environments in the context of an evolving dynamic and complex healthcare system.  Healthy work environments ensure optimal patient outcomes as measured by morbidity and mortality rates, and patient survey results.  Many health organizations are posting a preference of graduate education for the nurse manager/leadership position as evident in a review of job postings for Interior Health.  In support of this, Scott & Yoder-Wise (2013) believe, ?If nursing persists in accepting managers and leaders with less than this level of education, one might argue that the profession does not value high-level preparation and that, therefore, no need for such program exists? (p.  2).  Ideally, the nurse manager prepared at the graduate level will not only have a broad knowledge and understanding of leadership and advanced nursing knowledge , but will also be equipped with the business of healthcare (Russell & Scoble, 2003).  Such a nurse graduate program is not available in Canada.  The Dorothy M. Wylie Nursing Leadership Institute in Toronto (Simpson, Skelton-Green & Scott, 2011) and the British Columbia Nursing Leadership Institute (BCNLI) (McPhee & Suryaprakash, 2011), have made great strides by conducting research to identify nurse manager learning needs, competencies and frameworks for leadership development, and offering leadership certificate programs but no nurse graduate program has been formulated.  The purpose of this chapter is to analyze existing nurse graduate programs in Canada for their vital leadership role in preparing relevant nurse managers for the current healthcare system.  This chapter will also explore other supportive measures that help ensure successful leadership development for the nurse manager.    Preparing Nurse Leaders                                                                                                              51    Graduate Programs  Currently there are 24 nurse graduate programs across Canada as identified from an internet investigation for this paper.  The CNA website1 lists 32 nurse graduate programs as of 2009, but this information is no longer current and most of the programs offered in Quebec are difficult to decipher as they are listed in French.  The 24 nurse graduate programs offer up to 3 streams of academic study: (1) Nurse-Practitioner, (2) Education or (3) Leadership/ Management.  All of the 24 programs offer similar foundational core courses rooted in nursing theoretical knowledge and components of research methodology and application.  Each program offers a selection of either a thesis based or a non-thesis based degree, and most offer some or all classes by distance.  A leadership and/or leadership theory course is offered in all nurse graduate programs but almost all programs lack an introduction to human resources and the business aspects of healthcare management.  Despite the broad availability of nurse graduate programs across Canada, none focuses on management development for the nurse manager in preparation for the current context of the healthcare environment.    In 2005, Kilty conducted an extensive literature review regarding nurse leadership development across Canada for all levels of nursing.  From her analysis she concluded that there is a serious gap in the number of nurse managers and nurse leaders in positions of leadership in healthcare organizations.  She considers it necessary to educate, recruit, promote and advocate for nursing leaders, and for their voices to be a vital part of healthcare decision making.  Graduate knowledge and skill preparation is essential for a competitive edge in advocating for healthy work environments and patient safety.  Her study found two universities in Canada that                                                  1 http://www2.cna-aiic.ca/nursingpgms/public_browse.asp  Preparing Nurse Leaders                                                                                                              52    had a focus on leadership in Healthcare at the graduate level, of which only one was in part a nurse graduate program (Kilty, 2005, p. 8).  The University of Windsor in Ontario offers one course entitled ?Leadership Innovations in Nursing Leadership? in the Masters of Nursing program2.  This course focuses on the application of leadership, organizational theories, and research that support excellence and innovation in professional nursing practice, education, and workplace environments.  Students examine issues pertaining to operations management, including finance, quality and risk management, information systems development and policy development, and learn strategies to influence current policy and legislation that impact nursing practice, education, health care systems, and the health of Canadians.  Albeit it is only one course in a graduate program, the topics it addresses are essential for the nurse manager.  The University of Toronto in Ontario offers a combined Masters in nursing degree with a Masters in Health Science Administration3.  This program completed in 2.5 years of full-time study, builds on the strengths of both disciplines to prepare graduates for nursing leadership in complex and inter-disciplinary health environments.  This on-site program provides a solid foundation in nursing management and leadership combined with a broader health services focus in health policy, business and management.  Key leadership competencies include: workload measurement, quality improvement, organizational behaviour and change management, leadership, marketing, health care trends and issues, strategic planning, health policy and economics, outcomes and evaluation, knowledge exchange and translation, human resource                                                  2 http://web4.uwindsor.ca/units/registrar/calendars/graduate/cur.nsf/ 982f0e5f06b5c9a285256d6e006cff78/f58c0ace1412493d852572bf0061bba2!OpenDocument. 3 http://www.ihpme.utoronto.ca/about/pp/combined/mn-mhsc.htm  Preparing Nurse Leaders                                                                                                              53    management, information systems, accounting and finance, and quantitative methods for decision-making.  The program curriculum is valuable for nurse manager preparedness, but has primarily an executive administrative focus.  Regardless, Scoble & Russell  (2003), believe that no matter the level of nursing leadership, the theories, principles and concepts of management, technical skills, methods and procedures are essentially the same and can be valuable at all levels (p. 325).  The University of Dalhousie in Nova Scotia offers a combined graduate program in Nursing and Health Administration4.  Students advance their nursing knowledge and skills while developing the management abilities required by health care organizations and health-related government departments. However, students must apply to each school separately for this thesis based program, on-site.  Both the University of BC and the University of Victoria offer courses in the nurse graduate program for advanced practice leadership, but it is within the capacity of advanced practice in nursing and not healthcare management or administration.   The lack of nurse graduate programs to help advance leadership preparation for the nurse manager/leader in Canada is concerning.  Many nurse managers who hold a graduate degree have pursued other disciplines out of their own best interest to prepare for a leadership, manager or administrative role.  Some common examples of graduate degrees pursued by nurses are Master?s in Business Administration, Masters in Health Administration or a Masters in Arts with a focus on informatics, adult education, or leadership.  A recent small survey conducted by UBC Okanagan indicates that only 15.9% of nurse participants were interested in the focus of leadership and health policy if they were to choose to pursue a graduate degree in nursing (Appendix H).  Wong et al., (2013) demonstrated that ?advanced education courses and degrees that in include management education were critical to consideration of a career in management?                                                  4 http://www.dal.ca/faculty/healthprofessions/nursing/programs/mn-master-of-health-administration.html  Preparing Nurse Leaders                                                                                                              54    (p. 235).  An innovative graduate program designed to meet the relevant needs of nurse managers could attract nurses to the role and ensure adequately prepared future nurse leaders.    There are non-nursing graduate programs available in BC for leadership management development reinforcing the notion that leadership skills and knowledge are transferable and applicable to all sectors of professional and personal life.  In these programs nurses meet and learn valuable perspectives from colleagues outside of nursing.  One such program is at Royal Roads University in BC which offers a two year Masters in Arts program with a focus on Organizational Leadership.  Nurses have the opportunity to learn from people outside of the health sector, broaden perspectives and learn in a blended environment (personal communication, M.  Hawkins, October 2, 2013).  Another graduate program that is highly regarded in the business world is an Executive MBA program focused on healthcare offered at the Sauder School of Business located at UBC Vancouver5.  This program is offered by distance, with classes once per month over a five day weekend, and is 15 months long. Unfortunately, the program costs 66,000.00 dollars which makes it prohibitive for many nurses, but the curricula is well suited to the health business needs of a nurse manager.  Further, there is a concern that nurse managers who pursue a non-nursing graduate degree such as an MBA or Health administration (MHA), will lack important advanced nursing knowledge, research and evidence based practice, and the patient care perspective and thus may be unable to promote the profession (Herrin, Jones, Krepper, Sherman & Reineck, 2006).  Aspects of this concern may have some validity; however, such thinking may create silos in the very profession that promotes the value of diversity.  Nurse leaders with a non-nursing graduate degree are well prepared to manage the business aspects of healthcare in the absence of a more relevant nurse graduate program.  Nurses who obtained non-                                                 5 http://www.sauder.ubc.ca/Programs/Executive_Education/EMBA_in_Health_Care   Preparing Nurse Leaders                                                                                                              55    nursing graduate education have gained the broader perspective needed for effectiveness for decision making in healthcare, for empowering staff and for building healthy work environments (personal communication, M. Hawkins, Oct 2, 2013; T. Coletti, July 2013).   Supportive Initiatives  Despite the lack of nurse graduate programs available in Canada dedicated to optimizing the nurse as manager, there are various web-based programs available to foster leadership development.  The Canadian Healthcare Association offers a two year Health Services Management program by distance education, for middle and senior managers in health services6.  York University in Ontario offers a master?s certificate in healthcare management, a 4 month comprehensive program7.  McMaster University in Ontario offers a master?s certificate in healthcare management, a 4 month program by distance education8.  Royal Roads University in BC, offers a post graduate certificate in Health Systems Leadership, a 6 month program in partnership with the Canadian College of Health Service Executives (CCHSE)9.  This program is based on the LEADS framework (Dickson, 2008), but at Royal Roads University an ?R? for research is added (LEADRS) for the graduate arts degree in organizational leadership (personal communication M. Hawkins, Oct 2, 2013).  British Columbia Institute of Technology (BCIT) offers an Advanced Certificate in Healthcare Leadership that also follows the LEADS framework10.  This certificate is a new 2 year program for emerging leaders in healthcare with the first graduating class to be in 2014.                                                  6 http://www.cha.ca/learning/courses/health-services-management-program  7 http://www.seec.schulich.yorku.ca/long_program_faculty.aspx?id=bf0953cb-52b4-4b2a-a3d03dcfbe5840c&tab=4   8http://fhs.mcmaster.ca/nursing/education_leadership_distance.html  9 http://www.royalroads.ca/ prospective-students/graduate-certificate-health-systems-leadership 10 http://www.bcit.ca/study/programs/6860adcert Preparing Nurse Leaders                                                                                                              56    Organizational Support  Organizational support from the employer and professional associations is vital in the development of effective nurse managers.  A lack of preparation and organizational support results in role strain, role ambiguity, stress, frustration and sense of failure leading to high nurse manager turnover and increased costs to the organization (Embertson et al., 2009).  Adequate preparation and organizational support for the nurse manager contributes to a sense of empowerment and role satisfaction that leads to the ability to create positive work environments and to be a role model for potential nurse leaders within the organization (Patrick & Laschinger, 2006).  Organizational support and commitment from the employer to develop nurse managers include access to needed resources and information, networking and mentorship, and support for professional growth and development (RNAO, 2013, p. 68).  Support could include funding and mentorship for ongoing leadership development or education.  Positive work experiences within a supportive organization can attract new nurse managers to the role.  Further, nurses are more likely to be positive about assuming management roles in environments where work experiences are congruent with goals and values that align with the organization (Laschinger et al., 2013, p. 221).  A supportive organizational culture that values employees has shown to contribute to the nurse manager?s sense of empowerment, job satisfaction and role retention (Brown et al., 2013; Laschinger, Purdy, Cho & Almost, 2006; Laschinger, Wong, Grau, Read & Stam, 2011).  Adequate organizational support for on-going leadership development ensures nurse manager effectiveness to create healthy work environments and optimal patient outcomes.  An underinvestment in nursing leadership development places the organization at risk of underperforming (O?Neil et al., 2008).    Preparing Nurse Leaders                                                                                                              57     The Interior Health (IH) organization in BC is one example of an organization that provides internal assistance by means of an accessible corporate partner to support the nurse manager with the business knowledge of healthcare.  They also promote various internal web-based i-learn modules for specific business and human resource processes.  A coaching /mentorship program for novice nurse leaders is available through an electronic matching system, and an electronic link is provided on the IH InSideNet through an Education/ Development portal for management/leadership development.  IH also delivers a ?Pathways to Leadership? program in the form of the ?People Management Series?, classes offered a few times per year (Appendix G).  IH nurse managers are aware of the resources available through the InSideNet, internal email system and by invitation.  Most of the IH management/leadership resources are available electronically and travel is only necessary to attend the People Management Series classes.    Organizational support must also come from the provincial and federal professional nursing bodies.  Recently the Association of Registered Nurses in BC (ARNBC) initiated an innovative network leads program to create a forum for nurse managers to provide support for nurse leaders in healthcare (personal communication, B. Reece, August 19, 2013).  Financially, nurse professional associations can support graduate education for nurse managers similar to funding nurses for advancement in clinical skills.  Hibberd & Smith (2006) believe nurse managers need a broad knowledge base and would benefit from understanding the history of the current Canadian healthcare system, healthcare economics, political influence, legal aspects of labor laws and collective agreements, and the driving forces for healthcare funding and spending; all of which shapes the context of the current healthcare system and contributes to systems thinking and effective decision making.  This type of knowledge can be offered in a nurse Preparing Nurse Leaders                                                                                                              58    graduate program, and the day to day new information can be disseminated by the professional bodies to assist nurse managers to remain current.  Information sharing by the professional bodies through email, social media, literature links, web-based learning, seminars or e-learning modules would demonstrate the value and importance placed on nursing in leadership.    None of the Canadian provincial nursing associations or the CNA offers e-learning modules for the novice nurse manager.  In the US, the American Association of Critical-Care Nurses (AACN) has taken a lead in nursing management leadership development.  This organization recently held a nurse managers conference in Las Vegas (Sept, 2013) and have established an e-learning module entitled ?the essentials of nurse manager orientation? available for novice nurse leaders on-line but there is a cost of 600.00 dollars US.  The program outline and objectives aim to foster leadership through this comprehensive introductory course for new and aspiring nurse leaders (Appendix I).  In the US many nurse authors have researched and developed competencies and curriculum needs for a nurse graduate program for administration in nursing (Harris et al., 2006; Herrin et al., 2006; Huston, 2008; Miltner & Patrician, 2012; Russell & Scoble, 2003; Scott & Yoder-Wise, 2013) in collaboration with the Council for Graduate Education for Administration in Nursing (CGEAN).  The CGEAN position statement on educational preparedness of nurse executives and nurse managers advocates that graduate education is an expectation for the future, especially for complex organizational settings (Scott & Yoder-Wise, 2013, p. 2).    The RNAO is the only professional organization in Canada that has established best practice guidelines for developing and sustaining nurse leadership.  The 138 page document contains a thorough list of nurse leadership competencies for professional development and a conceptual framework as a guide for building healthy work environments (RNAO, 2013).  It is Preparing Nurse Leaders                                                                                                              59    well researched and referenced to support nurse leaders in general and to foster leadership development, but is not binding for the nurse or the organization. Significance  It is surprising to learn that given the input of nursing research and evidence linking healthy work environments and patient outcomes with nurse manager leadership effectiveness, that no nurse graduate program exists in Canada to meet the diverse leadership/management needs.  It is also evident that the current context of healthcare and the systems that operate within it are dynamic, diverse and evolving as a complex adaptive system.  Nurse managers must be able to function effectively within this environment.  Recommendations to support this pivotal role will follow in chapter six.                Preparing Nurse Leaders                                                                                                              60    Chapter Six: Analysis of Findings and Recommendations for Future Education.  The literature is clear that the nurse manager holds a pivotal responsibility in creating healthy work environments.  The achievement of healthy work environments is evident by staff recruitment, staff retention and optimal patient outcomes.  Given the contextual nature of the current healthcare system, and the diverse role of the nurse manager within the social construct of leadership, the knowledge base needed to be effective is broad.  As noted in chapter 5, the broad knowledge base is not offered in its entirety in any nurse graduate program in Canada.  This chapter will discuss four recommendations based on the information in this paper.  The development of a nurse graduate program that focuses on business knowledge and expertise can better ensure credibility for the nurse manager role.  Yoder-Wise et al., (2013), believe ?a master?s degree in nursing administration or leadership prepares the nurse to lead nursing and interprofessional teams, to create new and innovative approaches to improve care processes and outcomes within their scope of responsibility as well as traditional management responsibilities related to budgets, human resources, quality and safety and a healthy work environment? (p. 327).  Nurse managers must empower staff and be critical thinkers, systems thinkers and change agents for quality improvement to ensure patient safety.  They must also balance resources to meet the organizational goals of cost effectiveness.  This challenge demands creative decision making, effective collaboration and a calculated certainty of risk that can emanate from a broad knowledge base and understanding of health care complexities and systems.  A nurse graduate program can prepare nurse leaders and managers for the level of responsibility they will encounter in healthcare and be the voice that needs to be heard within the healthcare business paradigm.    Preparing Nurse Leaders                                                                                                              61    Discussion  Nurse leaders without adequate educational preparation will have limited power and influence for future models of care (Yoder-wise et al., 2013).  Nurse managers must understand and be able to translate nursing care into business language to effectively advocate for nursing and patient care initiatives.  Business knowledge can lead to persuasive business proposals and the ability to speak the language of the power structures and systems in place to influence decision making and improve patient care outcomes.  Graduate preparedness can further inspire lifelong learning in leadership and healthcare knowledge, and instil confidence to envision a future in healthcare that is sustainable and holds a priority to make a difference in outcomes.  Graduate preparation for the nurse manager will influence personal and professional transformation and have a noticeable impact on practice.  The CNA 2009 position statement for Nursing Leadership states that nurses are the optimal leaders for healthcare.  Nurses think critically and independently, inform their practice with evidence, and use research to shape health policy.  A nurse graduate program can prepare nurses to develop, analyze and interpret health policy and health regulatory systems within frameworks of health economics and political forces.  The nurse manager needs to learn the business of healthcare and adopt the concept that healthcare is a business embedded within the broader relational capacity.  This enables the manager to understand corporate decision making, and removes the tension between ?care and cost? enabling the nurse manager to advocate for staff resources within a financial and benchmark framework to improve quality and patient care outcomes.  Considering the impact of the necessary knowledge required, and the absence of a well-rounded relevant nurse graduate program in Canada, M. Macphee stated that she is a proponent of a combined MSN-MBA program based on her professional practice experience in Preparing Nurse Leaders                                                                                                              62    the US (personal email communication, June 3, 2013).  However, this combination of education does not exist in Canada.  Based on the knowledge and research gathered for this paper, a summary of four recommendations are presented.   Recommendations  Nursing research is clear regarding the impact of effective nursing leadership for a healthy work environment and optimal patient outcomes.  This evidence should result in educational formats to optimize relevant academic preparation for nurse leaders and managers.  Armed with this knowledge, those responsible for creating nurse graduate programs have a means to advocate for education to best support nurse managers and nurse leaders in the clinical realm.  The first recommendation is that nurse managers and leaders need to be truly aware of the pivotal role they play in healthcare, specifically in creating healthy work environments and the implications of this responsibility.  This vital commission must be made known to all nurse managers and leaders.  Once they truly know it, and can name it and define it, it will change the conversation.  Awareness can be incentive to assess and evaluate and empower for effectiveness, and foster the need to obtain further educational support and leadership development.    The second recommendation is to develop an innovative and collaborative nurse graduate program to meet the diverse academic needs of the nurse manager.  The milieu of healthcare management should not be foreign to the nurse leader/manager but portioned into vital knowledge for practice.  Nurse leaders can better manage if they have a well-rounded knowledge of the precepts that will impact decision making and if they know to pay attention to key organizational changes that will impact the healthcare environment.  Nurse managers live the day to day challenges of their work.  Policy development acumen and leadership competency can empower the nurse manager to effectively navigate changing variables.  Nurse managers need Preparing Nurse Leaders                                                                                                              63    the best of the best.  They have a complex job.  Although a graduate program cannot prepare them completely, the integrated knowledge they obtain through a graduate program can enable them to tackle the challenges in the dynamic healthcare environment.  Courses from a nurse graduate program and an MBA program can be combined to help the nurse leader effectively manage in an evolving healthcare system.  Graduate elective courses from other disciplines such as business, healthcare economics, human resources management and program planning can address the challenges of nursing and help the nurse manager to broaden their thinking.  Nurse graduate programs are in an optimal position to embrace the identified learning needs of nurse managers and prepare them for a future healthcare system.  Academic preparation will value diverse life and work experiences, instil confidence with knowledge of processes and systems, and work within the context of the healthcare environment to support dynamic critical thinking for effective decision making.  The third recommendation is the implementation of diverse learning formats for a graduate program.  The success in the dissemination of a diverse wealth of knowledge to best prepare the nurse manager may be contingent on the best format of learning.  A variety of learning formats are available in various graduate programs such as: problem-based learning (Baker et al., 2007), experiential learning (Cathcart & Greenspan, 2012), group learning, e-learning modules, classroom learning and alumni mentorship programs.  Learning formats supported by the four transformational strategies of reflection, emotional intelligence, mentoring and coaching, and collaboration will promote the development of new knowledge and cultivate personal leadership growth.  Further, innovative collaborative processes can translate into a successful nurse academic program through partnerships with healthcare organizations, senior leadership experts, business experts who understand healthcare and government policy, political Preparing Nurse Leaders                                                                                                              64    leaders in healthcare and economic experts.  Innovative collaboration will ensure that a nurse graduate program that fosters nursing knowledge, theory and research, can also facilitate the necessary diverse knowledge and skills needed for the nurse manager, and maintain standardization within an academic research paradigm.    The fourth recommendation is to attract nurses into management and leadership positions with an innovative graduate education that will reshape the role based on nursing research evidence.  It is apparent from the statistics in chapter one and appendix A that the tail end of the baby boomer generation (1946 - 1964) occupy a majority of nurse management positions.  This generation coined the term ?workaholic? and is heading into retirement.  Generation X (1965 ? 1983) values a better worklife balance and generally has no desire to take on the current workload for the nurse manager role or strive for the academic preparedness (Laschinger et al., 2013).  Generation Y (1984 - 2000) has an incredible ability to collaborate and make use of technology, has no intention of conforming to traditional norms of the workplace, and has come to expect immediate and complete access to information as their right (Towns, 2013).  Thus they want to work smarter, more efficient, hold their own relational values and truths as the norm, and work best in a collaborative environment with management that facilitates shared leadership (Towns, 2013).  All generations can benefit from a nurse graduate program to generate interest and to prepare them for the changing and challenging role of the nurse manager.  Nursing leadership research also demonstrates that the baby boomer generation is largely responsible for mentoring the younger generations, and that the absence or presence of effective nursing leadership has an impact on the learning, the work environment and patient care outcomes (Maltais & Crupi, 2012).  With innovative educational learning formats, nurse graduate programs can also creatively liaise with senior nurse mangers/leaders to mentor novice nurse Preparing Nurse Leaders                                                                                                              65    managers into leadership positions with professional guidance, coaching and resources.  Nurse graduate programs can also help senior nurse managers understand the different generations in the workplace and how best to understand, attract and retain these employees.   Conclusion  It is evident from the nursing research literature that the impact of nurse leadership on healthy work environments is crucial for optimal patient outcomes.  It is also evident that a broad knowledge and understanding of leadership and management is necessary to empower others, engage in complex decision making and manage the financial ramifications of care delivery in the evolving and changing culture of a variable healthcare system.  With awareness of the upcoming severity of a shortage of nurse managers, it is necessary to attract younger nurses into leadership roles.  The role of the nurse manager is multifaceted and requires adequate educational preparation and experience for effectiveness.  A nurse graduate program for managers will not only facilitate knowledge but will inspire life-long learning and deep personal transformation.  Nurse graduate programs can foster an understanding of the foundational leadership skills required to empower staff and can help nurses obtain accurate healthcare business knowledge to operate and adapt in a dynamic and diverse healthcare system.  Innovative nurse graduate preparation is possible and necessary to best support todays nurse manager for a sustainable future in healthcare.        Preparing Nurse Leaders                                                                                                              66    References Arvidsson, N. (2010).  Designing more effective political governance of turbulent fields: The  case of healthcare.  In R. Rameriz, J.W. Selsky & K. Van der Heijden (Eds.), Business  planning for turbulent times: New methods for applying scenarios (pp. 130-146).   Earthscan.  ISBN 9781849710619. Baernholdt, M. & Mark, B.A. (2009).  The nurse work environment, job satisfaction and  turnover rates in rural and urban nursing units.  Journal of Nursing Management, 17,  994-1001. Baker, G.R. (2003).  Identifying and assessing competencies: A strategy to improve healthcare  leadership.  Healthcare Papers, 4(1), 49-58. Baker, S., Marshburn, D.M., Crickmore, K.D., Rose, S.  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Preparing Nurse Leaders                                                                                                              77             Appendix A: Interior Health Nurse Manager Demographics        Preparing Nurse Leaders                                                                                                              78      Preparing Nurse Leaders                                                                                                              79             Appendix B: Interior Health Manager Job Description             Preparing Nurse Leaders                                                                                                              80        Job Title:  Manager  Facility:    Department: Acute Services   Reports to:     Classification: Non Contract   Date: Developed: April 2002  Revised: June 2013    JOB SUMMARY:   In accordance with the established vision and values of the organization, the Manager reports to the appropriate Director.  The Manager is responsible for the delivery, management, and performance of quality and cost effective patient services within the patient services.   TYPICAL DUTIES AND RESPONSIBILITIES:  ? Provides leadership to staff, motivating them towards the attainment of unit goals and direction.  ? In partnership with the Director, develops and administers the annual operating and capital budget for the assigned area of responsibility.  ? Manages and authorizes expenditures within limits of approved budgets.  Accounts for variances when they arise.  ? Responsible for human resource management.  Interview, hire, discipline, and terminate staff as appropriate.  ? Responsible for staff performance.  Develops, maintains, and evaluates strategies to achieve expected levels of employee performance.  ? Responsible for attendance management including approval of vacation, leaves, etc.  ? Coordinates nursing, medical, and support service to promote maximum utilization of manpower resources.    ? Responsible for development of policies and procedures.  ? Ensures nursing, medical, and support staff comply with departmental and hospital policies and procedures.    Preparing Nurse Leaders                                                                                                              81    ? Develops goals and objectives for the unit which is related to patient outcomes, support the mission and strategic goals of the hospital, and are supportive of and integrated with the goals of the other support services and departments.  ? Performs other duties as assigned.  QUALIFICATIONS:  Education, Training, and Experience ? Baccalaureate degree in nursing required. ? Current CRNBC registration required. ? Three to five years of clinical experience with at least three years of recent experience in a management role. ? OR an equivalent combination of education, training, and experience.  Competencies ? Interior Health Emotional Intelligence Competencies.  Skills and Abilities ? Ability to lead, plan, organize, direct, manage, and implement. ? Ability to communicate effectively, verbally and in writing. ? Ability to work independently and interdependently as a team member. ? Ability to facilitate problem-solving toward creative solutions. ? Ability to operate related equipment. ? Physical ability to perform the duties of the position.               Preparing Nurse Leaders                                                                                                              82             Appendix C: Interior Health Emotional Intelligent Competencies          Preparing Nurse Leaders                                                                                                              83         Preparing Nurse Leaders                                                                                                              84     Preparing Nurse Leaders                                                                                                              85      Preparing Nurse Leaders                                                                                                              86      Preparing Nurse Leaders                                                                                                              87             Appendix D: Nurse Manager Essential Knowledge Chart             Preparing Nurse Leaders                                                                                                              88    Authors and year published  Country  Format Asserted Knowledge needed for the Nurse Leader/Manager Baker (2003) Canada Competency Framework for healthcare leadership ? Leadership (communication, empowerment, conflict resolution, shared vision) ? Collaboration & communication ? Management practice (strategies, organize, planning, clinical operations) ? Learning and performance improvement (quality, safety and value of healthcare) ? Professionalism (ethics, values, accountability)  ? Personal and  community health systems (global, interconnectedness, responding to changing demographics, economic, political and epidemiological needs)   Hawkins, Carter & Nugent (2009) USA Nurse Manager Orientation program  ? Leadership and staff retention (aware of systems and leadership roles in the organization, the scope of decisions, leadership values and effective strategies)  ? Clinical management (systems and processes) ? Coaching and mentoring (education, resources and support for the role) ? Human resource management (performance and conflict resolution) ? Fiscal management (various budgets and monitoring processes) ? Performance improvement and evidence based practice (risk management, patient safety, quality improvement initiatives, benchmarking)   Hibberd & Smith (2006) Canada Knowledge in nursing leadership & management  ? The  context of health services in Canada (political, social & economic systems, services of care, the nursing workforce in Canada) ? Structure and organization (governance, organization design and management) ? Standards and accountability (legal frameworks, standards of quality, accountability in the healthcare system) ? Professional leadership (ethical dimensions, complex relationships, evidence-based practice, nursing information and outcomes, leadership challenges) ? Leadership and management skills: Hibberd & Smith (2006) Canada Leadership & Management skills ? Teamwork and collaboration ? Leading and managing  change ? Intraorganizational politics ? Project management ? Human resources ? Conflict resolution and negotiation ? Working with unions  ? Business planning and budget preparation ? Influential writing ? Policy analysis  Preparing Nurse Leaders                                                                                                              89    Huston, (2008)      USA      Essential Nurse Leader competencies for 2020  ? A global perspective or mindset regarding healthcare and professional nursing issues ? Technological skills which facilitate mobility and portability of relationships, interactions, and operational processes ? Expert decision-making skills rooted in empirical evidence ? The ability to create organization cultures that permeate quality healthcare and patient/worker safety ? Understanding and appropriately intervening in political processes ? Highly developed collaborative team building skills ? The ability to balance authenticity  and performance expectations ? Being able to envision and proactively adapt to a healthcare system characterized by rapid change and chaos       Canadian Nursing Association (2009) Canada Position statement: Nursing Leadership, approved by the CNA board of directors, 2009  Herrin, Jones, Krepper, Sherman & Reineck, 2006 USA Graduate curriculum framework  Leadership domains ? Business ? Leadership ? Environment ? Communication ? Professionalism  Kleinmann (2003) USA Leadership competencies for the role, survey results ? Financial knowledge (budgeting, trend variance analysis) ? Clinical operations knowledge ? Human resource management ? Legal and risk management ? Health law ? Strategic planning ? Operations management (strategic planning, information technology)  Kouzes & Posner, 2007 USA Five practices of exemplary leadership    ? Model the way (clarify values, set the example) ? Inspire a shared vision (imagine the possibilities, enlist others) ? Challenge the process (search for opportunities, experiment and take risks) ? Enable others to act (foster collaboration, strengthen others) ? Encourage the heart (recognize contributions, celebrate the values and victories) MacPhee & Bouthilette (2008)  Canada  Core Competencies BC NLI career development ? Developing the leaders (understand power & influence, leadership styles, change agents, innovators, leading from the middle) ? Leading others (empowering, team building, conflict management, influence strategies, healthy work environments) ? Leading through effective planning (change management, project planning, budgeting, resource allocation) ? The Mentee-Mentor Relationship (roles and responsibilities, mutual understanding, project and learning objectives) ? Evaluative responsibilities (evaluation, reports, tracking career)  Preparing Nurse Leaders                                                                                                              90    MacPhee & Suryaprakash (2011)  Canada  BC Nursing Leadership Institute Competencies  Program evaluation report ? Leadership theory ? Leadership styles ? Quality practice environments ? Power dynamics ? Business charters/cases ? Human resource allocation ? Communication ? Teamwork ? Quality and safety ? Accreditation ? Time management ? Networking ? Organizational structures, processes, outcomes   ? Empowerment theories, strategies ? Emotional intelligence ? Change management ? Project planning, implementation, evaluation ? Innovation theory, diffusion theory ? Complexity science principles ? Conflict resolution ? Finance and budgeting Registered Nurses Association of Ontario (2013)  Canada Nursing Leadership best practice guidelines ? Building relationships and trust ? Creating an empowering work environment ? Creating a culture that supports knowledge development and integration ? Leading and sustaining change ? Balancing the complexities of the system, managing competing values and priorities   Registered Nurses Association of Ontario (2013)  Canada Nurse leaders needed knowledge ? Professional nursing ? Leadership ? Philosophy ? Ethics literature and ethics ? Group processes ? Human and moral development ? Business and management knowledge ? Change management ? Team building ? Leading a diverse workforce ? Research and research use  Registered Nurses Association of Ontario (2013) Canada Key Concepts to develop nursing leadership ? The Canadian healthcare system: social, economic and political factors, national and provincial ? The political process, including political persuasion and nurses impact at all levels of governance ? Historical development on health professions and their influence on nursing ? Health and social policy development and reform, national, provincial, local ? Current approaches to health service delivery models ? The role of professional organizations and their influence on nurses and service delivery ? Current and emerging issues and priorities for health service and policy Preparing Nurse Leaders                                                                                                              91    Russell & Scobie (2003) USA Suggested graduate curriculum  ? Leadership and management ? The business of health ? Managing human capital ? The learning organization ? Information systems in health care and nursing ? Health policy, Law and ethics ? Managing quality in health care organizations ? Healthcare delivery systems ? Practicums (2) Sherman & Pross, (2010) USA Nurse Manager Learning Domain Framework ? The Science: managing the business ? (financial management human resource management, performance improvement, foundational thinking skills, technology, strategic management, clinical practice knowledge) ? The Art: leading people ? (human resource leadership skills, relationship management, influencing behaviours, diversity, shared decision making) ? The Leader within: creating the leader in yourself.  (personal and professional accountability, career planning, personal journey disciplines, optimizing the leader within. Sherman, Bishop, Eggenberger & Karden (2007)  USA Competency model ? Personal mastery (understanding one?s self, demonstrate self-confidence, trust and empower others, trustworthy, treat others fairly, acknowledge and learn from mistakes) ? Financial management (staffing budget, operating costs, proposals, quantified costs of issues, understanding financial information) ? Human resource management (recruit, retain, reward, motivate, and orientate staff.  Open minded and team building) ? Interpersonal effectiveness (Listen to understand, visible, accessible, conflict management, constructive communication) ? Caring for staff, patients and self (connectedness with staff, supportive behaviours, self-care, optimistic and resilient in turbulence and change)  ? Systems thinking (interconnectedness of healthcare, big-picture thinking, develop broad understanding of new initiatives and implications) Simpson, Skelton-Green, Scott & O?Brien-Pallas (2002) Canada Nursing Leadership competency model ? Profession of nursing (entry, scope, standards,  competency, professionalism) ? Competencies of Leadership (challenge the process, inspire as shared vision, enable others to act, model the way, encourage the heart) ? Business of Healthcare (political and health environment knowledge, human and organization behaviour, relationship management, resource management, results management) ? Use of Self (self-knowledge, lifelong learning, power, humility, communication, trust, courage, emotional intelligence, work-life balance) Stefl (2008) USA Leadership model - 5 competency domains for healthcare managers ? Communication and relationship building ? Leadership (vision, inspire, organize, manage change, measure outcomes)  ? Professionalism (ethical professional standards, commitment, lifelong learning for     improvement) ? Knowledge of the healthcare environment (systems and environment) ? Business skills and knowledge (apply business principles: systems thinking, financial management, human resource management, organization dynamics and governance, strategic marketing and planning, risk management, quality improvement.  Preparing Nurse Leaders                                                                                                              92    Thompson, Wolf & Sabatine (2012) USA Skills and competencies for nurse leaders      *Skills for the nurse executive: ? Contract management  ? Negotiation prowess ? Aptitude in healthcare economics                  *Competencies for the nurse leaders: ? Communication and relationship  building ? Knowledge of the healthcare environment ? Leadership skills ? Professionalism ? Business skills  VanDeVelde-Coke (2010)  Dickson (2008) Canada LEADS leadership framework for nurse administrators. A BC initiative ? Lead self (self-aware, manage self, develop self, demonstrate character) ? Engage others (foster development, healthy organization, communication, team  building) ? Achieve results (set direction, strategy with vision/values/evidence, action, assess and evaluate ? Develop coalitions (purposefully build partnerships, commitment, mobilize knowledge, navigate the socio-political environment ? Systems transformation (systems/critical thinking, innovation, orientate strategically to the future, champion and orchestrate change) (Appendix: F)      Knowledge Themes of science: Specifically: ? Theory ? Nursing theory ? Leadership theory ? Systems theory ? Power theories ? Theories and models of change management ? Theories of ethics  ? Legal aspects ? Legal frameworks ? Labor laws ? Collective agreements ? Health policy  ? Research and evidence based practice ? Participate in research and support best evidence for quality health care ? Research knowledge and the ability to critically analyze research for:               Innovative strategies, risk management, quality improvement initiatives, benchmarking,                outcome measures, policy analysis  ? Technological skills ? Manage systems and tools ? Operations  ? Organizational structure, governance,  Preparing Nurse Leaders                                                                                                              93    ? Accreditations standards, clinical operations ? Standards of quality and accountability ? Human resource processes  ? Political and economic ? Historical shaping of current processes ? Healthcare environment and political and economic underpinnings  ? Business of healthcare ? Budgets, fiscal management,  ? Business planning, resource allocation ? Project management and program development Knowledge Themes of Art:  Specifically: ? Leadership styles ? Authentic, transformational, relational, congruent, distributed, shared, value based  ? Empowerment  ? Quality practice environments ? Coaching and mentoring ? Proactive and visionary  ? Team building ? Managing complex relationships and cultural diversity ? Global perspective ? Building trust, connectedness, collaboration  ? Decision making   ? Conflict resolution, negotiation ? Change agent, managing complexity in rapid change and chaos ? Optimistic, resilient, sensemaking  ? Communication  ? Listen ? Constructive feedback ? Relationship building, visible, accessible ? Networking, time management ? Leading and sustaining change ? Promoting evidence based best practice   ? Human resource management ? Interview, recruit, retain staff ? Motivate, organize and empower staff ? Maintain professional excellence  ? Lead yourself ? Personal development and continual life-long learning process by reflection ? develop insight and understanding, learn from others ? development of new knowledge, staying current, vision     Preparing Nurse Leaders                                                                                                              94                Appendix E: Mind Map of Nurse Manager Role and Responsibilities            Preparing Nurse Leaders                                                                                                              95    Mind Map of Nurse Manager Role and Responsibilities obtained from readings and conversations with Nurse Managers:  Responsibilities and Role Responsibilities and Role ? Create healthy work environment ? Managing complex problems simultaneously ? Program planning ? Fiscal responsibility, budgeting ? Recruitment, retention of staff ? Interview, screen and support staff ? Sick calls, vacation, staff issues ? Human resource management ? Performance evaluation ? Managing patient care incidents  ? Resource advocacy and allocation ? Managing change initiatives ? Maintaining best practice and promoting evidence based practice ? Support accreditation standards ? Support standardization ? Policy and procedure development ? Knowledge worker, broker ? Conflict resolution, dealing with difference ? Negotiation ? Flexible and adaptable ? Delegation ? Collaboration ? Empowerment ? Networking ? Political awareness of health policy ? Economic awareness of health ? Mentor/Mentee ? Ordering equipment and supplies ? Education planning ? Attend meetings ? Communication ? verbal, written, nonverbal, presence, accessible, visible ? Managing the workload ? Self-management ? Build production team ? Maintain quality ? Satisfy customers ? Set goals ? Support organization goals and initiatives ? Managing relational tensions ? Maintaining relationships  ? Setting goals, personal and group Context ? Healthcare viewed as a complex adaptive system ? Management systems ? Environment is contextual and situational and socially constructed ? Management and Organization culture ? permanent ?white water? ? Dynamic interplay between leadership and organizational culture ? job satisfaction and nurse retention ? Nursing culture and healthy practice environments ? Broad and diverse ? Complexity and chaos  environment, complex role ? Dynamic, nonlinear, Unique ? Uncertainty, ambiguity, instability ? Wicked problems ? define problem, scenario planning ? Interconnectedness ? Production versus efficiency ? RN/Physician/interdisciplinary team relationships  Preparing Nurse Leaders                                                                                                              96    Need to know Need to know ? Leadership theory ? Empowerment theory ? Leadership styles ? Leadership skills ? Emotional intelligence ? Critical thinking skills ? Strategic planning ? Scenario planning ? Foresight ? Generational diversity ? Research  and critique skills ? Leadership management competencies ? Effective listening skills ? Interview skills ? Communication skills ? Interpersonal skills ? Interprofessional collaborative practice ? Integrated health   ? Systems theory ? Complex adaptive systems theory ? Chaos theory ? Complexity theory ? Management theory ? Management strategies ? Business skills & principles  ? Understanding of advanced technology systems ? Clinical operations ? Legal and Risk management ? Collective agreements ? Labour laws and labour relations ? Health policy ? Professional practice standards ? Organizational culture ? Strategies for goal attainment Effects and outcomes ? Healthy work environment, supportive practice environment ? Nursing and allied staff job satisfaction, retention, improved ?intent to stay? ? Staff empowerment ? Optimal quality of patient care, safe and best practice ? Team work, collaboration, staff input ? Manager role satisfaction and personal empowerment ? Creating sustainable environment for safe practice ? ?magnet status? ? Transparency, authentic, accessible and visible ? Reliable and competent, trustworthy ? Lifelong learner         Preparing Nurse Leaders                                                                                                              97              Appendix F: The LEADS Framework          Preparing Nurse Leaders                                                                                                              98     Preparing Nurse Leaders                                                                                                              99    Preparing Nurse Leaders                                                                                                              100                Preparing Nurse Leaders                                                                                                              101            Appendix G: Interior Health Management Resources         Preparing Nurse Leaders                                                                                                              102   Management & Leadership Interior Health is committed to the development of an environment where learning and innovation are highly valued.  This commitment is rooted in our goal to build an organization where learning is continuous, interactive and encouraged. Pathways to Leadership: Pathways to Leadership is a series of initiatives designed to develop and encourage transformational leaders.This multi-level approach to skills development and education provides initiatives for individuals from every level of the organization.   Programs and initiatives included in Pathways to Leadership are: ? People Management Series ? Business Management Skills Program ? eLEADER ? Transitioning to Management ? BC Health Authorities Mentoring Network ? IH Coaching Program ? Next Generation Clinical Leadership  Talent Management:  This program identifies required competencies for all identified IH Critical positions then works with a talent pool to assess and develop these competencies.  For more information on the program see Succession Planning. Leadership Onboarding: Leadership Onboarding is an integrated program that facilitates the transition of new leaders into the cultural adaptation, political connections and role expectations of a leadership position in Interior Health.  For more information on this initiative see Leadership Onboarding.             Preparing Nurse Leaders                                                                                                              103            Appendix H: University Of BC Okanagan, Small Survey           Preparing Nurse Leaders                                                                                                              104     Preparing Nurse Leaders                                                                                                              105     Preparing Nurse Leaders                                                                                                              106     Preparing Nurse Leaders                                                                                                              107     Preparing Nurse Leaders                                                                                                              108     Preparing Nurse Leaders                                                                                                              109     Preparing Nurse Leaders                                                                                                              110     Preparing Nurse Leaders                                                                                                              111     Preparing Nurse Leaders                                                                                                              112     Preparing Nurse Leaders                                                                                                              113     Preparing Nurse Leaders                                                                                                              114     Preparing Nurse Leaders                                                                                                              115     Preparing Nurse Leaders                                                                                                              116     Preparing Nurse Leaders                                                                                                              117     Preparing Nurse Leaders                                                                                                              118     Preparing Nurse Leaders                                                                                                              119     Preparing Nurse Leaders                                                                                                              120     Preparing Nurse Leaders                                                                                                              121     Preparing Nurse Leaders                                                                                                              122     Preparing Nurse Leaders                                                                                                              123            Appendix I: Association of American Critical-Care Nurses  e-learn module         Preparing Nurse Leaders                                                                                                              124     Preparing Nurse Leaders                                                                                                              125    

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