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An examination of front line nurse leaders' project work: 1) What types of issues are front line nursing… Piddocke, Pamela 2011

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AN EXAMINATION OF FRONT LINE NURSE LEADERS’ PROJECT WORK: 1) What types of issues are front line nursing leaders in British Columbia being expected to address within their practice environments? 2) Do the types of front line nursing leader responsibilities (as reflected in project work) change over time?   by   Pamela Piddocke  B.Sc.N., The University of British Columbia, 1996    A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF   MASTER OF SCIENCE IN NURSING   in   THE FACULTY OF GRADUATE STUDIES       THE UNIVERSITY OF BRITISH COLUMBIA  (Vancouver)    April 2011   © Pamela Piddocke, 2011   ii Abstract   The learning initiative called the British Columbia Nursing Administrative Leadership Institute (BCNLI) for first line nurse leaders was developed to address the need for educating and mentoring new nurse leaders. The program was a joint project between the Ministry of Health Services Nursing Directorate, British Columbia‟s Chief Nursing Officers and the School of Nursing at UBC. The BCNLI program is evidenced based and included information on leadership, management concepts and relevant issues for leaders, (MacPhee & Bouthillette, 2008). The front line nurse leaders who participated were provided education and mentoring, to increase their skills. The front line nursing leaders selected year long projects as part of the program. This study examined if there was any change to the types and scope of control of projects front line nurse leaders chose as part of learning and mentoring initiative. 211 nurse leaders‟ projects from the BCNLI project data web pages were examined for scope of control, type of project, and Donabedian‟s (1982) structure process outcomes framework using content analysis (Graneheim & Lundman, 2004).  These projects provide a window to the types of issues that were relevant and seen as important to the front line nurse leader participants in each cohort of the BCNLI program from 2007 to 2010. This research found that there was no change between the nine cohorts as to structure or process coding. The majority of the projects were structure coded. The content analysis identified five main themes of recruitment/retenton, communication, education, care delivery evaluation, and tool development. The ability to identify the scope of projects of front line nurse leaders was important as very little research exists on scope of control for front line nurse leaders. Only 61% of the projects are at the nursing unit or front line (level two) position. There are concerns that front  iii line nurse leaders were working beyond the nursing unit level. This research will help to understand if nurse leaders are taking on issues or problems that are beyond their roles and the type of projects that exist in the British Columbia Health Care.     iv Preface This research was done under the approval of the Behavioural Research Ethics Board at the University Of British Columbia Office Of Research Services. The certificate number is H07-01559. The title of the research for the certificate of approval by principal investigator Maura MacPhee is “2007 REISS full-scale application development funds: A logic model to guide nursing leadership development across Canada.” My research project was added and approved by the board on July 16, 2010. Chapter 3 provides the description of front line nurse leaders’ projects that were part of the “2007 REISS full-scale application development funds: A logic model to guide nursing leadership development across Canada” study. I was able to use the information publically available on the website that described their projects. This information on the web pages was provided by the participants and was collected by Dr. Nitya Suryaprakash and Dr. Maura MacPhee.     v Table of Contents  Abstract .................................................................................................................................... ii Preface ..................................................................................................................................... iv Table of Contents .................................................................................................................... v List of Tables ......................................................................................................................... vii List of Figures ....................................................................................................................... viii List of Abbreviations ............................................................................................................. ix Acknowledgements ................................................................................................................. x Dedication ............................................................................................................................... xi 1    Chapter: Introduction ...................................................................................................... 1 1.1 Health System ....................................................................................................................... 2 1.2 Historical Perspective ........................................................................................................... 4 1.3 Nursing Leadership Today .................................................................................................... 6 1.4 Significance ........................................................................................................................... 9 1.5 The Research Questions ...................................................................................................... 10 1.6 Assumptions ........................................................................................................................ 10 1.7 Ethics ................................................................................................................................... 11 1.8 Outline for Thesis................................................................................................................ 11 2    Chapter: Literature Review ........................................................................................... 13 2.1 Introduction ......................................................................................................................... 13 2.2 Organizational Support and Restructuring .......................................................................... 13 2.2.1 Global Context ................................................................................................................ 14 2.2.2 Effects of Restructuring .................................................................................................. 17 2.3 Workload ............................................................................................................................. 20 2.4 Quality Work Environments ............................................................................................... 21 2.5 Changes to the Role Of Front Line Nurse Leaders ............................................................. 22 2.5.1 Background ..................................................................................................................... 22 2.6 Roles of Front Line Nurse Leaders ..................................................................................... 25 2.6.1 Role ................................................................................................................................. 25 2.6.2 Style ................................................................................................................................ 27 2.6.3 Education ........................................................................................................................ 28 2.7 Scope of Front Line Nursing Leaders ................................................................................. 30 2.8 Evaluation of Change Through Structure-Process .............................................................. 31 2.9 Conclusion .......................................................................................................................... 32 3    Chapter: Research Design and Methods ...................................................................... 34 3.1 Introduction ......................................................................................................................... 34 3.2 Research Approach and Rationale ...................................................................................... 35 3.3 Ethical Issues ...................................................................................................................... 36 3.4 Participants and Setting ....................................................................................................... 37 3.5 Data Collection and Study Procedures ................................................................................ 37 3.6 Data Analysis and Transformation ..................................................................................... 38 3.7 Measures: Reliability and Validity...................................................................................... 39 3.8 Study Limitations ................................................................................................................ 41  vi 4    Chapter: Results.............................................................................................................. 43 4.1 Demographics ..................................................................................................................... 43 4.2 Introduction ......................................................................................................................... 43 4.3 Scope of Control ................................................................................................................. 44 4.3.1 Level One (Macro) ......................................................................................................... 45 4.3.2 Level Two (Meso) .......................................................................................................... 45 4.3.3 Level Three (Macro) ....................................................................................................... 45 4.3.4 Level Four ....................................................................................................................... 46 4.3.5 Unknown Level .............................................................................................................. 46 4.4 Type of Projects .................................................................................................................. 46 4.4.1 Retention and Recruitment Initiatives ............................................................................ 49 4.4.2 Tools and Resources ....................................................................................................... 50 4.4.3 Communication .............................................................................................................. 51 4.4.4 Education ........................................................................................................................ 52 4.4.5 Care Delivery Evaluation ............................................................................................... 53 4.4.6 Change Management ...................................................................................................... 54 4.5 Conclusion .......................................................................................................................... 54 5    Chapter: Discussion ........................................................................................................ 56 5.1 Introduction ......................................................................................................................... 56 5.2 Scope of Control ................................................................................................................. 56 5.3 Type of Projects (themes) ................................................................................................... 60 5.3.1 Retention and Recruitment ............................................................................................. 60 5.3.2 Communication .............................................................................................................. 61 5.3.3 Education ........................................................................................................................ 63 5.3.4 Tool Development .......................................................................................................... 64 5.3.5 Care Delivery Evaluation ............................................................................................... 65 5.4 Limitations .......................................................................................................................... 66 5.5 Recommendations ............................................................................................................... 67 5.5.1 Implications for Research ............................................................................................... 67 5.5.2 Implication for Nursing .................................................................................................. 68 5.5.3 Implications for Organizations ....................................................................................... 69 5.6 Conclusion .......................................................................................................................... 71 References .............................................................................................................................. 73 Appendices ............................................................................................................................. 85 Appendix A Comparison of Level of Scope of Control by Cohort.................................................. 85 Appendix B Project Themes Examples by Cohorts for March 2010 to March 2009 ...................... 86 Appendix C Project Themes Examples by Cohorts for November 2008 to October 2007 .............. 89 Appendix D Condensed Grids Showing Meaning Unit with Themes and Donabedian Category by Cohort Dates .................................................................................................................................... 92   vii List of Tables Table 1 Number for projects at each level of scope of control. .............................................. 45 Table 2 Project themes by cohort (*project coded in both themes) ........................................ 48 Table 3 Project SPO framework by cohort ............................................................................. 48 Table 4 . Numbers of projects in retention and recruitment theme coded for Donabedian‟s framework by cohort ............................................................................................................... 49 Table 5 Numbers of projects in tools theme coded for Donabedian‟s framework by cohort . 50 Table 6 Numbers of projects in communication theme coded for Donabedian‟s framework by cohort ...................................................................................................................................... 51 Table 7 . Numbers of projects in education theme coded for Donabedian‟s framework by cohort ...................................................................................................................................... 52 Table 8 . Numbers of projects in care delivery evaluation theme coded for Donabedian‟s framework by cohort ............................................................................................................... 53   viii List of Figures  Figure 1 Quality of care model (Donabedian, 1982) .............................................................. 36 Figure 2 Front line nurse leaders‟ employment setting .......................................................... 43 Figure 3 Comparison of scope of control number for projects by cohort ............................... 46  ix List of Abbreviations  British Columbia Nursing Administrative Leadership Institute………………BCNLI College of Registered Nurses of British Columbia ……………………………CRNBC British Columbia Nurses Union………………………………………………..BCNU Front line nurse leaders ………………………………………………………...FLNL British Columbia ……………………………………………………………….BC Registered Nurse……………………………………………………………….RN Institute of Medicine …………………………………………………………..IOM    x  Acknowledgements I would like to acknowledge all those directly involved in my thesis. From the University of British Columbia, The British Columbia Nursing Administrative Leadership Institute, and the British Columbia Nurses‟ Union. I would like to thank Dr. Nitya Suryaprakash for her assistance in answering my questions about the BCNLI. I would like to specially thank my thesis committee; Maura MacPhee, Patricia Wejr, and Connie Cannam, whose assistance and input were both inspiring and motivational. I would like to give a special thank you to Dr. Maura MacPhee for taking the time to answer my questions and allowing me to participate in this research as part of their larger study on the BCNALI. Maura was encouraging, very understanding and thoughtful in her comments and direction. I would like to thank my family who had the patience and understanding to allow me to finish this project. Especially, my parents for supporting and husband for taking the kids out on adventures so that I could do the work and focus, read and write. I would like to thank all the front line nurse leaders who provided projects and information that I reviewed. These nurses work tirelessly to improve the health care system with limited resources and support.   xi Dedication I would like to dedicate this to all the health care providers who work to provide quality care in a system that is often not supportive or caring. Also to the researchers who want to improve the system and produce work that is valuable and useful.  I would like to dedicate this to my entire family that encourages my heart and supports the desire to seek more information and ask questions.    1 1    Chapter: Introduction This study examines the British Columbia Nursing Administrative Leadership Institute (BCNLI) for First line Nurse Leaders projects. These projects provide a window to the types of issues that were relevant and seen as important to the front line nurse leader participants in each cohort of the BCNLI program from 2007 to 2010. This study will discuss the context of the BCNLI and the first line nurse leaders‟ projects, as well as, the literature that exists on nursing leadership and the reasons for proceeding with the study. This research was formulated to gain greater understanding of the issues front line nurse leaders face in their practice environments by examining the types of issues that front line nursing leaders in British Columbia are being expected to address within their practice environments and examine if there is change over time. 211 nurse leaders‟ projects from the Nursing Leadership Institutes project data web pages were examined using content analysis (Graneheim & Lundman, 2004).  There will be discussion of the results of the study and recommendations of future study to better understand the complexity of nursing leaders work and the impact of organizations on nursing leaders. The ability to identify the scope of projects of front line nurse leaders may assist in providing areas where more resources are needed and help focus existing resources for front line nurse leaders. Also the projects identify if nurse leaders are taking on issues or problems that are beyond their roles which then may lead to further understanding of organizational structure issues.  By identifying the types of projects nurse leaders take on, researchers will better understand the complexity of leading in health care settings. The first chapter will discuss the complex and interrelated parts of the health care system and nursing structure that frame the situation relating to examination of the data from the British Columbia Nursing Administrative Leadership Institute projects. There are three  2 main factors that impact the research on front line nurse leaders; these will be discussed in three sections. The first section discusses the structure of British Columbia's healthcare system, including the cost of health care provision and the ongoing changes to the system. The second section will examine how nursing leadership has changed over the last thirty years. The final section will look at the practice environment of nurses today, examining the issues around nursing leadership and scope of practice. These factors are extremely important in understanding how front line nurse leaders‟ responsibilities change with health reform and budget considerations. 1.1 Health System The British Columbia health care system is both complex and challenging. There are financial considerations rising out of how funding is collected and distributed. For example, each province is given partial funding from the Federal Government and then the province adds to the funding to provide the core health care services. Core services vary from province to province. In British Columbia, the cost of the health care system is well over three trillion dollars per year (Government of British Columbia, 2010). The Ministry of Health Services provides funding for services based on a mix of population and geographical area to each of the six health authorities. The Ministry of Health Services sets the standards and expectations for health services by providing leadership, direction and support (Government of British Columbia, 2010). The Health Authorities provide the health care services in the province based on the budget and overall goals dictated by the Ministry of Health Services. Service provision is decided by the government, and funding is targeted either through the Medical Service Plan to cover doctor and other professionals’ fees or to the six health authorities to provide community- and facility-based care.  3 Five of the health authorities (Fraser Health, Vancouver Coastal, Vancouver Island, Interior and Northern Health Authorities) are geographical, and the sixth, the Provincial Health Service Authority, provides specialized services for the whole province.  The health service plans must stay within the budget provided and cannot run in the red. This significant expenditure of public funds provides public access to high quality health services 24 hours a day and 365 days a year, but it is not enough to meet the ongoing and increasing public demand for services. The majority of front line care givers in the health authorities are Registered Nurses. In British Columbia, there are over 31,000 Registered Nurses providing care for a population of approximately 4.5 million people.  There are just over 2600 front line nurse leaders in British Columbia‟s health care system (British Columbia Nurses Union, 2010). The public has entrusted Registered Nurses with their daily care, and it is the day to day running of this system that is in the hands of front line nurse leaders.  The front line nurse leaders are the role models, mentors, and often the people called upon to make staffing and resource decisions (Lucas, Spence Laschinger, & Wong, 2008). The public obtains government approved services without understanding the complex funding system, but it is this system that can lead to issues for the front line staff and leaders. These leaders work with scarce resources and often without assistance from decision makers who hold the purse strings (Stein & Deese, 2004). However, the importance of front line leadership cannot be underestimated; it is key to achieving goals in health care as it is both “labour-intensive and based on powerful know how” (p. 776, Kanste, Kaarlainen & Kyngas, 2009). British Columbia's health care system is under extreme pressure from both public demand and limited resources. Senior management grasps at opportunities to make changes that will  4 provide services and reduce costs. These changes can lead to significant issues on the front lines of nursing. The management decisions are made not always based on the needs of one but on the needs of many. Unfortunately, the front line nurse leader is the one that must face the staff and the public as these issues are addressed. The quality work environments are those that provide clear roles and job duties, support and feedback, autonomy, and leadership that are based on a social leadership style (Kanste, Kaarlainen & Kyngas, 2009). The set budgets and formulas used to determine the amount of staff and how the front line resources are distributed are not flexible or visionary in their nature (Surakka, 2006). For example, a 26 bed medical unit may have a baseline staffing level of 5 Registered Nurses but on a daily basis there may be up to 30 patients because of the overcapacity protocols put in place to deal with public demand or need. This increase in patients is without the resources or staffing to support the patients needs.  Front line nurse leaders are left to deal with the challenges that affect the work environment of Registered Nurses and the limited number of staff impact patient outcomes.  It is similar to a restaurant were there are only a set number of tables but the customers keep coming and the staff must still serve them even though they are not staffed or equipped for the numbers. These front line nurse leaders are faced with issues of limited resources, staffing and inflexible policies on a daily basis (Hay, 2004; Dunleavy, Shamian, & Thomson, 2003). These challenges have changed over the years as roles and responsibilities of health care practitioners have evolved. 1.2 Historical Perspective   In the 1980s, tightening budget concerns, revolutionary changes in surgical procedures such as open heart surgery, and escalating pharmaceutical costs led to changes in how care was provided at the front line.  Post operation stays became shorter and surgical daycare was on the rise. Registered Nurses‟ roles expanded while research identified the  5 positive benefits of increasing the use of Registered Nurses to reach patient improvement outcomes (Levey, Hill, & Greene, 2002; Haynes, 2010; Crawford, 2003).  Unfortunately, management models were implemented to look at health care as a business model that reduced or eliminated the role of the head nurse (Hay, 2004). These new models were focused on budgets and fiscal accountability rather than patient needs (Haynes, 2010). Historically, the head nurse had been a senior nurse who was responsible for hiring, mentoring and staffing her unit. The head nurse was often the one advocating on behalf of her staff for increased funding and resources to meet the demands of the services, but this had changed by the end of the 1980s (Surakka, 2006; Crawford, 2003). In the late 1990s, these head nurse positions were replaced by management positions that often covered multiple nursing units, and these managers were not available for daily operations within the unit. The managers came from varying professional backgrounds. The day to day running of the unit was partly left to a charge nurse who changed every shift or every day. Human Resources departments did the hiring, with the final say of unit manager, and the mentoring and leadership roles were forgotten. The loss of head nurses created a void in the system (Stein & Deese, 2004). In addition, concerns about the rising average age of nurses were not adequately addressed by managers. By the early 2000s, the system was showing the effects of poor leadership or management at the front lines. Nurses were overworked, underpaid and leaving the province for other countries (Aiken et al., 2002).  During the early 2000s, the registered nurses in the British Columbia Nurses‟ Union started identifying ongoing issues through collective agreement language regarding professional responsibility. Nurses reported not being supported or assisted in decision making; there were concerns with patient safety, lack of  6 education or mentoring, and concerns that no one was dealing with system issues. These nurses supported and wanted front line nurse leaders who were clinically prepared and available to them during their shifts. Through this process, employers identified the need to implement the use of front line nurse leaders, often referred to as classification level two (L2). The L2 positions were intended to provide “on the ground” clinical support to front line nurses. They were to address daily staffing needs, acuity of patient assignments, communicate with other departments regarding the care and needs of the patient and make sure that staff was able to meet their professional standards.  These positions were implemented after managers identified that the scope of the managers‟ role often took them away from their units on a daily basis. The result was the posting of hundreds of L2 positions within a 10 year period. The effect was that front line nurses had a consistent leader available to them every day. This drastic increase in leadership positions, however, raised several questions as to the preparation and support available for front line nurse leaders. 1.3 Nursing Leadership Today Nursing leadership is vital to guiding and empowering health care workers to deal with the challenges and changes within the system (Alleyne & Jumaa, 2007). One current change is the composition of the healthcare workforce including the change in the role of the Registered Nurse; in many sites the Registered Nurse now leads a team of unlicensed (e.g. nursing care aides) and licensed health care workers (e.g. licensed practical nurses), thus moving the Registered Nurse further from the bedside (Simpson et al. 2002).  Another change is the increasing complexities in the organizations or workplace structures, such as system or leadership reorganizations from unit to program management, which can leave front line nurse leaders without the skills or training to make the right decisions (Watson,  7 2000). Front line nurse leaders are suffering from role overload brought on by the lack of support (MacPhee et al. 2010; Lee & Cummings 2008). The lack of training or education around decision making can have ongoing implications to the whole system. Fiscal restraint or reform is another issue that affects leadership; significant financial resources are spent on staffing provisions in health care. The front line nurse leaders are placed in difficult positions, often torn between staff or clinical needs and organizational needs, including the lack of financial resources (Fradd, 2010). The effects is referred to as program management which include a flattening of management levels intended to increase the autonomy of the registered nurse, but have lacked the organizational support and leadership support to work autonomously (Wynne, 2003; Armstrong & Laschinger, 2006; Cummings et al., 2008). These complexities make the role of the front line nurse leader challenging and there appears to be increasing responsibilities for front line nurse leaders as a result. The scope of responsibility and the complexity of the work environment for front line nurse leaders are not well researched. In the final report to the Joint Quality Work Life Committee, the writers identify that 50% of nursing leaders spend up to 25% of their time on staffing issues and that 27% spend up to 50% of their time on staffing (Dyke & Mateus, 2009).  The authors highlight that survey respondents stated that parts of their job descriptions could not be performed because of the significant impact that staffing issues had on their role. Unfortunately, the provincial survey did not identify how they prioritized their other work or how they addressed ongoing system issues. The survey did identify that there was a commonality of the core duties of front line nurse leaders in British Columbia (Dyke & Mateus, 2009).  8 The core duties of front line nurse leaders are similar but the job titles and descriptions differ greatly.  These differences create problems for both subordinate workers and senior leadership as expectations of the job are not clear. For example, research on the role and scope of clinical nurse consultants in Australia showed that ambiguity was evident in the roles, and that further work was needed to clarify roles and scope (O‟Baugh et al. 2007). The study identified that nurses in this role functioned differently in scope, depending on what they were directed to do by senior management. Research is needed to better understand front line leader roles and responsibilities so that training, resources and supports can be more effectively allocated to these critical members of our healthcare system. Unfortunately, little research is available on what issues front line nurses are dealing with or what the needs of the front line are that most impact their work. A study by MacLeod (2008) highlights the lack of support for front line nurse leaders in the Northern Health Authority in British Columbia. MacLeod's study confirms the ambiguous nature of front line nurse leaders' roles and responsibilities and their need for more organizational supports. Nationally, educators are working to develop programs and opportunities to provide the skills and education that front line nurse leaders require. The British Columbia Nursing Administrative Leadership Institute for First line Nurse Leaders (BCNLI) was developed to address the need for educating and mentoring new nurse leaders (MacPhee & Bouthillette, 2008). The program was a joint project between the Ministry of Health Services Nursing Directorate, British Columbia‟s Chief Nursing Officers and the School of Nursing at the University of British Columbia (UBC). The BCNLI program was evidence-based and included information on leadership, management concepts and relevant issues for leaders (MacPhee & Bouthillette, 2008). Each health authority could  9 send five front line nurse leaders per workshop; these participants were selected by their Chief Nursing Officer. The CNO was to provide a mid-level or executive-level leader to mentor and support new nurse leaders within their respective practice settings. As part of the program, the BCNLI participants selected year-long projects in consultation with a mentor. The year-long projects were often practice-based change management projects of significance to the practice environment. Collaborating on these projects with mentor support was an important component of BCNLI participation: learning new leadership competencies through hands-on project work. A total of 211 nurse leaders‟ projects are now posted on the BCNLI project page (http://www.nli.nursing.ubc.ca/projects.aspx). These projects provide a window to the types of issues that are relevant and seen as important to the sponsoring organization and the front line nurse leader participants in each cohort of the BCNLI program from 2007 to 2010. The projects identify practice environment issues that front line nurse leaders are asked to include in their scope of practice. 1.4 Significance Little is known about the types of practice environment issues that front line nurse leaders (FLNLs) are expected to address as part of their roles and responsibilities (Spence Laschinger et al., 2006). The BCNLI projects provide an opportunity to learn more about FLNL expectations. A closer examination of the projects will also help the Ministry of Health Services in BC determine the best types of training and supports needed by FLNLs to successfully complete the types of work they are being asked to do in their current roles. There is ongoing change within today's healthcare systems and little is known about the requirements of the work that is directed by senior management to front line nurse leaders (Spence Laschinger et al., 2006). An examination of FLNL project work will provide knowledge of how the complexity of this work is changing over time.  10 I will use Donabedian‟s (1982) framework of healthcare evaluation (Structure- Process Outcomes) to: a) classify the types of front line nursing leadership projects that have been completed or are underway within the province; and b) determine if FLNL responsibilities (as reflected in project work) are becoming more complex over time. 1.5 The Research Questions  The research questions were formulated to gain greater understanding of the issues front line nurse leaders face in their practice environments: 1) what types of issues are front line nursing leaders in British Columbia being expected to address within their practice environments? 2) Do the types of front line nursing leader responsibilities (as reflected in project work) change over time? 1.6 Assumptions  The primary assumption of this study is that an examination of project work will accurately depict the roles and responsibilities of front line nursing leaders (FLNLs). Another assumption is that FLNL work has been getting more complex over time, and that an examination of project work over the last few years will adequately capture changes in FLNL work complexity. The projects were examined to determine the scope in an effort to see if front line nurse leaders were addressing issues that had a larger area of influence than what is traditionally thought of as a front line nursing leadership area at the nursing unit level (Spence Laschinger et al. 2007). Another assumption is the front line nurse leader projects used language that reflected their work and the project that they wanted to achieve. A significant assumption or bias to this research is the author‟s support of nursing and nursing leadership education. The author works for the British Columbia Nurse‟s Union supporting and improving the work life and benefits of nurses in British Columbia. Any bias or reflection of the author‟s thoughts regarding the meaning or the themes in the projects is  11 identified and any interpretations are explained with evidenced-based literature. Also that the previous research supporting the inter relatedness of nursing work environments and nursing leadership effects the quality of client care (Mackay & Risk, 2001). 1.7 Ethics  In complying with the University of British Columbia policy on ethics review, the writer has taken the ethics tutorial. The Principal Investigator of research pertaining to the British Columbia Nursing Leadership Institute (BCNLI), Dr. Maura MacPhee, has ethics permission to grant this author access to data pertaining to BCNLI participants' project descriptions on the BCNLI website project page. 1.8 Outline for Thesis In this thesis, Chapter Two contains a literature review of the main topics of concern in the paper. Included in the literature review are information on leadership and its effect on nurses‟ practice and patient outcomes. There is research describing the implications of good management or leadership, as well as, the significant impact and financial consideration of leadership. This thesis discusses issues around leadership and work practice environments and its effect on patient safety. There is information on roles and scope of control using health care leadership models. Chapter Three contains a detailed description of the methods used to analyze the BCNLI projects. This includes a description of content analysis and the process used to identify common themes from the Donabedian‟s Structure-Process-Outcomes framework (1982). There is also a definitions of the themes and description of the data from the projects. Chapter Four provides a full description of the finding of the content analysis. The data themes include quotes from the project web page data to enrich and validate content analysis findings. In the final chapter there is a discussion of the results and the implications of the  12 findings. This section includes recommendations for nursing practice, organizational support and further research.  13 2    Chapter: Literature Review  2.1 Introduction Literature searches were conducted to examine the research that presently exists around front line nurse leaders‟ roles, scope and the effects of both organizational support and health care restructuring. These three main areas are presented in this chapter. The first section identifies the research on restructuring and health care reform on front line nurse leadership roles. The second section discusses and defines the scope of front line nurse leaders‟ roles. The last section identifies what research knows about the role of front line nurse leaders. The literature review was completed using the databases PubMed, CINAHL, Longwoods and Google Scholar. Key words used to create the searches are nursing leadership, front line leadership, health care reform, restructuring, nursing work environments, role, scope, span of control, retention, duties of nursing leaders, safety, nursing shortage, competency, leadership roles, patient safety and nursing. The literature searches looked for original research articles and systemic reviews. Also included in the literature review were editorials, practice guidelines, and reports by the Institute of Medicine, the Canadian Nurses‟ Association and the British Columbia Nurses‟ Union. 2.2 Organizational Support and Restructuring The ultimate goal of professional nursing is to provide care and healing for patients in a time of need through the provision of research-based, patient and family centered care so that they can obtain a quality of life that meets the patients needs (CNA, 2010). The College of Registered Nurses of British Columbia identifies on their website that ``nursing has a proud history of service to the public and that public expects competent nurses to provide safe and ethical nursing care`` (College of Registered Nurses of British Columbia, 2010).  14  2.2.1 Global Context A review of the literature uncovered the importance of examining the context of change and restructuring of the health care system over time. Nurses have been involved in this change both as participants and leaders. Health care reform has been occurring for over 100 years but the pace and intensity of the change has drastically increased since the beginning of the 1990‟s (Brown, Zijlstra, & Lyons, 2006). Restructuring is organizational reform or change: attempting to make organizations more efficient and effective with fewer available resources (Brown, Zijlstra, & Lyons, 2006; Meyer & Allen, 1991; Patterson Hines, et al., 1994). A discussion paper by the Canadian Nurses Association and University of Toronto Faculty of Nursing (2004) highlights the need for nurse leaders to examine and understand the context of health care reform by questioning the driving forces and using research to base their decisions. The paper concludes that when making reform the goal must be patient safety. Over the last two decades there has been a significant move to reduce and contain health care costs, specifically human resource costs.  During this time the nursing practice body of knowledge has been developing and refining how nurses practice. By 1995, 20 of the 29 countries in the OCED surveyed indicated that they spent more than 70% of their total budgets on public health care, and identified that most of this was due to the significant increase in paid female labour (Armstrong, & Laschinger, 2006). Armstrong and Laschinger (2006) identified that both the global movement for women‟s equality and the move away from “the welfare state” were pushing health care reform and requiring better management practices and communication. The importance of culture is vital in understanding and making reform changes. Nursing is predominately a female profession, and the overall change to  15 global values and respect for women‟s rights has influenced and continues to influence health care restructuring. Fuller (1998) highlights that by the end of 1997 the four most populated provinces in Canada were developing long term plans to “decrease the amount of money employers were spending on health care both in corporate taxes and premiums paid to health insurers” (p. 357, Fuller, 1998). Similarly, the USA is experiencing the lowest number of workers covered by health insurance plans and some of the highest health management costs, increasing the demand for change to their health care system (Bauer, 2007). These factors push restructuring processes and force the system to change. Another external force is the globalization of health care forced by the corporate ideology of a few powerful entities, which are pushing for financial control of the health care system (Varcoe & Rodney, 2002; Slivers, 2001). This creates a need for restructuring to improve financial returns by controlling the management of human resources and eliminates nursing as a profession or demotes it to something that is easily replaced or devalued; thus, they can continue to gain profit and control of the finances for the system (Varcoe & Rodney, 2002). Some argue that the current reform is based on an ideology of scarcity; this ideology comes from half-truths and hidden agendas that serve the rich elite (Varcoe & Rodney, 2002). In this way, the public is pushed into believing that resources are scarce and that without restriction and reform there will be no system. Fuller (1998) reports that to make restructuring efficient, leaders will need to make changes that are based on technological changes and surgical procedures because health care is a service industry that by its nature requires intense human resources. She states that the  16 greatest chances for reducing costs is through new procedures such as laproscopic surgery which significantly reduced length of stay and nosocomial infection. Another factor that affects the rate of change is public opinion, because of public access to information and media. There is conflict between the value Canadians place on the public system‟s five guiding principles and the free market nature of North American culture that creates change when public opinion pushes one way or the other.  Silvers (2001) raises this issue in his work, and he highlights that the constant changes in the system are often driven by companies taking advantage of guaranteed income from government support programs such as universal health care. He states that the public may hold the value that the government should take care of the elderly, but when the media reports that the cost of their care has become too high or capitalists have stepped in to take advantage of government funds, there is a shift in public opinion. This system tends to push change that is not based on patient care but on public opinion and profit margins, as evidenced by the need for regulation of long term care facilities where care under a free market was less than adequate (Slivers, 2001). Bally (2007) identifies that other factors such as patient involvement in decision making is changing the medical paradigm and thus forcing reform. This paradigm shift is part of the complex system that effects the provision of services at the front line. The need to communicate with and involve nurses, staff, patients and their families has significantly increased (Bally, 2007; Endacott et al., 2008). There is an expectation that information about restructuring and reform to the health care system will be provided (Stein & Deese, 2004; Surakka, 2006). Every year more research articles and journals are added to the plethora of information that managers and leaders use to inform their practice and create change and  17 hopefully efficiency that promotes quality care. Leaders play a significant role in building an organizational culture that provides for effective practice. 2.2.2 Effects of Restructuring Regardless of what ideology is present, managers are under both political and public pressure to address financial issues, contain costs and look for efficiency in the Canadian health care system. In British Columbia, over the last ten years, there have been changes to health care management structure within the hospital system, moving from health service areas to the present structure of six large health authorities. During the past decade there were enormous changes to health care service delivery, including the closure of whole hospitals, realignment of services from one hospital to another and the elimination of some services (Kitty 2005). The overall provincial mandates can be seen as health authorities try to meet these provincial government standards and service provisions and reduce wait times (Government of British Columbia 2010). From 2007 to 2010, significant global financial considerations have been impacting health care reform. There is a focus on increased restraint and regulation of money to make sure that public assets are not lost and leaders are accountable to the public (Bauer 2007). Research identifies that patient outcomes are directly related to work environments. Evaluating the impact of restructuring is critical to improving the overall system. Research in the US identified that during a three year period of restructuring there were over 600,000 preventable deaths caused from medical errors (Stein & Deese, 2004). There is significant research on the relationships between staffing levels of nurses and adverse events such as pneumonia, falls, length of hospital stay, urinary tract infections, pressure ulcers, post operative infections, sepsis, medication errors, and gastric bleeds (Institute of Medicine, 2010; Cooke, 2002; McGillis-Hall et al, 2008; Spencer Laschinger et al, 2006). Aiken et al  18 (2002) found that when nurses‟ workload increased, the risk of patient mortality increased by 7% within 30 days of admission. Nurse staffing levels are predetermined by managers, and the use of extra or overtime staffing is dependent on approval from management. Front line nurse leaders are often the ones at the unit making the day to day staffing decisions. However, deskilling of nurses is underway since the implementation of the managerial science of using patient care maps and planned discharge to address the flow of the patients and identify tasks within nursing (Daiski, 2004). These care maps can create problems for nurses where consistency and uniformity is all that is allowed, thus leaving nurses no support and resources to deal with abnormality or variations. Care maps provide specific clinical patterns for patients and make task identification easy. Nurses often raise the concerns related to the complexity of the system that maps don‟t address. Mackay and Risk (2001) identified twelve themes as elements in the work place that assist or hinder nurses‟ ability to meet their standards of practice. The themes most often identified were presence of competent workers and organizational characteristics. A study on the psychological effects identifies that restructuring changes have forced front line nurse leaders to put organizational demands as a priority over clinical expertise or patient needs (Brown et al, 2006). This creates a conflict for nurse leaders as they are governed by standards of practice which are changed by the reform and feel powerless as they are also employees in the health care system. There is significant research on the relationship between nurses‟ workloads and physical exhaustion, emotional burnout, and reduced job satisfaction (Leiter & Spence Laschinger, 2006; Spence Laschinger et al, 2006, Bauman et al, 2001). These are factors that front line nurses try to address daily.  19 An organization can be overwhelmed by the negative impact from lack of organizational support for front line nurse leaders. There are costs of ongoing recruitment and human resourcing issues and the costs of morbidity and mortality of the system users or the public (Fabbri, 2006). The provincial government, with the assistance of the British Columbia Nurses‟ Union, nursing researchers, and senior nursing leaders, identified the need to increase front line nursing leadership. In the last four years, there has been an increase to over 2600 front line nurse leadership positions through a provincial government mandated process (BCNU, 2010). These positions were identified as imperative in creating a sustainable system and quality work environment (Dyke & Mateus, 2009). Investment in front line nursing leadership positions is a factor in increasing the quality of work environments for nurses and creating better patient outcomes. In reviewing when restructuring generates positive outcomes, researchers identified that it requires the commitment of all staff to make sure that it is effective and focused on the best patient care outcomes (Patterson Hines, Smeltzer & Galletti, 1994). Adair et al (2006) state that in the last ten years, some organizations have moved from controlling change from a top down model to system-wide change leadership at all levels. This system-wide approach is evident in health care organizations such as magnet hospitals, which are challenged to identify what outcomes they see as indicators of positive restructuring. These magnet hospitals have increased patient and nurse satisfaction, increased recruitment and retention of nurses, and improved patient outcomes (Armstrong & Laschinger 2006). These are just a few of the evaluators that can be used to understand positive improvements.  20 The Institute of Medicine also identified five essential management practices that impact the quality of care nurses are able to provide. These are ”balancing tension between production efficiency and safety; creating and sustaining trust throughout organization; actively managing the process of change; involving workers in decision making regarding work design and flow; [and] using knowledge management practices to establish learning organization” (p. 179, Institute of Medicine, 2010). The examination of management practices is on critical piece of information that must be included in evaluation. For researchers the importance of identifying evaluators is critical. There is no one way to evaluate health care reform. There is ongoing research to identify what the evaluator should be. For example, the performance measurement system is based on defining what the measurement is or should be, such as improved health status of a population or quicker surgical procedure times. Unfortunately in a complex system the outcomes are not always directly correlated and can create negative effects (Adair et al. 2006). Also research is showing that nurse leaders want to understand how they impact patient outcomes, staff satisfaction and work environments (Anderson, et al., 2010). Further research is vital in this area to understand evaluators for health care reform and nursing work environments. 2.3 Workload Nurses have been reporting significant deterioration of their work environments during restructuring (Baumann et al. 2001). Many studies report increases in stress, burnout, sick time and loss of control in their practice (Spence Laschinger, et al. 2003). All of these factors affect efficiency at the micro level and the quality of patient care that can be delivered. Often, workload or work overload is raised as an issue during restructuring or work redesigns (Spence Laschinger et al. 2003). Gaudine (2000) researched what nurses meant by  21 workload and overload and found that nurses expressed a lack of control over their work, a lack of communication pathways for dealing with changes to patient acuity, an inability to address patient‟s family members concerns, and too many undetectable issues that were not covered in work measurement tools. She raised the need to have nurse leaders listen and address these concerns when using work measurement tools and implementing changes (Gaudine, 2000). Workload is an important component of nursing work life and patient care outcomes. Leiter and Spence Laschinger (2006) argue that the complexity of the system is another factor that affects the burnout of workers and the quality of the work environment. They identify that more work needs to be done to explain how the changes in the organizations affect and support the working environment. 2.4 Quality Work Environments Positive work environments create healthy workplaces for staff and produce leaders who are engaged in work, respect others and pride themselves on working cooperatively, and are provided high levels of support by the organization (College of Registered Nurses of British Columbia, 2005; Mackay & Risk, 2001).  Front line nurse leaders are engaged in the daily work of the organization‟s overall goals. The resources that FLNLs use to deal effectively with concerns of staff or patients affect the running of the worksite and the care that is provided. The relationship between patient safety and nursing work environments has shown that if nurses do not have a quality work environment then they cannot provide safe quality care (Aiken et al., 2002; Dunleavy et al., 2003; Spence Laschinger, 2008; Institute of Medicine, 2010). Evaluation of restructuring and quality work environments is one imperative to protecting patients. Front line nurse leaders play an important role in evaluation and  22 implementation of changes in the work environments (Levey, Hill, & Greene, 2002). Adair et al (2006) highlight that there is conceptual confusion between both performance measurement and total quality management, and that these two terms are interrelated (Adair et al. 2006). The authors identify the need to evaluate both management structure and processes and the performance of management with a view on patient outcomes and other factors with a long term goal of improving the whole system. The performance measurement model is currently being used in British Columbia, although outcome measures are not always available for public review or questioning (Government of British Columbia, 2010). There is no research available on evaluation processes that provide or examine a framework for evaluating front line nurse leaders‟ role on outcomes. 2.5 Changes to the Role Of Front Line Nurse Leaders 2.5.1 Background During the restructuring of health care, nursing practice has changed. In the late 1980s and early 1990s, front line nurses saw the loss of their head nurse position. This position was instrumental in advocating for resources, supporting their practice and mentoring other nurses. For the front line care givers the impact was enormous. Nurses‟ workloads increased and nurses reported greater acuity of patients (Baumann et al. 2001); nurses lost permanent positions and benefits as they moved to casual work, and recently the use of unlicensed caregivers has challenged registered nurses‟ ability to provide quality care as they are moved farther from the bedside (Daiski, 2004). The negative impacts of these changes include the “loss of crucial support networks and devalued staff perceptions” (Daiski, 2004). The front line nurse role changed over these two decades because of restructuring through increased acuity, higher turnover in patients, loss of support staff and significant workload pressure. Daiski (2004) reported that nurses  23 saw overwhelmingly negative effects on the quality of care at the bedside during restructuring, reporting that more time was “spent on paper work than on patient care.” Another study reported that nurses‟ commitment to the patient was high during restructuring but saw the loss of loyalty to the organization when patient care suffered as their inability to address quality of care issues became demoralizing (Bauman et al. 2001). The ongoing restructuring and reform is identified as increasing the span of control for front line nurse leaders to an extent that they are unable to lead. Span of control was defined as the scope of responsibility that nursing leaders were undertaking including the number of staff reporting to the number of units and number of patients that were directly under the leader (Sherman & Pross, 2010).  This decreases their effectiveness and ability to meet organizational overall needs (Sherman & Pross, 2010).  Cooke (2002) found that nurse managers‟ scope of responsibility was increasingly focused on financial constraints and senior leaders‟ goals than on communication and human resource capacity building. A report by the Canadian Nurses Association in 2000 raised the point that strong nursing leadership is a requirement to address concerns with patient safety that are caused by staffing shortages and work redesign. This report called for a strategic plan to address the aging workforce that included education and mentoring to support new leaders. Another study questioned the ability of nurses to buy into the discourse or language of restructuring without loss of the essence of the nursing profession (Rankin, 2004). Rankin highlights that when nurses support the need for restructuring without actually evaluating the outcome on patient care and overall health of the patient, there is a significant loss of professional nursing standard and a move to being more task-focused. Restructuring based on poor performance measures or not based on improving patient outcomes can have long term  24 impact on the provision of services and direction of future policy. Front line nurse leaders are often caught between this paradigm in trying to advocate for quality health care and meet organizational change mandates (O‟Brien-Pallas & Hayes, 2008; Poniatowski et al.2005). Several researchers identify the importance of including front line nurses and leaders in the decision making so that quality outcomes are included (Hay, 2004; Wong et al. 2010; Spence Laschinger et al, 2001; O‟Brien-Pallas & Hayes, 2008; Udod, 2008; Wessel Krejcki, & Mallin, 1997). Watson (2000) calls for the use of transformational leadership in communicating and information sharing with front line staff and front line nurse leaders. Front line nurse leaders are described as being the on-the-ground assistants to managers. These leaders function by performing the day-to-day running of the unit or program (Sherman & Pross, 2010). Often they are involved in mentoring new staff, dealing with staffing shortages, training issues and communicating the policies and procedures of the organization and managers (Institute of Medicine, 2010). They are typically not at the bedside, but they must possess significant clinical skills and ability to assist other staff as needed and guide them in their work (Sherman & Pross, 2010). These positions are within the collective agreement of the British Columbia Nurses‟ Union and are not excluded and that can create a conflict when addressing issues for the front line nurse leaders.  Also, stress among charge nurses is reported to have both health and organizational impacts including high job demands, low supportive relationships, work overload, uncooperative families and patients, and the inability to deliver care because of organizational resource issues (Miller, Riley, & Davis, 2009; McGillis-Hill, Doran, & Pink, 2008). Effective leadership is a significant factor in human resource retention and  25 recruitment for organizations (Brady Germain & Cummings, 2010). Front line nurse leaders are important in creating a culture that supports and retains nurses (Bally, 2007). Resource allocation in a time of restraint is crucial to make visionary changes that improve the Canadian health care system. Nurse Managers in Finland reported spending less time in both direct and indirect care and most of their time in leading and guiding others (Surakka, 2006). If front line nurse leaders are dealing with daily resource allocation and long term human resource issues, it is imperative to identify areas where senior management may be better able to support front line nurse leaders. 2.6 Roles of Front Line Nurse Leaders To best understand the role of front line nurse leaders, the author‟s examination of the literature included research on the role of the front line nurse leaders and what is currently known about front line nurse leaders‟ education and work style. The research on front line nurse leaders was limited.  Most research focused on satisfaction with roles and/or roles of senior managers or front line staff nurses. 2.6.1 Role  Very few studies could be found that clearly defined the role of front line nurse leaders. A study examining the differences between nurse managers‟ work in the 1990s and 2000s showed that managers moved from more of the traditional bedside assistance including communication, organizing and mentoring to activities that were more managerial, such as organizational communication and planning (Surakka, 2006).  A descriptive and exploratory study in South Africa identified that nurse managers were “responsible and accountable for quality nursing service management to facilitate optimal attainment of the goals/objectives and outcomes within the context and scope of health service delivery of the health care organization” (page53 Buys & Muller, 2000). A Swedish study examined the clinical  26 supervisors‟ view of their leadership role and found that supervisors valued clinical supervision techniques, facilitating processes, and creating a work environment that is conductive to supervision through consistent leadership and supportive open communication (Severinsson, & Hallberg, 1996). A large Canadian study of nursing leadership identified that there were several identifiable factors that made senior nursing managers‟ roles effective. These included being part of the senior executive structure, having a reporting relationship with the Chief Executive Officer, and including the title chief nursing officer in their job descriptions (Spence Laschinger et al. 2006). This study found that an average of 71 staff reported to first line managers, and that working relationships among all levels of management were important to satisfaction and role effectiveness. The study also noted that the restructuring and change to organizations created barriers that made the nurse managers‟ roles and functions broader (Spence Laschinger et al. 2006). This study defined first-line managers as “nurses in positions with line responsibility for nursing and acute care patient unit/wards with staff nurses reporting directly to them” (Spence Laschinger et al. 2006). Two studies found that the role and scope of nurse leaders as requiring significant technical skills but that their role was not clear and there was significant ambiguity in how the role was described and utilized in their study. The studies agreed that leaders all needed to have strong transformational leadership skills (McIntosh, & Tolson, 2008; O‟Baugh et al 2007). An Australian study identified that a leadership model that had clear role and service definitions and was based on a framework would provide clearer use of advanced practice nurses (Gardner et al., 2006). The importance of clearly defining the role of front line nurse  27 leaders and their scope of control is vital so that nurses and administrators can develop similar language and expectations from front line nurse leaders. Wynne (2003) concluded that macro level (system wide) restructuring was driving change at the meso level (hospital or program) which significantly impacted the micro level (service delivery or unit level) and the role of front line nurse leaders, and that this change had little if no input by front line nurse leaders. This can be seen as the health authority‟s senior leadership restructure using program management models that are implemented at the meso level giving a director control of the a program within a health authority, then managers in each hospital or service area report to the director. Often the managers will cover more than one unit or worksite which significantly impacts the micro level; front line nurses are often without input and unit leadership. The role of front line nurse leaders during restructuring must be clear so that the best outcomes for patient care are possible. 2.6.2 Style A systematic review identified several studies that showed that leadership style had an influence on the performance of staff and the quality of patient care provided (Wong& Cummings, 2007). This study called for further research to identify if nursing leadership has an impact over the long term health reform and restructuring that is occurring. In another study, Kanste (2007) found that passive leadership style increased burnout in nursing staff, whereas active and future-oriented transformational leadership and rewards systems seemed to protect staff from burnout. Another study concluded that nurse job satisfaction and turnover were affected by supervisor incivility (Spence Laschinger et al., 2009). The use of providing education on transformational leadership style has been found to be an effective in developing leadership skills (MacPhee, & Bouthillette, 2008). Transformational leadership is defined as behavior that include inspirational motivation,  28 idealized influence, individualized consideration and intellectual stimulation that transforms the values and priorities of followers and motivates them (Kark, Shamir, & Chen, 2003). Transformational leadership style principles were incorporated into the BCNLI. 2.6.3 Education The report by the Canadian Nurses Association highlights that support and education for nursing leadership has four areas of influence: research, teaching, administration and clinical practice (Kitty, 2005). Today‟s nurse leaders need skills that transcend all areas. The report identifies nurse leaders as able to provide vision for others to follow, able to promote and use research to improve the clinical practice, able to administer policies and be a voice for nursing to organizational leaders and able to understand the needs of clinical practice and front line nursing staff (Kitty, 2005). Although the report put out by the Canadian Nurses Association describes nursing leadership as “alive and well,” the skills identified in the report highlight the critical need for training and support of front line nurse leaders (Kitty, 2005). The report does not identify how front line nurse leaders prioritize, communicate and address leadership issues, but recommends ongoing education and training to achieve desired outcomes. In the United States, a new Clinical Nurse Leader (CNL) role was developed in 2004 to improve patient care outcomes and lower costs related to resources such as staffing and supplies (Stanley & Sherratt, 2010). This clinical nurse leader role, which consisted of providing front line leadership on nursing units, was evaluated and shown to improve patient outcomes such as lowering rates of pneumonia and congestive heart failure, as well as improving retention of nursing staff and increasing satisfaction of both patients and physicians (Stanley & Sherratt, 2010). This role had a master‟s level preparation with a focus on leadership education and with CNL certification by the American Association Clinical  29 Nurses AACN (Stanley & Sherratt, 2010). This CNL position was independent of human resource issues such as filling staffing vacancies and dealing with shortages in the daily workforce. This role is different than the front line nurse leaders (level two) in British Columbian‟s health care system. The front line nurse leaders in British Columbia are involved in staff assignment, reallocation and retention measures (Dyke & Mateus, 2009). A study that looked at enhancing nurse leaders‟ perceptions of patient safety culture identified that training initiatives and organizational support for leaders improved patient safety (Ginsberg et al., 2005). Another study tried to identify if there was a relationship between nurse education level and patient safety but found that patient indicators were not as clear, as there were too many variables that impacted patient outcomes; thus, no absolute conclusion could be made (Ridley, 2008). In Ireland, a study identified five areas of education for new leaders: practical skills, leadership skills, learning methods, increasing leadership experience, and training of new workers (Rani, 2010). Education and mentoring provide a significant part of creating new front line nurse leaders. A comprehensive systematic review on developing and sustaining nursing leadership and promoting a healthy work environment found eight themes that impacted nursing practice: collaboration, education, emotional intelligence, organizational climate, professional development, positive behaviours and qualities and the need for a supportive environment (Pearson et al., 2007). The authors called for further research and support of education for nursing leaders. The skills front line nurses need are both learned through formal education and on-the-job mentoring (Hay, 2004). Further investigation of the educational needs of front line nurse leaders is required, especially given the rapid pace of restructuring and change in health care.  30 2.7 Scope of Front Line Nursing Leaders  In examining the scope of front line nurse leaders, it became apparent there is no research on what their scope is or should be. The College of Registered Nurses of British Columbia (2005) defines Scope of Practice as “activities nurses are educated and authorized to perform as set out in the Nurses (Registered) and Nurse Practitioners Regulation under the Health Professions Act and complemented by standards, limits and conditions set by CRNBC.”  The College Registered Nurses of British Columbia provides indicators for each of the six professional standards for nurses working in clinical practice, education, administration and research. These indicators for administration focus on responsibility for one‟s own actions, communication, use of information to support staff and patient safety, change process, ethics, and improvement of the health care system. One item highlighted in the research is the issue of span of control for nurse managers. In 2000 a report to the Canadian Nurses Association defined span of control as the “average number of direct reports for each nursing supervisor” (p.25 Canadian Nurses Association, 2000). Currently, there is a three year study in progress titled “Evaluating the impact of nursing span of control on manager, staff and organizational performance in Ontario Academic Hospitals” (University of Western Ontario website, 2010).  This study identifies the concerns that health care restructuring has increased the span of control for front line nurse managers, which is creating concern regarding workload and outcomes that can have significant costs including retention and resource allocation (University of Western Ontario website, 2010). It also identifies that there is little research on the impact and outcomes of changes to span of control. A systematic review examining job satisfaction of front line nurse managers identified that job satisfaction increased when organizations addressed span of control issues  31 by encouraging decision making through increased support of supervisors and empowerment of managers (Lee & Cummings, 2008). Another study looking at the impact of span of control on emotionally intelligent leadership found that managers with strong emotional intelligence had difficulty empowering their staff if their span of control was too large (Lucas et al., 2008). Scope of control and span of control appear to be defined differently. There is no one agreed to definition of scope of control. 2.8 Evaluation of Change Through Structure-Process  There has been a call for health care leadership to examine the use of patient outcomes as an evaluator prior to implementing any change. As one of the founders in the movement to evaluate health care quality, Donabedian developed a causality framework that allowed exploration of the links between structure and process within an organization to predict patient outcomes (Donabedian, 1982). The framework is logical and establishes a way to examine the policies, standards, resources, orientation programs, tools, and organizational resources using the structure part of the model. The process phase examines the actual work of the nursing staff. Then, the framework looks at outcomes, including patient care outcomes, adverse events, rate of recovery, and satisfaction (Donabedian, 1982; El-Jardali & Lagace, 2005).  Donabedian‟s framework (1982) can be used when looking for causality in front line nursing leaders‟ work. Using the Structure-Process-Outcomes (SPO) framework developed by Donabedian (1982) researchers can categorize factors that influence outcomes. El-Jardini and Lagace (2005) identify that the higher levels of process such as managerial decisions have greater impact on the outcomes for patients. They give the example of an employer implementing a policy on length of shift where a 12-hour shift is known to increase the risk of medical errors significantly. This predictive model allows for us to identify organizational  32 flaws and prevent poor patient outcomes. El-Jardali and Lagace (2005) concluded that “hospital structural factors influence what nurses do, which in turn impacts the occurrence of adverse events” (p. 47). They found that the structural factors were more likely to create systematic adverse events.  A study by Upenieks and Abelew (2006) focused on structures, processes, and outcomes associated with magnet hospitals. These hospitals are considered gold standards for nursing practice environments. The researchers found that magnet structural factors included effective leadership. Effective leaders, in turn, were associated with two important processes: sharing information and commitment to staff participation.  They identify that the stable organizational structures influence nursing practice and the level of staff engagement. They found that the structure factors of staffing, pay, and role of leaders was important before building in processes. The SPO framework allows for evaluation of organizational structure and processes that influence patient outcomes. This framework is a valid way to examine health care setting and the nursing work environment (Closs &Tierney, 1993; Upenieks & Abelew, 2006; El- Jardali & Lagace, 2005) 2.9 Conclusion  The current frenzied pace of change is requiring front line nurse leaders to deal with more complex issues and systems. Restructuring has a significant effect on patient outcomes through changes to structure and process. The need to support and educate front line nurse leaders is vital, but to achieve this there needs to be a greater understanding of the type of work they do and the influence of restructuring. As organizations make changes to structure such as policies, resources and contractual agreements, there are effects on the role of front line nurse leaders.  33 The role of front line nurse leaders is dynamic and both skill- and knowledge-based. There is very little agreement on the definition of scope or span of control. Although few studies examined the role front line nurse leaders hold, there is currently strong support for the impact this position can have on resources and quality work environments. It is imperative to continue to research this critical role as restructuring and change to health care delivery is constantly impacting the way leadership is provided. The long term cost savings to the system from using effective nursing leaders needs to be examined. The questions of how and what front line nurse leaders do with resources will make a significant impact to the daily outcomes in the system by identifying clear frameworks and areas that organizations can support front line nurse leaders.  34 3    Chapter: Research Design and Methods 3.1 Introduction The purpose of this research study is to examine the British Columbia Nursing Leadership Institute (BCNLI) projects of front line nurse leaders using content analysis. The content analysis approach was used to better understand the types of roles and responsibilities required by front line nurse leaders, as well as how these roles and responsibilities changed over time, as reflected in their BC NLI project work. These projects provide an opportunity to understand the issues that front line nurse leaders and their mentors (and organizations) identified as relevant and worthy of being a project. There were 211 projects completed by front line nurse leaders from 2007 to 2010. These projects are described on the BCNLI website. Each project description and details were added to the BCNLI website project page by the front line nurse leaders. The website is constantly being updated and more information is being added. Content analysis is widely used in nursing studies to examine a phenomenon through description (Elo & Kyngas, 2007). The latent or underlying themes are examined to discover if there are similarities that can be exposed (Graneheim & Lundman, 2004).  These similarities are then examined based on chronological date of the projects to see if there was change over time. The process of content analysis is a valid and trustworthy form of understanding similarities or meanings in the projects text (Graneheim & Lundman, 2004). By using a process of identifying the meaning unit, then condensing the meaning unit, then interpreting the underlying theme and finally developing the theme, a greater understanding of what types of issues are current to each cohort of nurse leaders projects were identified (Graneheim & Lundman, 2004).  35 3.2 Research Approach and Rationale This study did three different analyses. Firstly, the projects are categorized into four levels to identify their scope of control or responsibility: (1) micro level, meaning within the nursing unit level, (2) meso level, meaning within several units in the hospital or health care service program, (3) macro level, meaning health region or hospital-wide, and (4) covering all provincial service programs.  If there was insufficient information to determine the correct level, the project was coded as zero (0). Using content analysis, each project was categorized based on what level of influence or scope the project focused on. Scope of control was defined as the influence or responsibility of the project. The cohorts were examined for changes between each group. Secondly, the projects were analyzed for the type of project the front line nurse leader was addressing, in order to see if there were changes in the types of projects between cohorts. Using content analysis, themes were identified (Graneheim & Lundman, 2004).  The themes are first grouped within each cohort. By counting the number of times the theme is repeated, a numeric transformation of the text occurs from the qualitative data. The numeric values allow the author to identify differences from each cohort‟s types of projects. The themes are examined to see if there is change over time and cohorts. The themes developed from the projects are discussed and further study is proposed. The type of projects were identified and included issues such as mentoring, education of staff, orientation of staff, organizing resources and support for families, and streamlining issues and resources for staff such as developing tools and checklists. Finally, using Donabedian‟s (1982) SPO framework, projects were examined and categorized into either or both structure and process categories. For this research, structure was defined as the resources of an organization and includes policy, procedures, staffing  36 levels, shift agreements or negotiated agreements and anything that is stable to the organization (Closs & Tierney, 1993). Process was defined as the way work was done by staff, and included aspects of communication, team building, meetings, use of tools and staffing changes (Closs & Tierney, 1993). Although there is disagreement in the research literature as to what constitutes a structure or process, and there is even further research that adds another category of managerial process prior to staff process, in the model for this research I have used the more traditional definitions described above (Closs & Tierney,1993). I did not code outcomes as the web pages did not include information on completed projects. This framework is a tool to increase the understanding of the role and responsibilities of front line nurse leaders. The SPO categories identify were front line nurse leaders are focusing their practice. The SPO framework and the types of projects will help senior managers to understand the work of front line nurse leaders. Figure 1 Quality of care model (Donabedian, 1982)  3.3 Ethical Issues  The British Columbia Nursing Leadership Institute (BCNLI) projects were available to the general public via the website. These participants provided information under five headings on the project pages. These headings are key issues, general background, project goals, brief overview, and leadership goals. Participants gave their ethics permission to content analyze their project page information as part of a larger study funded by the Canadian Health Services Research Foundation (CHSRF). Project data used for this study is covered under the CHSRF ethics application, and no names or other personal identifiers were used in this content analysis.  structure process outcome  37 3.4 Participants and Setting  The total study population between May 2007-May 2010 included 211 participant projects. This study sample consisted of 161 project pages for the content analysis. There were 50 projects that had limited information and text and could not be content analyzed.  These projects were to be completed within one year of attending the Nursing Leadership Institute. The FLNL spent time working with their mentors and finalizing their projects on the last day of the NLI study week that was held at Harrison Hot Springs Hotel. The supportive senior manager and organization were involved with the project selection. Participants had the opportunity to post their project information during the last day of the study week. Further information could be passed on to the researchers for posting to the website. The project information is publicly accessible at http://www.nli.nursing.ubc.ca/Projects.aspx. 3.5 Data Collection and Study Procedures  Each project write up for British Columbia Nursing Leadership Institute (BCNLI) participants between May 2007 and May 2010 was reviewed and a spreadsheet created to manage the information. Each project outlined the key issues that the FLNL identified and gave a short description of relevant background information. Project titles, health authorities, and text phrases were entered by cohort date. The project pages listed the project goal with a brief overview of the project and the leadership goals that the participant wanted to achieve. Text phrases corresponded to types of projects and project span of control or scope. For example, several projects developed orientation tools for staff. The information was reviewed several times to ensure that all phrases from the text were included in the database before content analysis was performed. These sheets were collected and analyzed in May 2010.   38 3.6 Data Analysis and Transformation  For this thesis the whole project page description on the website was considered the unit of analysis (Graneheim & Lundman, 2004). To understand the types of leadership projects and their scope or span of control, each project was first reviewed for general understanding and to gain knowledge of how the leaders expressed their project goals. Then, key phrases that described the project scope were compiled and entered as meaning units in the data spreadsheet grid. Each project was examined for level of scope to determine if it was (1) micro level, meaning within the nursing unit level, such as “developing a orientation manual for the unit” (2) meso level, meaning within several units in the hospital or health care service program, such as “developing a orientation program for public health nurses” (3) macro level, meaning health region or hospital-wide, such as “reviewing the orientation process for the hospital”  and (4) covering all provincial service programs.  If there was insufficient information to determine the correct level, the project was coded as zero (0). See appendix B for comparison chart of scope or span of control. After the scope of the project was determined then the type of project was analyzed. Verbs and verb phrases were indicators of an action the FLNL wanted and were recorded in the data. For example, verbs such as “develop” or “create” provided information on the goal the FLNL hoped to accomplish. From these meaning units, concepts appeared using a manifest content technique, and the text words were used to provide the description of the components.  For example, phrases such as “develop standardized protocols” or “establish care givers support group” were taken from the text. The data was analyzed from the text phrases of the project pages, and then condensed to create the sub theme or themes within each cohort. The data was grouped by project dates to see if there were common themes in each cohort. The themes that developed allowed this  39 research to examine if there were differences between the cohorts. Grouping by themes allowed for the number of items in each of the categories to be counted. The numeric counting facilitated the identification of which themes were most common in each cohort (Neuendorf, 2002). These projects were then examined to see if there were changes between cohorts in the number of projects with regards to the type of project (Appendix A). The Structure-Process-Outcome framework was used to categorize the project information. These categories identify if front line nurse leaders are focused on structure or process or both. These categories were determined using the text phrases. Each project text page was examined and a determination as to which category the project fit into using the SPO framework. The SPO framework was used as a tool to understand how the work of front line nurse leaders‟ work was done and what or where resources could be utilized to improve patient outcomes. 3.7 Measures: Reliability and Validity Graneheim and Lundman (2004) describe trustworthiness as “interrelated and intertwined.”  They break down trustworthiness into the sub-category of credibility, which deals with “confidence in how well data and process analysis address the intended focus” (p.109, Graneheim & Lundman 2004) When looking at the trustworthiness of research, three concepts are discussed. The first concept is credibility. The first component of credibility is negative case analysis, which is when research must identify any unusual cased or outliers that may create problems for the analysis, and then decide how they will handle these cases (Craig & Smyth, 2002). In reviewing the data, 50 projects were identified as having limited information and the decision was made not to include these projects in the content analysis. The component of credibility is triangulation, which requires more than one way to develop the conclusion from the data  40 (Creswell, 1994). In this analysis, triangulation was completed by reviewing the initial themes with the thesis committee chair and discussing the analysis process to see if the same conclusions could be identified in the data. As the data on the website was the typed words of the participants, it did allow for analysis and review multiple times by myself. In one situation there was enough information for the project to be included into 2 themes; this is discussed in the results section. The third component of credibility is constant comparative analysis, which was used to compare the projects of each participant while being analyzed (Graneheim & Lundman, 2004). For example, each cohort‟s meaning units were analyzed and sub themes were identified. Then the second cohort‟s meaning units were analyzed and sub themes compared to the first cohorts to see if there were similarities. This comparison was completed on all nine cohorts and allowed for clarity in the development of themes. Another component of credibility is member checking, and is a limitation of this research because the coded themes were not reviewed by the front line leaders. The second concept is dependability which is the link between the consistency of the results and the data (Graneheim, & Lundeman, 2004). This condition was met by using the project pages from the website leaders‟ projects from a specific time (May 2010). Also the inclusion of the text phrases in the study results section so that readers are able to identify the accuracy of the work.  This research was a content analysis of the website information on nursing leadership projects. The information from the website has changed from the time this study was initiated, but the information in this study is very dependable as it consists of the participants written words as of May 2010. Also, reflectivity is review of the data by the researcher and was demonstrated by this researcher by methodically reviewing each project,  41 pulling out each meaning unit and using notes to make comments on issues or codes that may be identifying in the information. By using the actual written words of the participants to ensure the themes being made reflected the actual context of the projects; the data could be deemed trustworthy (Graneheim & Lundman, 2004). The third concept of transferability is the ability of the findings to be transferred to other situations (Graneheim & Lundman, 2004). This condition is more difficult to determine and is left up to the readers as suggested by Graneheim and Lundman (2004). These themes are based on the type of work and working conditions that exist for these front line nurse leaders at a given time and for a specific experience, the BC nursing leadership administrative institute. The use of comprehensive description of the meaning unit is important so that other researchers can see how the conclusions of this research were made (Craig & Smyth, 2002). As there can be many interpretations of the meaning units, it was important to examine the full text that was captured on the website. There must be exploration of all possible perspectives that could be hidden in the meaning units (Craig & Smyth, 2002). This is reported in the results section. 3.8 Study Limitations This study is limited by the number of participants that are able to participate in the BC Nursing Leadership Institute. Each cohort had a maximum of 29 participants that were selected by the senior management within each health authority. As this study focused on looking at the differences between cohorts the lack of numbers in each cohort significantly limits the study. There were not enough projects to identify all the issues that are present in the work of front line nurse leaders. Also the short time period made it difficult to identify any changes over time. A longer study would provide greater information so that change over time can be recognized.  42 The projects identified issues that were important to both senior management and front line nurse leaders. This study did not have detailed information or the ability to collect information on the level of support from the organization or the mentor. All of these projects were supported by senior management and the participants were selected to participate in the program which could create a bias in the type of projects selected.  It is not known if senior leaders selected people to attend who already had projects identified or if the project was something that senior leaders wanted addressed and needed to find the right person to do the work. This lack of information limits the ability to generalize about the results of this study. There was also a lack of information on the current restructuring that each front line nurse leader‟s worksite was experiencing. The restructuring affected each worksite or program differently as evidence by the information BCNU provided in news releases and bulletins describing layoffs of registered nurses and replacement with licensed practical nurses in some facilities or worksite. Some worksites identified job losses and human resource realignment that was not necessarily supported by staff but was directed by organizational needs (BCNU, 2010).  43 4    Chapter: Results 4.1 Demographics This study included project pages from front line nurse leaders in all health authorities. There was no significant difference in the number of front line nurse leaders between employers. The majority of the participants (68%) were employed in acute care setting (MacPhee, 2011).  There were 90.5% females and 9.5% males. Also 49% of the front line nurse leaders were bachelorette prepared and the average age of participants was between 40 and 49 (MacPhee, 2011). Figure 2 Front line nurse leaders’ employment setting  4.2 Introduction The results of this study are divided into three main sections. The first section examines the scope of control of the projects. The scope of control was determined using content analysis to see whether the project was focused within the nursing unit, within multiple units, hospital/program wide, regionally or provincially. Scope of control was defined as the focus of the project responsibility. The second section discusses the results of the content analysis on the themes that were identified in the projects. The projects identified Front line nurse leaders' employment setting acute care residential care public health home health and community mental health and addictions other  44 five main themes and one sub theme. These themes are explained using examples. Each project was classified, and then the number in each classification was tallied for each cohort to see if there was any difference between cohorts with respect to type and scope of projects. By identifying the types of leadership projects and their scope of control, researchers can better understand the complexity of leadership in health care settings. This chapter also contains discussion of the results of systematically coding the projects by type. Donabedian's framework was used to categorize projects as "structure", "process" or both.  For this research, structure was defined as the resources of an organization and included policy, procedures, staffing levels, shift agreements or negotiated agreements and anything else stable to the organization (Closs & Tierney, 1993). Process was defined as the way work was done by staff, and included aspects of communication, team building, meetings, use of tools and staffing changes (Closs & Tierney, 1993). Although there is disagreement in the research as to what constitutes a structure or process, and there is even further research that adds another category of management process prior to staff process, in the model for this research I have used the more traditional definitions described above (Closs & Tierney, 1993). 4.3 Scope of Control The projects were examined to determine their scope of control. If a project was at the unit level it was classified micro, or level 1; if it was covered a program or several units it was classified meso, or level 2; if it covered a health region or hospital it was classified as macro, or level 3; if it covered the whole province it was classified as level 4. If there was insufficient data to provide classification it was classified as level “Zero”. There were 211 projects and only 6 projects were classified as “Zero.”    45 Table 1 Number for projects at each level of scope of control.  Level One Micro Level Two Meso Level Three Macro Level Four Provincial Level Zero Unknown Number of projects 129 60 15 1 6 4.3.1 Level One (Macro)  There were a total of 129 projects at the unit level, which was over 61% of the total number. These projects focused on creating support groups for clients, procedures for staff, developing and delivering education, and developing resource lists or materials. For example, one project‟s meaning unit was “implementation of the surgical safety checklist in the operating room”. This meaning unit clearly identified the unit and the intent of the project. 4.3.2 Level Two (Meso)  There were a total of 60 projects (28%) that were at the program level or covered more than one unit. The projects encompassed issues like evaluation of patient flow, collaboration with other departments, orientation tools or educational support for staff and clients. For example, one project identified the need to create “patient care equipment access and storage at Richmond Hospital (excluding OR and OBS).” 4.3.3 Level Three (Macro)  At the macro level there were a total of 15 projects (7%). These projects included development of policy manuals, tools for hospital-wide use during orientation, and methods for increasing communication. For example, one project looked at “classifying emergency patients in the emergency departments in the Northern Health Authority”. The goal was to describe a health authority wide classification system for emergency patients. Another example was from the Interior Health Authority, which describes the evaluation of the health authorities‟ respite care program. The participant wrote that the project was intended “to critically review Interior Health‟s policy and delivery of respite services and make recommendations for quality improvement”.   46 4.3.4 Level Four  There was only one project classified at level four. This project examined a business case for the expansion of a provincial program. This project only included the title, but provided a rich description of the project‟s intent, which was the “development of a strategic plan and business case for the expansion of province wide health care associated infections surveillance.” This project would have many stakeholders and require significant support from senior leadership in the health authorities and provincial government. 4.3.5 Unknown Level  Six projects were coded as "zero" due to insufficient information. One example was a project titled “Project Yellow Bus”. These six projects could not be coded by type or scope. Figure 3 Comparison of scope of control number for projects by cohort  4.4 Type of Projects  The data presented five main themes and one sub theme from the text phrases. These themes were: recruitment and retention initiatives, care delivery evaluation, communication, education and tool development. There was one sub theme of change management. Each of 0 10 20 30 40 50 60 O ct -0 7 Ja n -0 8 A p r- 0 8 Ju l- 0 8 O ct -0 8 Ja n -0 9 A p r- 0 9 Ju l- 0 9 O ct -0 9 Ja n -1 0 totals 4 is provincial 3 is facility or region 2 is program or more than one unit 1 is unit level 0 not identified  47 these themes is defined and discussed separately below. These themes were developed out of the meaning units through content analysis. Each project was reviewed and text phrases that captured the goal of the project were used as the meaning unit. Similar meaning units were identified and grouped together to identify sub themes and then main themes. Review of the themes allowed for the determination for the code of structure, process or both. In some situations projects were coded using Donabedian‟s (1982) framework but there was not enough information to use content analysis to categorize the meaning unit and develop the theme accurately; these are noted in Appendix A.  Using data collected in May 2010, only 161 projects could be analyzed because 49 did not provide enough information to fully develop the meaning unit. Also, 50 projects provided insufficient information to determine the SPO framework categories. Using Donabedian‟s (1982) framework, the process coding identified a total of 20 projects, or 12% of the 161 projects, that could be coded. The process themes were often related to activities within regular work, such as team building, communication and work flow. For example, included in the process themes are projects with titles such as “multidisciplinary collaborative group”, “information sharing along the continuum of care” and “measure and collect performance indicators in ambulatory care.” A total of 115 projects from the 161 were coded as structure projects, which is 71%. The structure coding was developed from the meaning units that best described the overall project direction, such as “develop a performance appraisal tool for staff nurses” and “telephone case management program” and “developing a peri-natal depression prevention program.” These structure-focused projects identified resources or policies that the organization needed to address to improve the work environment.  48 There were 27 projects coded in both the process and structure categories. These projects make up the remaining 18%. The cohorts were consistent in their distribution of SPO coding. The November 2007 cohort did not have any process codes and the March 2010 cohort did not have any process and structure codes. The structure and process theme described ideas such as changes to policies, work design, staffing and methodology for how work was implemented and carried out.  For example, projects such as “developing an innovative learning approach for BSN students within the PHN work environment” and “enhancing job satisfaction in a climate of change” and “streaming-improving patient flow in the emergency department” all involved both structure and process changes. Appendix B contains the "type of project" content analysis comparison grid. Table 2 Project themes by cohort (*project coded in both themes) Types of projects March 2010 Nov 2009 Oct 2009 Mar 2009 Nov 2008 Oct 2008 Mar 2008 Nov 2007 Oct 2007 Retention and Recruitment 4  1 6 2 1 1 3 5* Tools and resources 6 2 4 3 2 10 11 3 5* Communication 4 3 5 3 7 2 3 4 4 Education 4 4 4 5 2    1 Care delivery evaluation 3 3 6 4 3 8 3 5 4 Change management       1 Unable to code 6 3 5 3 5 6 8 11 1 Total projects 27 15 25 24 21 27 27 26 19  Table 3 Project SPO framework by cohort   March 2010 Nov 2009 Oct 2009 Mar 2009 Nov 2008 Oct 2008 Mar 2008 Nov 2007 Oct 2007 Process 2 1 3 6 3 1 3  1 Structure  18 8 11 10 9 17 12 16 14 Process and Structure  1 5 5 3 4 5 1 3 Unable to code 7 5 6 3 6 5 7 9 1 Total projects 27 15 25 24 21 27 27 26 19  49 4.4.1 Retention and Recruitment Initiatives The retention and recruitment initiatives theme was defined from projects that worked to address human resource issues related to attracting staff and keeping them within the practice setting. A total of 23 projects (11%) had a main theme of recruitment and retention. One of the projects in the October 2007 cohort had a project that fully developed two main themes and was coded in both the recruitment theme and the tools theme. Leaders identified that nursing work environment issues needed to be addressed and more support provided to sufficiently recruit and retain staff. For example, one participant wrote that “a number of...staff are unhappy and dissatisfied with their master rotation...resulting in workload for the program.” Another example from the retention themed projects was the meaning unit that “some staff expressed desire to resign from the department… (the goal is) to develop core group of nurses from within the department to help identify key issues.” Table 4 . Numbers of projects in retention and recruitment theme coded for Donabedian’s framework by cohort   March 2010 Nov 2009 Oct 2009 Mar 2009 Nov 2008 Oct 2008 Mar 2008 Nov 2007 Oct 2007 Process    2   1 Structure  3  1 1 1 1  3 5 Process and Structure    2 1 Unable to code 1   1 Total projects 4 0 1 6 2 1 1 3 5 Retention and recruitment can be treated separately, but most of the projects overlapped in their efforts, as they applied both retention of existing staff and capturing new staff into the nursing areas. These projects included issues like team building, “fairness in the workplace”, mentoring and support for staff. Each cohort presented the theme of retention and recruitment in the project information, with the exception of the November 2009 cohort, which only had 15 projects at the time the data was collected. This exclusion is likely due to  50 the limited amount of data in that cohort. Most of the recruitment themed projects were coded as structure projects. 4.4.2 Tools and Resources  Every cohort had projects coded under the tools theme. Tools were defined as having the goal of producing a document, list, framework, model, manual, or pathway that would be used in the workplace. These included electronic lists, websites or templates. There were 46 projects (21%) that identified this theme. One project from October 2007 was coded in both the retention and recruitment and tools theme, as noted above. The majority of the tools themed projects, 44, were categorized as structure projects using Donabedian‟s framework. Only 4 were coded as projects that addressed both structure and process; these were projects where the tool was developed using process or involving process. No projects were coded as process only. If the goal was the use of the tool or resource, the meaning unit was captured in the content analysis through coding and resulting themes. If the goal was education or communication as a main theme and a tool was used to accomplish this goal, these projects were coded under the main goal of the project (education or communication) and were not included in the tool theme. Tools and resources included projects such as a “surgical safety checklist”, a “domestic violence screening tool”, reporting tools and clinical decision making tools. There were also online, manual and classroom educational tools included in projects. Table 5 Numbers of projects in tools theme coded for Donabedian’s framework by cohort  March 2010 Nov 2009 Oct 2009 Mar 2009 Nov 2008 Oct 2008 Mar 2008 Nov 2007 Oct 2007 Process Structure  5 2 5 3 2 10 9 3 5 Process & Structure 1      3 Unable to code  Total   6 2 5 3 2 10 12 3 5  51  4.4.3 Communication Table 6 Numbers of projects in communication theme coded for Donabedian’s framework by cohort  March 2010 Nov 2009 Oct 2009 Mar 2009 Nov 2008 Oct 2008 Mar 2008 Nov 2007 Oct 2007 Process 2 1 3 2 3  2  1 Structure  2 2  1 2 1  4 1 Process and Structure   2  1 1 1  2 Unable to code     1 Total projects 4 3 5 3 7 2 3 4 4 Communication was another theme that was present in all cohorts. Communication was defined as the information flow from one individual or group to another individual or group, including the use of posters, reports, and communication walls. A total of 35 projects (17%) developed the theme of communication. Several projects identified the goal of increasing communication either among staff or with other departments or units. For example, one meaning unit was “regular updates to staff, once per month face to face, email updates every month, provide opportunity to ask questions and provide feedback.”  Not all projects included the component of information flow in both directions. Other words or phrases that helped categorize meaning units in the communication theme included “engagement,”  “meeting to discuss,” and “information, demonstration boards, and presentations.”  These projects consisted of both process and structure codes. The project was coded as structure when the information only discussed the goal of improved communication, such as “I have instructed all the nurses that scrub” or “increase and formalize the interdepartmental communication.” Some projects were process only, such as “improving communication between RN‟s and RCA‟s” and “building relationships and strengthening support of nurse case managers.”  52 Other projects incorporated both structure and process, such as “transfer of care shift handover reporting” and “engaging staff in the process…and email all staff the process….have feedback mechanism.” 4.4.4 Education  Education was a theme that was present in six out of the nine cohorts. The education theme was defined as projects that had a goal of providing education or training for more than one person. There were a total of 20 projects (9%) in this theme. These projects included meaning units such as, “develop and implement a training program,” “plan and implement a skills and education day,” “provide the nursing staff with education on the early signs and symptoms of agitation” and “educate staff on collaborative nursing.” These projects tended to be structure based projects but some projects included both process and structure. One meaning unit was rich in describing the process and the structure, and was intended to “develop leadership and communication skills in front line staff… empower team and create a culture of collaboration and develop an understanding of how the organization or systems work.” The education theme could have been a sub theme of communication, but there was enough information regarding education-related projects to allow for the theme to be extracted unto itself. Table 7 . Numbers of projects in education theme coded for Donabedian’s framework by cohort  March 2010 Nov 2009 Oct 2009 Mar 2009 Nov 2008 Oct 2008 Mar 2008 Nov 2007 Oct 2007 Process    1 Structure  4 4 2 2 1 1 Process and Structure   1 2 1 Unable to code  1 1 Total projects 4 4 4 5 2 1 0 0 0   53 4.4.5 Care Delivery Evaluation Table 8 . Numbers of projects in care delivery evaluation theme coded for Donabedian’s framework by cohort   March 2010 Nov 2009 Oct 2009 Mar 2009 Nov 2008 Oct 2008 Mar 2008 Nov 2007 Oct 2007 Process Structure  3  4 2 3 5 3 3 3 Process and Structure 1*  2 1  3  1 1 Unable to code  Total projects 4 0 6 3 3 8 3 4 4 The care delivery evaluation theme was developed from the meaning units of projects that examined patient flow and work flow issues, including conceptual items like patient satisfaction and support for involvement in care. Care delivery evaluation was defined as organizational structure or processes that were evaluated, implemented, reorganized, reviewed or changed. This was based on the work done by Mackay and Risk (2001) that defined care delivery processes as “planning and providing clinical care/services” and that included “nursing care program delivery models, staffing ratios, staffing mix, standards of care, professional accountability and continuous practice improvement activities” (p.21). A total of 38 projects (18%) developed the care delivery evaluation theme. Some examples of the care delivery evaluation meaning unit were “measuring and improving surgical wait times,” “improving patient flow through surgical daycare,” “implement regional delivery model,” “identify and evaluate the equipment needs and excesses,” “evaluate the IH respite policy,” and “standardization and support of nurse case manager practice in community.” These projects had structure, process and both structure and process codes. Some of the projects identified desired outcomes such as to “increase efficiency,” or provide “better patient flow,” but this research did not identify or code any outcomes. Text phrases  54 indicated leaders‟ concerns with ongoing restructuring and a desire for efficiency in all cohorts. 4.4.6 Change Management  One project identified the sub theme of change management. This project was rich in describing the process of change management. This project provided the following description: “using change management...to engage team members in the process, to bring two units together into a larger unit, create new identity that the team members feel proud to be part of, units will be moved together into a shared space.”  This project was in the March 2008 cohort and was coded as both structure and process using Donabedian‟s framework. This project could be included in the theme of care delivery evaluation but it provides such rich description of the full process and the structure change that it stood out from other projects. 4.5  Conclusion The BC Nursing Leadership Institute projects were representative of the vast amount of work that front line leaders take on. The complexity of the health care system was evident in the types of projects and the scope of responsibility of many of the projects. There appears to be no letting up of the hectic pace of restructuring during the three years as indicated by the types of projects. With only 61% of the projects coded at the micro or unit level there is indication that a great number of front line nurse leaders are involved with the organization beyond the front line nurse leader level. There was no significant variation between cohorts as to the scope of projects undertaken. The information in the projects led to the five main themes that can be used to understand the role of the front line nurse leader and the importance of organizational support. The five main themes of recruitment/retention, communication, education, care  55 delivery evaluation, and tool development are important windows into the work that nurse leaders facilitate and the breadth of their role. The reoccurrence of the themes in each of the cohorts identifies the continuation of the same types of issues facing nursing between 2007 and 2010. This study identified that the majority of the projects (71%) were coded as structure-focused using Donabedian‟s framework, 12% were coded as process-focused, and 18 % were coded as both structure and process. These results give rise to a discussion of the importance of understanding leadership in nursing in British Columbia. These projects give valuable information about the types of work front line nurse leaders do and the importance of supporting their education and professional development.   56 5    Chapter: Discussion 5.1 Introduction This study provides information that can be used to further explore the role of front line nurse leaders and identify the need of organizations to support healthy work environments for all staff. Although there was no significant change in the types of projects over the three and half year period that was analyzed, the information gained shows that front line nurses take on and attempt to manage significant issues. This chapter will discuss the results of the study with a perspective on the needs of front line nurse leaders for the future, specifically looking at organizational needs, education, and quality work environments as viewed through the themes of the projects and their scope of control. This research highlights five areas that front line nurse leaders focused on to improve the work environments. These areas will be discussed separately. The majority of the projects were identified as structure-focused issues using Donabedian‟s SPO framework (1982).The front line nurse leaders‟ addressed staffing needs, through retention and recruitment initiatives, communication, education and the needs of patients by examining structure or process to assist the staff were able to meet their professional standards. These results highlight the complexity of the health care system and nursing leadership. There is a need to examine how researchers and employers define the work of front line nurse leaders, especially around scope of control. 5.2 Scope of Control The L2 positions were intended to provide the front line nursing unit support. The results of this research found that front line nurse leaders were taking on projects that were beyond the front line nurse leaders‟ role. This study found that 61% of the projects were unit based and within the scope of front line nurse leaders’ identified responsibilities at the front line nursing leader or Level two positions. These projects identified common themes of  57 communication, education, care delivery evaluations, retention/recruitment and tool development. Front line nurse leaders identified that restructuring was a significant part of their work, and their projects used phrases such as “remodeling outpatient psychiatry using lean principles” and “ambulatory care redesign.” As restructuring is significant in health care, there needs to be ongoing education and support for front line nurse leaders so that they have the skills and abilities to work with staff to address these changes. Effective leaders need to be educated and supported in their professional growth (Pearson et al., 2007). The projects also highlighted the need for education and training of staff. Some examples of identified training needs were “building safety culture in the OR/ implementation of the surgical safety checklist,” “the educational role out of the fractured hip pathway,” “applying best practices in our inpatient oncology clinic” and “orientation through developing a clinically strong team.” Other projects identified the need for team building and communication, and project topics included “communication and continuity of care” and “building an effective team in home health care.” These projects support the idea that front line nurse leaders need the skills and abilities to motivate and assist nurses with addressing change, improving communications, and working in teams. Front line nursing leaders are governed by the standards of practice of the College of Registered Nurses; these standards impact patient care and it is a delicate path that nursing leaders navigate between meeting the standards of direct care and providing adequate administration. These standards provide nursing leaders with the requirement to use evidence-based care in making decisions (CRNABC, 2005). Front line nurse leaders are most effective when there is consistency between organizational commitment to change and patient care outcomes, so that the patient is not lost in the change (Hay, 2004; McKiel, 2002).  58 The skills that front line nurse leaders require to communicate effectively with a variety of stakeholders and facilitate changes that are in the best interests of the patients are vital to maintaining a good nursing environment. Research supports the need for nurse leaders to be able to develop staff self directedness rather than directing staff decision making at the unit level (Mackay & Risk, 2001).  The need for ongoing education and support is vital if front line nurse leaders are going to assist nurses at the unit level. Supporting front line nurse leaders to improve education and communication during restructuring will increase the quality of care provided. Other literature suggests providing front line nurse leaders with resources and workloads that help them achieve realistic results and better patient outcomes (Institute of Medicine, 2010). Further research on the scope of control of front line leaders‟ workloads is needed. Some nurses took on projects beyond the unit level. Almost 36 % of the projects identified a scope of control greater than unit level. These projects included such things as intra-departmental communication, amalgamation of different nursing units, development of hospital or program wide orientation programs, and development of online materials for more than one unit. These included developing, revamping or implementing programs or education or business cases. Some examples of these projects were “the standardization of palliative care education across Interior Health”, “acute rural nursing orientation and retention plan” and “establish a learning culture for Fraser Canyon Hospital.” There were a large number of projects that covered more than one unit or program. These projects show that front line nurse leaders need support and assistance in developing communication and resources between units or departments. The complexity of the health care system  can be  59 seen at the front line level from the projects that described the need to facilitate intra- disciplinary and intra-departmental communication. Very few projects were at the macro level, and there are concerns that front line nurse leaders should not be taking on projects with this breadth of scope. These projects highlighted the need for organizational support in evaluating and developing health authority-wide programs. Some of the projects included developing a business case for provincial flu coordinator positions, and developing clinical leadership pathways. There needs to be a review of the role of front line nurse leaders to identify whether these are appropriate projects for front line nurse leaders to pursue, or if these projects should be developed at a higher level in the organization. The reasons why some front line nursing leaders took on these broader project is unknown. These front line nurse leaders may have held positions beyond the level two positions; they may have taken on hospital, regional or provincial issues because of a lack of middle management positions; or, senior management may have identified these projects as issues that needed to be addressed, and determined these front line nurse leaders were capable of doing the work. Further investigation into how work is organized or assigned would help to better understand scope of control for nursing leadership. When the scope of projects becomes greater than the meso level there are concerns that the front line nurse leaders are no longer front line. The restructuring of the 1990s left many nursing units without support and leadership (Hay, 2004). The importance of supporting realistic roles for front line nurse leaders is critical to reducing burnout and retention of leaders and thus supporting the work environment (Spence Laschinger et al, 2007). The scope of control that front line nurse leaders have is critical for them to be  60 effective in their work (Patrick & Spence Laschinger, 2006). By examining the workload of leaders and their ability to support front line staff and improve nursing environments, increased efficiency and better system outcomes are possible.  Many of the projects that front line nurse leaders took on looked at system structure issues, such as increasing base line staffing, orientation tools or kits, changes to staffing composition, and evaluation of staffing. Over 32% of the front line nurse leader‟s projects covered more than just their unit or program, and others were involved in health authority wide projects. Some of these types of issues could be addressed on a larger basis throughout the health authorities, by either project teams or people in middle management positions. Many of the projects taken on by front line nurse leaders focused on structure versus process. When leaders take on projects, there needs to be an inclusion of context regarding restructuring as well as the impact of such changes. The context of restructuring is vital to understanding how patients and nursing will be affected. If the restructuring continues to be undertaken at its current pace and intensity, research is needed to examine both the benefits and concerns related to these changes. It is also clear that there is a vital need to involve all employee levels from senior leaders to front line staff in any health care organization‟s restructuring process (VanDeVelde-Coke & Richards, 2010). Research has shown that complex organizations affect nursing work environments during restructuring and reform. 5.3 Type of Projects (themes) 5.3.1 Retention and Recruitment  In examining front line leaders‟ work through the projects, the common themes of retention/recruitment, care delivery evaluation, communication, education and tool development became apparent. These themes highlight the important role of front line nurse leaders in the changing health care system. Eleven percent of the projects had a main theme  61 of recruitment and retention, and this theme was present in almost all cohorts. Many projects examined issues that would support nurses in their work environments through technology, communication and team building. Some identified direct plans for recruiting nurses, such as “coordinator could alleviate issues,” “enhancing care to include weekend coverage,” and “implementing a team leader.”  Other projects identified retention of nurses such as, “retention in the workplace,” “create a positive culture minimize staff nurse turnover, decrease overtime and sick time,” “increase staff involvement in the unit based council … to increase job satisfaction,” and “improve recruitment and retention of new graduate RN‟s through adequate support and mentorship.” Front line nurse leaders are seen as a resource for front line nurses and are expected to support the clinical standards in a unit. Nurses have identified that strong leadership is vital to retaining nurses. Also that front line nurse leaders have a role in supporting their clinical decision making (Brady Germain & Cummings, 2010). Retention of both staff nurses and front line nurse leaders is vital to the functioning of the health care system. Hay (2004) calls for the implementation of the Canadian Nursing Advisory Committee recommendations for the need of more first line managers. 5.3.2 Communication This study showed that front line nurse leaders and senior managers were aware of issues that affected nursing work environments, such as communication, and that potential solutions included increasing staff input and feedback towards implementing change. The communication theme was developed in over 17% of the projects. The leaders identified the need for communication to assist in all areas from providing care to team building to dealing with the issues of change in the workplace.  62 There needs to be trust to build relationships between staff and leaders (Simons & Peterson, 2000). These projects identified that front line nurse leaders perceive and want a respectful workplace that supports relationship building and communication as found in other studies (Ulrich et al. 2010; Meyer & Allen, 1991; Rankin, 2001). Therefore, nurse leaders must have the skills and knowledge to build relationships and provide appropriate communication at many levels within complex systems and be able to advocate for staff nurses (Parsons, Cornett, & Wilson, 2004). The need for front line nurse leaders to be involved in the decision making process is critical (Sherman & Pross, 2010).  Front line nurse leaders are empowered when they are directly involved in the decision making. This involved should start at the grass roots with staff nurses, who are empowered and enabled by front line nurse leaders, who in turn are empowered by those supervising them. Magnet hospitals and healthy work environments are known for participatory decision making that gives voices to nurses and nurse leaders at all levels within the organization. Cooke (2002) calls for the decentralization of decision making and sharing of information through transformational leadership. Thus, if nursing leaders embrace transformational leadership, there may be better uptake by staff and higher quality care for patients. The importance of decision making is vital to developing a supportive work environment. Front line nurse leaders need to be able to collaborate with people from other disciplines, other leaders, and organizational managers to effectively provide care for patients. Reports highlight the need for ongoing education and communication to meet the needs of the ever changing health care system (IOM, 2004; Laschinger et al. 2009). Several projects highlighted the need to build relationships and communication between disciplines  63 and departments. These projects highlighted that front line nurse leaders are utilizing information gained during participation in the British Columbia Administrative Nursing Leadership Institute (BCNLI) training on leadership, evidence-based practice and communication with staff. 5.3.3 Education The theme of education was present in most of the cohorts. Twenty projects had a main theme of education. These projects included the need for better education on nursing standards, the roles of nurses, and educating nurses about programs and pathways. For example, the use of education in developing “collaborative nursing” and “site specific orientation” was presented in several projects. There is significant crossover between education and communication and many projects used similar words and phrases, such as team building and collaboration. Evidence exists that health organizations need to invest in human resource planning including education and support for front line nurse leaders (O‟Brien et al., 2003; Parsons, Cornett, & Wilson, 2004; Macphee & Bouthiledtte, 2008).  If ongoing restructuring is successful in making the health care system more efficient then leaders must have the skills and abilities to implement and assist with the   changes. Front line nurses leaders must be knowledgeable about change management and have significant skills relating to communication, leading, team building and marketing. Research has shown that even though some meaningful leadership activities, such as communication, team building, and development of supportive work environments, are often unrecognized by staff members, (Cooke, 2002), these unseen skills improve the work environment and create more efficient workplaces. The front line nurse leaders indicated that the information they learned in the  64 BCNLI regarding using change theory to create better working environments and engaging staff through education, was utilized in the workplace (Macphee & Bouthiledtte, 2008). 5.3.4 Tool Development Twenty-two percent of the projects looked at tool development. The importance of providing resources and tools to assist leaders is critical to the functioning of the whole health care system. The use of technology was an important component of the nursing projects; several projects looked at using or developing online resources, establishing inventories online and orientation processes that were more accessible. The use of technology will continue to increase in health care and front line nurse leaders will need the skills and abilities to make use of this resource and support staff in its use to ensure that it is in the best interests of patient outcomes. Berwick (2003) recommends developing a strategy for using innovations in the health care system. Front line nurse leaders often deal with day to day issues and complex system problems that create frustration and time loss for staff. By understanding what issues front line nurse leaders are addressing, senior management may be better able to allocate tools and resources to manage the system appropriately. Tools such as equipment lists and resource lists can increase efficiency and reduce time loss, making nurses more productive. In addition, if front line nurse leaders are able to address these issues to make the health care system and workers more efficient, there will be a savings to the system (Gardner et al. 2007).  Also, being able to identify when front line nurse leaders have taken on issues or problems that are regional or hospital wide may lead to a greater understanding of ways to increase tool use in the whole health care system.  Thought must be given to more regional and provincial development of resources and tools, as issues are often similar between  65 facilities and regions. These tools could be developed at a higher level for use by many at the front line, thus reducing redundancy. 5.3.5 Care Delivery Evaluation This study identifies that nurses are focused on increasing efficiencies in the system and improving the work environments through evidence-based practice. A total of 38 projects (18%) developed the care delivery evaluation theme. The care delivery evaluation theme examined management or organizational processes that improve the work environment through evaluation, program change or redesign/remodeling. The projects in the care delivery evaluation theme were examining implementation or evaluation of work process or structure. These front line nurse leaders were utilizing the information and applying it to their practice and leadership roles from the BCNLI (MacPhee et al. 2010) Some examples of the care delivery evaluation meaning unit are “measuring and improving surgical wait times,” and “improving patient flow through surgical daycare.” The care delivery evaluation theme projects had structure, process and both structure and process codes. Research on magnet hospitals supports examination of both structure and process to improve nursing work environments (Kaplow & Reed, 2008). Crawford (2003) states that until all three aspects of Donabedian‟s framework structure, process and outcomes are in alignment there cannot be system reform. The costs related to managing the health care system and the impact on quality work environments are significant (Kitty, 2005). If opportunities for increase efficiency are identified by front line leaders, there is a need for organizational support to implement and assist with these changes.   As front line nurse leaders look to increase the efficiency of the system, they must strive to keep the best patient outcomes as their goal. Studies have shown that as lengths of hospital stay decrease, so does the acuity of patients and the amount of nursing services the  66 patient require (McKiel, 2002).  McKiel (2002) raises the concern that patient teaching and participation in care decisions has been significantly reduced, and nurses report that patients are not given full information or time to make informed decisions. Many of the projects looked at increasing patient flow or creating procedures for increasing efficiency; although these are valuable objectives, it is vital that the patient outcome is examined during the change and again at the final stage of the process. Front line nurse leaders must keep the patient needs at the forefront of any change that is driven by the organization (Curley, 2007). One way to support patient outcomes is to improve nursing work environments through front line leadership. Nurses value the support of front line nurse leaders who are also nurses (Cooke, 2002). Crawford (2003) calls all nurses and nurse leaders to commit to a shared vision to meet standards of practice and advocate for systems that support professional practice and quality outcomes for clients. When front line leaders are Registered Nurses there is an increase in support for clinical decision making, and improvement in the availability of information and resources that are relevant to patient care and quality patient outcomes; this is because nurse leaders who are RNs understand nursing practice (Surakka, 2006). Nursing leaders are critical to quality working environments, so by providing front line nurse leaders with realistic and supportive workloads there is an improvement in the work environment. However, beyond the unit level there is still a need for improvements that will positively affect nursing leaders, and this need was identified in the research. 5.4 Limitations The participation in this study was limited to the number of nurses funded to attend the British Columbia Nursing Leadership Institute over the three year period. These nurses were selected by their senior managers to attend the institute. Each cohort ranged between 13 and 29 participants with a total of 211 at the time of data extraction in May 2010.  67 The data was collected in May of 2010 and is a snapshot of the information from the projects at that time. The themes and information are updated throughout the year, as they are part of a larger study. The analysis process required refining and review from the chair of the committee so that more accurate information was obtained.  Six of the projects did not provide enough information to determine the scope of the project. Ninety-five projects had limited information as to background and overall goals and of them, and fifty projects were not coded using the SPO framework. One project developed two themes simultaneously. This limited the ability to clarify the information and gain a full understanding of the projects. For future studies it would be valuable to have clearer and more accurate information on the projects. At present there are 229 participants‟ projects on the website, and the number of front line nurse leaders has increased in the last three years to over 2600 full time positions (Dyke & Mateus, 2009). This increase in front line nurse leaders highlights that there has been a significant change to management‟s recognition of front line leaders' roles in supporting quality work environments. 5.5  Recommendations 5.5.1 Implications for Research Further research is recommended to examine the scope of control of front line nursing leaders, the type of projects they undertake and their ability to use transformational leadership during change and restructuring. To understand the scope of control of front line nursing leaders, there is a need to develop a common language with definitions. Researchers can share the latest information and research and build partnerships that increase organizational capacity and support during change. Using research techniques that are based on patient outcomes, an evaluation of restructuring can help focus organizations  68 and nurses to provide the overall quality of health care. It is also important to evaluate the effects of restructuring on the nurses' work environments to ensure that patients are not negatively affected.  Research can assist in evaluation of the change, thus making the organization more accountable to the patients, the public and the staff who work in the province‟s hospitals and care centres. If front line nurse leaders are to assist in cost reduction and increased management efficiency, there must be further research into the types of issues and projects that impact their work. This research should maintain a focus on patient outcomes. Fiscal restructuring is continuing, and front line nurses leaders need to be involved in decision making and participation in advocating for quality patient outcomes. 5.5.2 Implication for Nursing Some of the projects had a scope beyond the nursing unit. These projects covered multiple units and programs, and some were hospital-wide, health authority-wide or provincial. These types of projects heighten the concern for the ability of front line nurse leaders to have clarity in their role and job performance (Watson, 2000). Examination of the effects of downloading work from the senior management level to front-line nursing staff is vital to creating a better working environment and improving patient outcomes (Institute of Medicine, 2010). Further examination of the scope of the duties and roles of front line nurse leaders, including the types of issues and challenges they face, is critically needed. Developing a positive work environment within a nursing unit is critically important to the functioning of the nursing staff and the patient outcomes. Several projects identified issues that called for increased support for nursing environments, such as staff evaluations. Staff evaluations are seen by staff as being a way of confirming their role and value to an organization (Spence Laschinger et al., 2009). The more committed staff are to the  69 organization, the more likely they are to support changes in the organization (Baumann, et al., 2001). Team building and developing relationships is seen as vital in supporting clinical decision making and supporting front line staff in their roles (McGillis-Hill et al, 2006). The challenge facing nursing is the need to be included in primary discussions about system changes, because this clear perspective on patient outcomes can lead to better health policy decisions (Fradd, 2010). Involving both front line nurses and front line nurse leaders in policy making through organizations such as the British Columbia Nurses‟ Union is important when looking at issues such as scheduling and job descriptions. Policy makers play a vital role in changing health care, which can have a significant impact at the bedside. This study supports the need for nurses to continue to play a role as leaders in health care and health policy. 5.5.3 Implications for Organizations An examination of organizational structure needs to be undertaken to allow for identification of other potential issues that nurse leaders may want to take on. Front line nurses and nurse leaders will need a process for identifying issues and a way of communicating other projects worthy of senior management support. Researchers have found that staff perceptions of the work environment impact their willingness to accept change (Spence Laschinger et al. 2003). Involvement of front line nurse leaders is therefore critical to making positive changes that are cost effective and patient centered. Senior management and policy makers may be able to utilize the results of this study to inform methodology for the ongoing support and education of front line nurse leaders. The results may help provide for further support of educational opportunities such as the Nursing Leadership Institute that give opportunities for front line nurse leaders and senior leaders to identify and solve problems. Also, policy makers may examine the need for further research  70 in the role of front line leaders and of work processes on the work environment. Senior management may find that the results of this study give them the opportunity to support examination of structure or processes in the health care system that need evaluation or change. Pathways for ongoing education and leadership also need to be developed to ensure the long term success of health organizations and the continuation of positive patient outcomes. Working with researchers and educational institutes is valuable for organizations undergoing change. Also, organizations must examine their present capacity to provide education and training for front line nurse leaders. By having organizations work with universities to create educational opportunities like the British Columbia Nursing Leaders Institute, both parties gain significant benefits.  The loss of many front line nurse leaders in the 1990s created a void that devastated many working environments and reduced patient care quality. The acknowledgement of the problem and efforts by the provincial government to rectify this issue are ongoing.  Recently, the shortage of registered nurses created further issues for front line nurse leaders including increased overtime, staff shortages and replacement of nurses with lower skilled workers. In the near future there will be even more difficulties as over 5,000 registered nurses in BC become eligible to retire (Campbell et al, 2010). It is imperative that organizations support and assist front line nurse leaders to advocate for quality patient outcomes during restructuring. The heightened focus on providing safe quality care will assist nurse leaders in advocating for patients, but they must be participants in the discussion and not be pushed to the side.  71 Without an agreed to evaluation framework for change that is taking place in organizations and in the overall health care system, there cannot be proper evaluation of the outcomes. The constant need to restrict finances and contain costs will continue to drive change, but without a clear evaluation process many nursing leaders will not know if the change is appropriate. Front line nurse leaders are patient advocates and can use their knowledge to call for proper evaluation of changes to their workplace and the overall health care system. The Institute of Medicine (2010) found that evaluation of nursing processes such as having enough time to assist with feeding or bathing and caring for patients were better indicators of the quality of patient care than morbidity or mortality, as these processes tended to be overlooked when earlier intervention changed the course of patient care. The Institute of Medicine (2010) report calls for the need to have three simultaneous approaches to the regulation of nursing staff.  These are: (1) mandated hours of professional care, (2) improvement in workload or patient classification systems to determine acuity and staffing needs that are more elastic and empower staff to make changes to the flow of work, and (3) the need for ongoing support, education and collaboration of different professionals. This study supports the need for better evaluation of the projects that front line nurses leaders undertake. 5.6 Conclusion Ongoing examination of health care restructuring is necessary to ensure that patient outcomes are not being jeopardized when changes occur. By maintaining and supporting quality working environments, we know that better patient outcomes can be achieved. This research examined the projects of the participants in the British Columbia Nursing Leadership Institute and identified the need for further research on the scope and role of front line nurse leaders.  72 The role of the front line nurse leader may change over time, but their ultimate goal should be providing a safe, quality work environment for staff and the public. Registered nurses and nursing leaders must be advocates for quality patient care. Organizational demands can cause great dysfunction in nursing work environments when they prevent nurses from achieving quality patient outcomes. By using transformational leadership and supporting quality work environments front line nurse leaders will be more likely to assist in protecting patients. Front line nurse leaders‟ advocate for staff and staff must support their nursing leadership as these positions are vital to improving the working environment and patient outcomes. Trust can be built when front line nurse leaders‟ work from evidence-based practice that seeks to provide the best quality care for patients. This support for nursing leadership will assist in keeping nurse leaders at the organizational decision making tables so that the voice of a registered nurse is present to advocate for the best patient outcomes. This research project opened a window on the types of projects front line nurse leaders are dealing with in their current work. Further research is crucial to exploring the links to improving patient outcomes.  73 References  Adair, C., Simpson, E., Casebeer, A. & Birdsell, J.(2006). 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Journal of Nursing Management 11, 98-106.  85 Appendices  Appendix A   Comparison of Level of Scope of Control by Cohort   0 5 10 15 20 25 30 O ct -0 7 D ec -0 7 Fe b -0 8 A p r- 0 8 Ju n -0 8 A u g- 0 8 O ct -0 8 D ec -0 8 Fe b -0 9 A p r- 0 9 Ju n -0 9 A u g- 0 9 O ct -0 9 D ec -0 9 Fe b -1 0 0 not identified 1 is unit level 2 is program or more than one unit 3 is facility or region 4 is provincial totals  86 Appendix B  Project Themes Examples by Cohorts for March 2010 to March 2009 Types of projects March 2010 Nov 2009 Oct 2009 Mar 2009 Total number of Retention and Recruitment themes by cohort 4  1 6 Example of retention theme Enhancing interdisciplinary care to include weekend coverage  Create a positive culture minimize staff nurse turnover decrease overtime and sick time ....create a new rotation Improve recruitment and retention of new graduate RN‟s through adequate support and mentorship.... To establish and promote quality practice environments through workload management Total number of Tools and resources 6 2 4 3 Example of tool theme To produce a dvd that will provide visual and didactic information necessary for patient transport Electronic template for unit orientation implementation of surgical safety checklist Provide an electronic solution to identify and categorize “reason for visit” of Emergency department      87 Types of projects March 2010 Nov 2009 Oct 2009 Mar 2009 Communication 4 3 5 3 communication Identify stakeholders and meet to discuss fall prevention project, create communication wall for interprofessional team Improving communication channels within the Medicine Portfolio at RJH....create and maintain a useful venue for front line staff members to access valuable professional resources Transfer of care shift handover report increase and formalizing the interdepartmental communication Total number of Education 4 4 4 5 education Develop a business case to inform and educate all 7A/B staff on magnet hospital concept Plan to implement a skills and education day that would be mandatory for CHW to attend Developing leadership and communication skills in front line staff...empower team and create a culture of collaboration and develop an understanding of how the organization or system works     Provide training opportunities and support to RC A s  88 Types of projects March 2010 Nov 2009 Oct 2009 Mar 2009 Total number of Care delivery evaluation 3 3 6 4 Care delivery evaluation Evaluate family/resident/ interdisciplinary team satisfaction with annual care conference  To increase patient safety by developing a formal process of patient handover and rounding twice Evaluate IH respite care policy    89 Appendix C  Project Themes Examples by Cohorts for November 2008 to October 2007 Types of projects Nov 2008 Oct 2008 Mar 2008 Nov 2007 Oct 2007 Total number of Retention and Recruitment themes by cohort 2 1 1 3 5* Example of retention theme Scheduling changes to encourage retention of current experienced PHN …recruitment of PHN and review of other ways to provide services Creating a delegate role in a level 2 NICU To increase staff morale through team building and workload evaluation staff recruitment to fill needed LTCA positions and creation of staff schedule Increasing staff morale in having them do less night shifts, redistributing heavier workload Total number of Tools and resources 2 10 11 3 5* Example of tool theme develop a tool that will evaluate/assess the value, structure and content information of the parent group Develop a orientation manual Develop a toolkit of workload assessment tools that will provide quantitative and qualitative data to guide resource allocation and service delivery   To develop a tool that will ensure the care plan is done and time lines are followed Create tool kit for mentorship  90 Types of projects Nov 2008 Oct 2008 Mar 2008 Nov 2007 Oct 2007 Total number of Communication 7 2 3 4 4 communication Facilitate open communication around level of intervention between patient family and doctor/hospitalist regular updates to staff, emails, face to face, provide opportunity to ask questions Engage staff in role, improve communication between families, patients and nursing team; support and educate staff Collaborative communicati on between staffing and emergency department staff, decrease overtime in the unit with more consistent baseline coverage Improved communication between LTC and MH…. Monthly meetings, monthly leadership workshops, developing standards of practice Education 2    1 education To educate staff on side effects of medication and on proper assessment and monitoring of medication effects         To aide in facilitating change by empowering staff through education and support  91 Types of projects Nov 2008 Oct 2008 Mar 2008 Nov 2007 Oct 2007 Total number of Care delivery evaluation 3 8 3 5 4 Care delivery evaluation Transforming the report physical location and the report process discuss the review and devise a plan for meeting that challenge review chart audits at six months and one year  to identify process improvements To identify role in the regional / organizational structure and DRP by liasing with regional leads and stakeholders, develop a current DRP for Raven Song To convert residential beds to short stay beds, diverting geriatric patients from emergency to short stay units Develop clear guidelines of scope of practice with supporting documentation  92 Appendix D  Condensed Grids Showing Meaning Unit with Themes and Donabedian Category by Cohort Dates  March 2010 Cohort Meaning Unit  Condensed meaning unit  Theme  Donabedian Category Engagement of staff and residents to feel greater sense of empowerment, Engagement of staff and residents Communication  Structure To illustrate that an influenza coordinator could alleviate most of the issues, develop a business case Illustrate coordinator could alleviate issues develop a business case Recruitment  Structure Create a health passport aimed for oncology patients to assist in the accumulation and dissemination of their information Create a health passport Tool  Structure Develop a desk top version of where everything is and where it goes back to Develop a desk top version Tool  Structure To develop a tool that uses a variety of strategies to provide clinical supervision and compassion fatigue strategies to the mental health and addictions team Develop a tool  Tool  Structure Develop a business case to inform and educate all 7A/B staff on magnet hospital concept Develop a business case and educate all staff Education Structure To produce a dvd that will provide visual and didactic information necessary for patient transport Produce a dvd  Tool Structure  93 Meaning Unit  Condensed meaning unit  Theme  Donabedian Category Will track some real data to look to accommodate current number of scopes per day without impacting the completion time at the end of the day, decrease missed breaks, decrease amount of OT Track data of scopes per day Care delivery evaluation Structure Arranging professional development for all staff, researching and implementing team building Arranging professional development, implementing team building Education  Structure Reviewing all content on the team site Reviewing content Care delivery evaluation Structure Develop performance reviews for RNs and Care assistants Develop performance reviews Tool  Structure Develop/distribute/analyze survey for key stake holders on care conference Develop/distribute/analyze Tool & Care delivery evaluation Structure and process Identify stakeholders and meet to discuss fall prevention project, create communication wall for interprofessional team Meet to discuss, create communication wall Communication  Process To develop a clinical nurse leader pathway for direct care nurses Develop CNL pathway Education  Structure Education information to help promote staff wellness, quarterly demonstration boards, presentation, speakers engaging and challenging staff Education information, demonstration boards, presentation, speakers Communication Structure Develop and implement a training program and mentorship system for staff moving into the role of charge nurse Develop and implement training program Education  Structure  94 Meaning Unit  Condensed meaning unit  Theme  Donabedian Category Apply participative leadership by communicating with leaders, team and patients, distribute communication updates each month Communicating, distribute communication updates Communication  Process Does the LPN scope of practice meet the needs of the ambulatory care oncology patient   Unknown Retention in the workplace  Retention Retention Unknown Cardiac services access and flow initiatives   Unknown Implementing a team leader role for the Fraser health regional CD team Implementing a team leader Recruitment  Structure Increasing acute care bed capacity in assessment / triage room by decreasing NST visits Increasing capacity by decreasing NST visits  Unknown Regional nursing practice council for PHN‟s in the interior health   Unknown Unit council   Unknown Evaluate family/resident/ interdisciplinary team satisfaction with annual care conference Evaluate satisfaction of care conference Care delivery evaluation Structure Increase resident‟s satisfaction at meal time   Unknown Enhancing interdisciplinary care to include weekend coverage Enhancing care to include weekend coverage Recruitment  Structure     95 November 2009 Meaning Unit  Condensed meaning unit Theme  Donabedian Category To increase the percentage of surgical safety check list in the operating room in Fort St. John I have instructed all the nurses that scrub .... plan is to increase cooperation of all staff to complete the list Instructed all the nurses  Communication  Structure  Improving communication channels within the Medicine Portfolio at RJH....create and maintain a useful venue for front line staff members to access valuable professional resources Improve communication and access to resources Communication  Structure Plan to implement a skills and education day that would be mandatory for CHW to attend Education day mandatory Education Structure  Educate staff on collaborative nursing, involve staff in change to collaborative practice by organizing and developing working groups Educate staff on collaborative nursing Education  Structure Develop and deliver learning modules and in-house training sessions Develop and deliver modules Education Structure  96 Meaning Unit  Condensed meaning unit Theme  Donabedian Category Site specific orientation Orientation  Education Structure Create an environment of trust and respect as leadership is aligned with program management implement regional ACE care delivery model to multisite acute care of the elderly  units Create an environment and implement regional delivery model unknown Structure and process Demystifying the concept of mental health patients being dangerous   unknown Building and developing tools to facilitate the transfer of effective and concise patient information and treatment plans Building and developing tools Tools  structure Supporting leaders through organizational transitions Supporting   unknown Electronic template for unit orientation Electronic template t Tool structure Development of collaborative care team within a multidisciplinary team Development of collaborative care team  unknown Disaster preparedness   Unknown Developing communication and professionalism within the community dialysis units Communication Communication process Leukemia/BMT daycare work redesign project   unknown     97 October 2009 Cohort Meaning Unit  Condensed meaning unit  Theme  Donabedian Category Implement a successful adult addictions program Implement program Care delivery evaluation Structure and process To establish a care givers support group for patients admitted to the psychiatric inpatient unit Establish a care giver support group for patients Care delivery evaluation structure To increase patient safety by developing a formal process of patient handover and rounding twice Developing formal process for patient handover Care delivery evaluation Structure and process Separate ambulatory care and PARR from main units create a new rotation for the units Separate units  Care delivery evaluation Structure  Create a positive culture minimize staff nurse turnover decrease overtime and sick time ....create a new rotation Create a positive culture...create a  new rotation Retention structure The discharge planning tool I want to create will not be owned by any single discipline but rather the entire team Discharge planning tool  Tool  Structure Enhance the current data base to accurately track patients on the waiting list and have standard follow up  so they are transplant ready Enhance the current data base Tool structure  98 Meaning Unit  Condensed meaning unit Theme  Donabedian Category To redesign patient flow ...engaging staff in the process, discuss plans with head of department, discuss and email all staff the process, support staff by being in the clinic, have a feedback mechanism, ensure all changes are emailed and verbally communicated email and verbal communicate Communicatio n Structure and process Provide the nursing staff with education on the early signs and symptoms of agitation aggression Provide staff with education Education  Structure  Developing leadership and communication skills in front line staff...empower team and create a culture of collaboration and develop an understanding of how the organization or system works Develop skill ...and knowledge in staff Education Structure and process Create a self learning module for orientation to oncology Create self learning module Education  structure Create a teaching tool to assist staff in the process of staff injury reporting and resources available to them. Create teaching tool Education tool  Structure Identify all patient care equipment at Richmond hospital and storage area... and evaluate needs and excesses Identify equipment and evaluate Care delivery evaluation Structure Building safety culture in the OR/implementation of surgical safety checklist Implementation of safety checklist Tool structure  99 Meaning Unit  Condensed meaning unit  Theme  Donabedian Category Motivating staff to the next level of practice to provide excellence inpatient care  Motivating staff  Communication  Process Transfer of care shift handover report  Shift report  Communication  Structure and process Health care map an effective tool for reporting and communicating the patient journey from admission to discharge  Tool for reporting and communicating Tool  Structure Development of clinical decision unit   unknown To reduce the high numbers of acquired facility wounds by improving communication between RN‟s and RCA‟s  Improving communication Communication  process Team building and interteam building  Team building   unknown Neonatal follow up clinic   Unknown Domestic violence screening ER    Unknown  Interpersonal collaboration  Collaboration Communication  process Training and development for rural nursing facility  Training  Education  unknown Standardization of the neonatal resuscitation procedure, equipment and equipment maintenance in BC‟s women hospital Standardization of procedure, equipment and equipment maintenance Care delivery evaluation Structure       100 March 2009 Cohort Meaning Unit  Condensed meaning unit Theme  Donabedian Category Evaluate IH respite care policy Evaluate policy  Care delivery evaluation Structure Provide an electronic solution to identify and categorize “reason for visit” of Emergency department  Electronic solution to identify and categorize patients Tool  Structure Improve recruitment and retention of new graduate RN‟s through adequate support and mentorship.... To establish and promote quality practice environments through workload management  Support and mentorship Recruitment and retention Structure and process Develop business case ... to increase FTE positions Develop business case Recruitment Structure To increase staff involvement in the unit based council.... to increase job satisfaction through empowerment and involvement by staff nurses Increase job satisfaction Retention  Structure and process Empower staff....restore sense of ownership ... rebuild the energy an d bonds of support and teamwork... rekindle the passion for who we are as a unit Empower staff  retention Process  To create  a high performance surgical services environment at ARHCC by empowering front line leadership across the continuum of care in the surgical program ... increase and formalizing the interdepartmental communication Increase and formalize the interdepartmental communication Communication  structure  101 Meaning Unit  Condensed meaning unit  Theme  Donabedian Category To create “online” educational resource for self administration of iv therapy for clients in the community Create online education Education Structure Provide training opportunities and support to RC A s Provide training  Education Structure Develop effective orientation process to meet the learning needs of casual public health nurses  Develop orientation ...learning needs Education  Structure and process Find some creative engaging ways to heighten staff awareness of Health and safety  Heighten staff awareness of health and safety Education  Structure and process Create a document that will be concise and easy to access for new hires around the culture expectations on 3R  Create a document on culture awareness Education tool  Structure Impact on clinical leadership/supervision on clinicians job satisfaction  Impact on job satisfaction Retention  process Building Team on ACE Building team Communication  process Supporting unit based/program CNEs in implementing Best Practice initiatives  Supporting CNEs in implementing initiatives Unknown  process Remodeling outpatient psychiatry using lean principles  Remodeling   structure Building relationships and strengthening collaboration between VCH and CD program leads Building relationships collaboration Communication  process  102 Meaning Unit  Condensed meaning unit  Theme  Donabedian Category Recruitment and retention Recruitment and retention Recruitment and retention unknown Standardization and support of nurse  case manager practice in community Standardization and support Care delivery evaluation Structure and process Primary health care a shift in thinking culture   unknown To prevent and reduce potentially aggressive incidents in hospital by providing a safe therapeutic environment through teaching staff nonviolent crisis intervention strategies Teaching staff  Education process Proposal development for a coaching model for emergency department staff Proposal development  Care delivery evaluation Structure Staff ward resource manual Resource manual  Tool  Structure             103 November 2008 cohort  Meaning Unit  Condensed meaning unit Theme  Donabedian Category Organize a trial run of 5-7 min inter-departmental charge nurse huddles….staff will know the different work area, network and build relationships  Organize inter- departmental charge nurse huddles Communication  Structure and process  Facilitate open communication around level of intervention between patient family and doctor/hospitalist  Facilitate open communication Communication  Process Scheduling changes to encourage retention of current experienced PHN …recruitment of PHN and review of other ways to provide services  Scheduling changes  Retention  Structure Use diverse channels of communication to meet the needs of all team members…promote and foster respectful communication  Use diverse channels of communication… promote communication Communication  Process Coordinate and lead multidisciplinary planning committee that will develop a framework for the parent group…develop a tool that will evaluate/assess the value, structure and content information of the parent group  Develop a framework and tool Tool  Structure  104 Meaning Unit  Condensed meaning unit Theme  Donabedian Category Transforming the report physical location and the report process   Transforming the report location and process Care delivery evaluation Structure Develop a vision for our hip program with team that articulates our goals and aligns with the vision of VGH…increase staff awareness of best practices …introduce new pathway  Develop vision… increase awareness … introduce new pathway Communication  Structure Improve communication between RNs and RCAs …team work building to promote communication  Improve communication b/t RNs and RCAs Communication  Process To educate staff on side effects of medication and on proper assessment and monitoring of medication effects  To educate staff  Education  Structure Enhance the quality of intake and discharge from transitional beds … develop a project plan to communicate project goals …participate in presentation of outcomes  Develop project plan to communicate… participate in presentation Communication  Structure Facilitate team building days …develop working groups to address and facilitate needed changes in work process issues, foster development of health and safety committee, develop educational opportunities  Facilitate team building… develop educational opportunities Education  Structure and process  105 Meaning Unit  Condensed meaning unit Theme  Donabedian Category To maximize the efficiency and planning of patient flow with improved use of the bed mapping system. Identify accountability for BMS , Review BMS processes  Improved use of bed mapping system, identify accountability, review process Care delivery evaluation Structure Team building setting the foundation for trust and engagement   Unknown Development of strategic plan and business case for the expansion of province wide health care associated infections surveillance  Development of strategic plan and business case care delivery evaluation Structure Measuring and improving surgical wait times  Measuring and improving tool Structure Introduction of a nurse practitioner into residential care practice  intro of nurse practitioner recruitment Structure and process The art of patient care   Unknown Prioritization of home care nursing services    Unknown Communication between members Communication Communication  Unknown RAI-HC scores and client outcomes   unknown    106 October 2008 Cohort Meaning Unit  Condensed meaning unit Theme  Donabedian Category Reduce anxiety of staff and increase acceptance of the prenatal public health program ...regular updates to staff, emails, face to face, provide opportunity to ask questions  Provide regular updates, email, face to face Communication  Structure and process Developing policies and procedures and tracking forms, education regarding the program for clinicians and physicians  Developing policies and procedures and tracking forms Tools structure Develop a modular orientation package and a skills competency list to educate new staff ... develop regular review of skill competency for all staff  Develop modular orientation package tool Structure Develop a clinically strong nursing and YFC staff on the adolescent unit... develop preceptoring and mentoring skills, .. develop new orientation packages  Develop preceptoring and mentoring skills and new orientation package Education /tools  Structure  Develop a orientation manual  Develop orientation manual tool  Structure To revamp the whole 2 day general Hcc orientation program  Revamp orientation program Tool  Structure To develop a framework for orientation process that supports our teachers and our learners while providing our services to clients  Develop a framework for orientation Tool  Structure  107 Meaning Unit  Condensed meaning unit  Theme  Donabedian Category Review outcomes from chart audits and choose the area requiring improvement ... discuss the review and devise a plan for meeting that challenge review chart audits at six months and one year  to identify process improvements  Review chart audits.. identify process improvements Care delivery evaluation Structure Provide nursing staff with comprehensive orientation and retention plan, develop plan that groups information forms of communication and education ... written orientation and retention structure  Provide orientation and retention plan Tool  Structure Ensure communication between families ... provide families with information through a variety of channels  Ensure communication  Communication  Structure Develop system of communication to know when and where newly hired staff are working develop specific mentors for new RCA`s develop feedback tool  Develop system to know when and where newly hired staff are working Care delivery evaluation Structure Operation yellow bus   Unknown Provide front line care givers with evidence based clinical guidelines and tools  Provide guidelines and tools Care delivery evaluation Structure Develop Patient care coordinator  orientation manual Develop orientation manual Tool  Structure  108 Meaning Unit  Condensed meaning unit  Theme  Donabedian Category To find from current CNL‟s what makes the role fulfilling to them …putting out 5 question survey Find role fulfilling survey Care delivery evaluation Structure and process To work with the nurses to find out what they think they need to increase the amount of time they spend at the bedside Find out what they think  Care delivery evaluation Structure and process Creating a task group responsible for doing baseline assessment of our unit looking at patient acuity and the care that is being provided “collaborative practice” Group responsible for baseline assessment Care delivery evaluation Structure and process Building a culture of high performing renal team in the community Building a culture of team  process Revising interview tools  Revising tools Tools structure Collaborative practice for orthopedics at LGH   Unknown Creating a delegate role in a level 2 NICU Creating a delegate role  Recruitment  Structure Creating a framework for communication within a complex multisite leadership team Creating a framework for communication Tool  structure Implementation of a parking proposal for a FHA community site Implementation of proposal  Unknown  Introduction of medication reconciliation into acute mental health Introduction of medication reconciliation Care delivery evaluation Structure Changing the culture a move to collaborative practice   Unknown Policies and procedures   Unknown The standardization of palliative care education across IH Standardization of palliative care education Care delivery evaluation Structure    109 March 2008 Cohort Meaning Unit  Condensed meaning unit Theme  Donabedian Category Using change management... plan to engage team members in the process, to bring two units together into a larger unit, create new identity that team members feel proud to be part of, units will be moved together into a shared space  Change management engage team members, create new identity, move together Change management Structure and process To identify role in the regional / organizational structure and DRP by liasing with regional leads and stakeholders, develop a current DRP for Raven Song  Identify role, develop current DRP Care delivery evaluation structure Develop a toolkit of workload assessment tools that will provide quantitative and qualitative data to guide resource allocation and service delivery  Develop toolkit Tool  Structure To establish a core group of nurses ... to identify key issues of concern and for this group help develop tools to find solutions and work with other key stakeholders  Establish a core group, identify key issues, develop tools  Tools  Structure and process To compile and develop self learning packages and tools which measure competencies and skills  Compile and develop self learning packages and tools Tools  Structure Create a task group to revise the fractured hip clinical pathway Revise pathway Tool Structure and process  110 Meaning Unit  Condensed meaning unit Theme  Donabedian Category Empower PHN staff to precept BSN students and increase BSN interest in PHN Empower staff and increase interest Communication  Process  Implement electronic shift handover to better communication between both units Implement electronic handover Communication tool Structure To review and purchase new resources for perinatal teaching To purchase new resources for teaching Tools  Structure Creating a space within our department that can accommodate patients who do not require stretchers for their care  Creating a space for patient not on stretchers Care delivery evaluation Structure Emergency preparedness plan for 2010 Olympics research other institutions have done to get ready, liaise with other institutions and review manuals  Emergency preparedness plan for Olympics Tool  Structure and process Developing plans and/or tools that will measure what we need to measure for delivery of care\ Using nine step process to guide the project  Develop plans and tools  Tool  Structure Engage staff in role, improve communication between families, patients and nursing team; support and educate staff  Improve communication and support and educate staff Communication  Structure and process To increase staff morale through team building and workload evaluation  Team building and workload evaluation Retention  process Information sharing along the continuum of care Information sharing  Communication  Process  111 Meaning Unit  Condensed meaning unit Theme  Donabedian Category Rapid access clinic    Unknown Establish a learning culture for Fraser Canyon Hospital  Establish a learning culture  Unknown Rn orientation package upgrade Orientation package upgrade Tool Structure Admission/Re admission process review  Admission Process review Care delivery evaluation Structure Recruitment issues in LMH critical care/telemetry unit    Unknown Structure of admitted cardiac patients post operatively    Unknown Developing a new patient transfer form for emergency  Developing transfer form Tool Structure Development of an orientation pathway for nurse working in an ambulatory chemotherapy care unit  Development of orientation pathway Tool Structure Public health nursing clinical decision support tools  Decision support tools  Tools  Structure VCH print health education materials program online catalogue partnership with providence   Unknown      112 November 2007 Cohort Meaning Unit  Condensed meaning unit Theme  Donabedian Category Develop a plan to introduce a new palliative clinician role to front line staff within the hospice consult team model  Develop plan to introduce new role to staff Communication  Structure Primary goal is to improve communication with staff, keep them updated on changes in a timely manner and to improve morale on the wards  Improve communication Communication  Structure To supervise and assist 2 staff members to set up a supportive therapy group and pilot this model of early intervention  To supervise and assist staff Care delivery evaluation Structure and process To develop a tool that will ensure the care plan is done and time lines are followed  Develop a tool  Tool  Structure To identify the outcome measures of indicators for evaluation of NP practice ...using the logic model will identify measurable outcomes  Identify measurable outcomes Care delivery evaluation Structure Develop stable leadership for the team, develop an effective team with clear goals and direction, to empower the leadership so that the leaders empower the staff...  Develop leadership, develop team Recruitment and retention Structure  113 Meaning Unit  Condensed meaning unit Theme  Donabedian Category To create a best practice standard of care with VIHA for the fractured hip patient through the rollout of the collaborative fractured hip pathway  Create a best practice standard of care Care delivery evaluation Structure Expansion requiring equipment purchase with limited budget, staff recruitment to fill needed LTCA positions and creation of staff schedule  Equipment purchase, staff recruitment and staff schedule Recruitment  Structure Implement a plan to increase communication and continuity of care, gradual introduction to EDEN alternative philosophy  Plan to increase communication Communication  Structure Collaborative communication between staffing and emergency department staff, decrease overtime in the unit with more consistent baseline coverage  Collaborative communication, consistent baseline coverage Communication Structure To convert residential beds to short stay beds, diverting geriatric patients from emergency to short stay units  Convert residential beds to short stay beds Care delivery evaluation structure Creating effiencies within ACU    Unknown Performance evaluations on 3 rd  floor medical/6 th  floor medical    Performance evaluations Retention Structure  114 Meaning Unit  Condensed meaning unit  Theme  Donabedian Category Development of interdisciplinary communication tools in home and community care for improved outcome of care for palliative clients  Development of communication tools Tools  Structure Mentoring and integrating of international nurses in the Canadian workplace Mentoring   Unknown Critical care education program   Unknown  Supporting muti generational teams   Unknown Oncology nurse clinician feasibility project   Structure Multidisciplinary collaborative group    Unknown Integration of LPN into heritage woods residential care facility    Structure Developing and implementing new rotations for both BCNU and HEU staff  Developing new rotations  Care delivery evaluation Structure Telephone case management program   Unknown Improving shift to shift handover   Unknown Implementing the PHC collaborative practice model for nursing on a geriatric medicine unit    Unknown  Bringing child daycare patients to an inpatient pediatric floor    Unknown  Develop a performance appraisal tool for staff nurses Develop tool  Tool structure  115 October 2007 Cohort Meaning Unit  Condensed meaning unit Theme  Donabedian Category Decongesting the ER through cooperative team approach in bed utilization… meeting with stakeholders to identify problems, revamp contingency plan, encourage collaboration and communication  Meeting with stakeholders, revamp contingency plan, encouraging collaboration and communication communication  Structure and process Develop competency framework for clinical/system …. Roles, identify staff skills/competencies  Develop competency framework identify skills Retention  Structure Increasing staff morale in having them do less night shifts, redistributing heavier workload  Less night shifts redistributing heavier workload Retention  Structure Enhance the provision of interdisciplinary care by addressing the constraining environment and system structure so that they better support client centered interdisciplinary care  Addressing the constraining environment and system structure Care delivery evaluation Structure  Develop clear guidelines of scope of practice with supporting documentation  Develop clear guidelines of scope of practice Care delivery evaluation Structure At time of admission each patient is screened for potential falls and PT feedback ….utilizing the falls and injury program and reducing falls Utilizing the falls and injury program Care delivery evaluation Structure and process Create tool kit for mentorship  Create tool kit  Tool  Structure Implement innovative/self scheduling in Fir   Implement self scheduling Retention  Structure  116 Meaning Unit  Condensed meaning unit Theme  Donabedian Category To aide in facilitating change by empowering staff through education and support Facilitating change through education Education  Structure Develop questionnaire to identify at risk seniors regarding falls Develop questionnaire Tool Structure Develop an effective internship program for new graduates that offers support (mentorship), an increase in knowledge base, and self confidence Develop internship program for new grad Retention/educ ation Structure Development of new graduate and undergraduate nursing initiative…recruitment and education strategy… with a secondary goal of developing a mathematical model to use in determining recruitment numbers based on attrition rates Develop nursing recruitment and education strategy develop model Recruitment / tool Structure Improved communication between LTC and MH…. Monthly meetings, monthly leadership workshops, developing standards of practice Communication between LTC and MH Communicatio n Structure Update and revise ward orientation manual Revise manual Tool Structure Planning collaborative discharge transitions Collaborative  Communicatio n Process Clinical management guidelines for out of country kidney donors Guidelines  Tool Structure Developing collaborative assignments Rn/LPN Collaborative assignments Communicatio n Structure and process Development of a critical care education committee Development of committee Care delivery evaluation Structure Creating interest in perioperative nursing during baccalaureate nursing education   unknown 

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