Welcome to the personal website of:

Link to Study Website http://publish.uwo.ca/~hkl/national_leadership_study/index.htm

Co-Principal Investigators: Heather Laschinger & Carol Wong
Co-Investigators: Judith Ritchie, Danielle D'Amour, Leslie Vincent, Marjorie Armstrong Stassen, Sheri Price, Piotr Wilk, Sue Matthews, Marcy Saxe-Braithwaite,
Michael Kerr, Jerry White
Study Period: 2003-2007
Funding: Canadian Institute of Health Research

Description:
The overall goal of this study was to profile nursing leadership/management structures in current Canadian hospitals by examining the organizational and structural characteristics of nursing management roles in 66 teaching and community hospitals. This study also examined how nursing leadership roles in hospital settings across Canada have changed and the factors that are important in enabling nurse leaders to perform their roles.

Importance to Decision Makers:
This study provides information that can inform decision-making for the design of effective nursing leadership role configurations and organizational structures in hospitals and provide knowledge that can be incorporated into future preparation of nurse leaders. It also presents external policy makers and decision-makers with important empirical evidence to determine what organizational structures, supports and strategies may be instrumental in recruiting and retaining individuals in nursing leadership roles, as well as the essential factors that influence nursing leadership role articulation and effectiveness to achieve optimal staff and patient care outcomes.

Objective(s):
(1) To provide a descriptive analysis of nursing leadership/management structures at senior, middle, and unit levels of nursing management.
(2) To examine relationships among structural and process characteristics of nurse leader roles and work-related outcomes.
(3) To examine the effect of senior nurse leader role characteristics on middle and unit managers' work.

Approach:
This project has two components:
(1) a descriptive analysis of nursing leadership/management structures in Canada and, 
(2) a test of a model linking senior nurse leader characteristics to both senior nurse leader and lower level nurse manager outcomes.
Primary data will be collected at each site though a survey of senior nurse leaders, middle and unit managers and chief executive officers. A purposively selected subset of senior nurse leaders will also be interviewed.

Key Findings:
Overall, nurse leaders across the country were very experienced individuals with enormous responsibility for patient care within the health care system. A notable finding was the high average age (47-50 years) of nurse leaders at all levels, suggesting the immediate need for succession planning to ensure the future of nursing leadership. Despite very large spans of control, nurse leaders across the country were very positive about their work and their abilities to be effective in their roles. Nurse leaders roles at all levels have expanded to include responsibility for non-nursing personnel. Senior nurse leaders feel they are influential members of the Senior Management Team. Their decisional involvement is high in both traditional (distinct professional departments) and program management structures. Senior nurse leaders with operational/line authority are viewed by all levels of management as having higher senior management team status and greater decisional involvement in senior management decisions than those with staff authority. Perceived organizational support is an important factor at all levels of management. Transformational leadership styles and satisfactory supervisor communication have an impact on lower level managers’ satisfaction and patient care quality.

Nursing Leadership/Management Structures

Nursing Structures
The predominant senior nurse leader role configuration was line authority for clinical programs with a direct report to the Chief Executive Officer or senior Vice-president (84%). Senior nurse leaders in academic health centres were more likely to have responsibility for allied health than senior nurse leaders in community hospitals. A smaller number of senior nurse leaders (16%) had staff authority, reporting directly to the Chief Executive Officer or senior Vice-president. Professional practice leader-type roles were found in 68% of academic health centres and 25% of community hospitals. Traditional distinct nursing departments were rare (20%) and were found primarily in Quebec and in community hospitals.

Span of Control
Overall, managers reported very large spans of control with considerable variation in each management level. First-line managers averaged 71 direct reports with 20% reporting more than 100 reports. Middle managers averaged 12 direct reports with the majority having less than 20 reports. Senior nurse leaders also averaged 12 direct reports with a range from 2 to 47. More than 50% of the organizations were considering a decrease in managers’ span of control.

Senior Nurse Leader Role Functions: Changes, Facilitators and Barriers to Effectiveness
Senior nurse leaders identified 4 key role facilitators: part of senior executive structure, direct report to the Chief Executive Officer, inclusion of chief nursing officer in title; and operational/line authority. The main barriers to an effective role included financial and time constraints as well as increased organizational size and complexity. The most frequently reported changes during the past 3 years included: (a) organizational restructuring and/or merging of facilities, (b) additions to the portfolio, (c) addition of the chief nursing officer role and (d) changes in Chief Executive Officer incumbents.

Relationships among Structural and Process Characteristics and Work Outcomes

All levels of management reported moderate to high levels of:

• Transformational leadership behaviour used by senior nurse leader and themselves
• Job and role satisfaction, and job security
• Empowerment and organizational support
• Support for professional nursing practice
• Satisfaction with supervisor communication
• Influence in staff and policy decisions
• Patient care quality

Overall, nurse leaders rated these characteristics higher than those in leadership roles below them (senior nurse leaders were greater than middle managers who were greater than first-line managers). Nurse leaders at all levels agreed that access to resources was limited.

Senior Nurse Leaders Functions and Decision- Making Involvement and Influence
Senior nurse leaders reported being integral members of the senior management team with high levels of involvement and influence in senior management decisions and a title and salary comparable to other executives in their organization. Those who reported more influence in senior management decisions and higher quality of senior management decisions were more likely to feel empowered and valued by the organization. They also felt greater support for professional nursing practice with higher quality of care in their organization. Overall, senior nurse leaders felt that senior management decisions were compatible with existing constraints, timed to gain maximum benefit, based on an optimal amount of information, appropriately balanced between risks and rewards, with an understanding of the basis and implications of the decision by the senior team.

Impact of Organizational Structure on Outcomes

Traditional vs. Program Management
Senior nurse leaders and middle managers working within program management structures felt more support from the organization, secure in their job, and support for professional nursing practice structure. In comparison, nurse leaders working in organizations with traditional departmental structures were more empowered with greater influence in staff and policy decisions, and more confidence in the patient’s ability to manage care after discharge.

Line vs. Staff Authority
Compared to senior nurse leaders with staff authority, those with line authority felt they had a higher status (title and salary) within their organization, with not only more involvement in decisions but earlier involvement in the process as well. They were also more satisfied with their role and the quality of senior management team decisions. Middle managers and first line managers in these organizations also felt that their senior nurse leader was more involved in senior management team decisions with a higher status, and, in addition, provided more support for a professional practice environment. Senior nurse leaders with staff authority were more likely to use an enabling or ‘encouraging the heart’ leadership style. As a result, middle managers in these organizations felt more empowered and valued by the organization. Both middle managers and first line managers felt more involved in decisions than their counterparts in line authority organizations.

Effects of Senior Nurse Leader Work Conditions on Middle/First Line Managers Work life

Effects of Senior Nurse Leader Variables on Middle Manager and First-Line Manager Variables
Middle managers were more likely to report a higher quality of patient care, if their senior nurse leader was satisfied with her role. First line managers were more likely to report higher quality of patient care, if their senior nurse leader reported more influence on senior management team decisions and used transformational leadership behaviours.

Effects of Middle Manager Variables on First Line Managers
Higher middle manager perceptions of organizational support were significantly related to greater first-line manager empowerment, job and role satisfaction, organizational support, and ratings of patient care quality. Middle manager self-ratings of their leadership style were significantly related to higher first-line manager perceptions of a supportive professional practice environment in the organization and higher patient care quality. Greater middle manager communication satisfaction with their supervisor was significantly related to first-line manager job satisfaction.