Evaluation of an evidence based leadership education intervention for registered nurse leaders

Transcription

1 The University of Toledo The University of Toledo Digital Repository Master s and Doctoral Projects Evaluation of an evidence based leadership education intervention for registered nurse leaders Margaret McFadden The University of Toledo Follow this and additional works at: This Evidence-Based Practice Project is brought to you for free and open access by The University of Toledo Digital Repository. It has been accepted for inclusion in Master s and Doctoral Projects by an authorized administrator of The University of Toledo Digital Repository. For more information, please see the repository's About page.

2 Leadership Education 1 Running Head: Evaluation of an Evidence Based Intervention Evaluation of an Evidence Based Leadership Education Intervention for Registered Nurse Leaders Margaret McFadden, RN, MSN, NE-BC University of Toledo December 9, 2010

3 Leadership Education 2 Table of Contents Abstract... 3 Introduction... 4 Assessment of the Problem... 5 Link Between Intervention and Outcomes... 7 Evaluation Question... 7 Goals of the Project... 7 Review and Synthesis of Literature... 8 Theoretical Framework Design of the Intervention Stakeholders Implementation and Evaluation Methodology Sample Measurement Self Perceived Competency Demographic Characteristics Program Evaluation Procedures Informed Consent Process Administration of Survey Tools Statistical Analysis Results Demographic Characteristics Table 1: Frequency Distributions for Gender, Highest degree, and National Certification Table 2: Descriptive Statistics: Years as Nurse and Years in Leadership Self Perceived Competency Level Table 3: Statistically Significant Competencies Post Leadership Education Program Evaluation Discussion Limitations Integration and Maintenance of Change Implications for Practice Communication of Outcomes Conclusion Appendixes A. Appendix: Synthesis Table B. Appendix: Definitions of Levels and Quality of Ratings of Evidence C. Appendix: Topical Content of the ilead Program D. Appendix: AONE Nurse Executive Competency Tool E. Appendix: Subset of AONE Competencies in the Five Leadership Domains F. Appendix: ilead Demographic Inventory Tool G. Appendix: ilead Program Evaluation Tool References... 65

4 Leadership Education 3 Abstract Evidence based leadership practices are recommended to promote transformational leadership and a culture of patient safety. Healthcare environments have become exceedingly complex and require nursing leadership to excel. Nurses are sometimes promoted to leadership positions without being adequately prepared in leadership competencies. The purpose of this project was to implement and evaluate an evidence based leadership education program (ilead) utilizing Rosswurm and Larrabee s Evidence Based Practice model. The AONE Nurse Executive Competency model and Patricia Benner s Novice to Expert framework guided the project. Fourteen sources of evidence were reviewed and synthesized from the literature. Ten sources were non-experimental or qualitative, one a systematic review, and three were opinions or nonresearch reviews. The reviews supported leadership education to influence competency level of nurse leaders, but also identified the complexity of measuring leadership competency. The primary stakeholders, 29 registered nurses, were randomly assigned to a pre-assessment or postassessment group. They completed the AONE Nurse Executive Competencies Assessment Tool to evaluate the educational intervention to determine if there was a difference in self perceived competency level before and after attendance at the ilead program. Demographic variables and an evaluation of the program were also collected. A nonparametric, two independent sample test, was conducted utilizing SPSS (16.0) to determine a difference between the perceived competency levels before and after the evidence based intervention of education in five leadership domains. Descriptive statistics were used to describe demographics and program evaluations. Results indicated a statistically significant difference in the post education group in 23 of the 67 identified competencies (34%). All five domains demonstrated at least two statistically significant differences with the leadership (67%) and business skills (56%) domains showing the greatest percentage of change. One hundred percent of the participants were able to meet the program objectives and faculty members were rated from average to excellent. Nursing administrators can utilize the results of this evidence based educational intervention to improve the competency level of nurse leaders.

5 Leadership Education 4 Evaluation of an Evidence Based Leadership Education Intervention for Registered Nurse Leaders Introduction Evidence based leadership practices are recommended to promote transformational leadership and a culture of patient safety. Healthcare environments have become exceedingly complex and require nursing leadership to excel. Many nurses are promoted to leadership positions from clinical positions and are not adequately prepared in leadership competencies. Nursing faculties have prepared nurses for clinical patient care but have not adequately prepared them for leadership at the entry level into practice. Leadership roles are learned as clinical nurses gain experience in their practice. Currently, only a small percentage of nurses earn graduate degrees in leadership practice. However, in practice there are numerous nurse leadership positions, such as nurse manager, assistant nurse manager, charge nurse, and lead nurse. Nurses have sometimes been promoted to middle managers because they are good clinicians and willing to take on challenges offered by leadership positions. The nurse leader today plays a pivotal role in healthcare that requires a new set of competencies. This project was implemented based on Rosswurm and Larrabees Model of evidence based practice (EBP), which includes six steps of assessment, identification of the link between interventions and outcomes, synthesis of evidence, design of change, implementation and evaluation of a change, and integration and maintenance of the change (Melenyk & Fineout- Overholt, 2005). The project will be organized based on this EBP model.

6 Leadership Education 5 Assessment of the Problem In 2003 the Institute of Medicine (IOM) report Keeping Patients Safe: Transforming the Work Environment of Nurses, recommended that management practices of balancing efficiency and safety, creating trust, managing change, involving staff in shared decision making, and establishing a learning organization, are essential to create a safe work environment and reduce threats to patient safety. The American Organization of Nurse Executives (AONE) along with McManis & Monsalve Associates (2003) conducted a study of 61 nurse leaders related to the relationship between nurse shortages and the work environment. Leadership development and effectiveness were identified as critical factors in achieving work environment excellence. The American Association of Critical Care Nurses (AACN) in 2005 also identified six standards essential for establishing and sustaining healthy work environments. These standards included skilled communication, collaboration, effective decision making, appropriate staffing, recognition, and authentic leadership. Each standard is necessary to promote a healthy work environment to ensure patient safety. Porter O Grady and Malloch (2007) described the change of leadership and transition from the Industrial Age to a Technology Age. In the Industrial Age managerial skills such as planning, organizing, leading, implementing, controlling, and evaluating were important skills for leaders. Communication from leadership was limited but loyalty to the organization was rewarded. The transition to the Technology Age requires different leadership skills that will enhance a leader s ability to remove barriers and develop new structures, facilitate change, promote safety, implement new technologies, communicate in times of chaos, support others during change, promote successes, and celebrate progress as it is made (Porter-O Grady & Malloch, 2007, American Organization of Nurse Executives, 2005,). Much has been written in

7 Leadership Education 6 the literature related to success of nurse leaders based on the style of leadership, leadership behaviors, and competencies needed to meet the demands of healthcare (Firth-Cozens & Mowbray, 2001; Gallo, 2007; McGill&Yessis, 2008; Porter-O Grady, 2003 and Upenieks, 2002, 2003). Research demonstrated that leadership styles, behaviors, knowledge, attitude, and skills are all variables in creating a healthy work environment (Chiok Foong Loke, 2001; Corning, 2002; Herrin & Spears, 2007; Kleinman, 2004 and Tornabeni, 2001). Leadership development is a systematic process that immerses the new nurse manager in the role through formal managerial education and informal learning, multirater (360-degree) feedback, exposure to executives, action learning and mentoring programs (Gallo, 2007, p. 29). Leadership skills can be learned and successful leaders will be those who use the learned skills to achieve desired outcomes. The nursing leadership in a Midwest academic medical center conducted a strengths, weaknesses, opportunities, and threats (SWOT) analysis of nursing s readiness for Magnet status application. Magnet status is awarded to hospitals by the American Nurses Credentialing Center for meeting criteria which measures and strengthens the quality of nursing through excellent patient outcomes, high nurse job satisfaction, and low nurse turnover. One opportunity identified through the SWOT analysis was the lack of leadership education for its current nursing leaders and nurses who wanted to move into leadership positions. Leadership education was identified as a priority to promote a work environment that retained high quality nurses, enhanced patient safety, promoted nursing leadership satisfaction, and involved staff in clinical decision making. Nursing leadership identified the need to further develop their skills as leaders and improve their competency level.

8 Leadership Education 7 Link Between Intervention and Outcomes One strategy for promoting a healthy work environment for nurse leaders and a culture of patient safety is providing leadership education. Leadership education provides knowledge and skills to enhance the nurse leaders competency level. Measuring leadership skills is problematic due to the difficulty in demonstrating a cause and effect relationship between leadership education and competency level (Bradley, 2003). Self perceived competency is one outcome linked to the intervention of the evidence based educational program. Evaluation Question Evaluation of the educational intervention will seek to answer the question Do nurse leaders demonstrate a difference in self perceived competency level, as measured by the AONE competencies, after completion of a leadership education program? In addition, an evaluation of the ilead program provides an indication of the participant s achievement of the course objectives. Goals of the Project The goals of this project were to implement a leadership education program for current and aspiring nurse leaders, evaluate the self perceived competency level of nurse leaders, in five leadership domains, before and after attendance at a leadership education program, and evaluate the program objectives and faculty. The five leadership domains included communication and relationship building, professionalism, knowledge of the healthcare environment, leadership, and business skills and knowledge. The five leadership domains were based on AONE competencies for nurse executives.

9 Leadership Education 8 Review and Synthesis of the Literature A critique of the evidence based literature was conducted related to the effects of leadership education. Many variables affect leadership performance. The scope of this literature review has been limited to studies related to measuring the effects of leadership education on behaviors, leadership style, competency, skill level, and application of skills for nurse leaders and healthcare providers. Appendix A provides a synthesis table summarizing the findings of the literature review, type of study, strength of the evidence, and quality rating. Appendix B provides the definitions of the level and quality of the ratings of evidence (Melenyk & Fineout- Overholt,2005; Newhouse, Dearholt, Poe, Ouch & White, 2007). In a systematic review related to factors contributing to nursing leadership, Cummings, et al., (2008) reviewed 24 studies. Nine of the 24 studies were related to the effectiveness of educational interventions in developing leadership behaviors in nursing. All nine studies used some type of pre/post measurement of leadership skills and competencies. All of the studies reported an increase in skills and competencies when rated by self or by others. Two of the three studies reported long term effects 3 months following education and one demonstrated positive results at 6 and 12 months. The tools used to measure leadership included the Leadership Practices Inventory, Multifactor Leadership Questionnaire, Leader Behaviour Descriptive Questionnaire, and the Leadership Effectiveness and Adaptability Description, and tools developed by the researchers. The studies did not report the validity of the tools. In addition, because many different tools were utilized, they could be measuring different components of leadership. The findings of the review suggest that leadership qualities can be developed through specific and dedicated educational activities, but weak study designs may limit identification of specific factors that increase effectiveness of nurse leaders.

10 Leadership Education 9 Duffield (2005) described the development of a master class for 17 nursing unit managers in leadership education. The program was evaluated, six months after completion to give participants time for reflection on their learning. Utilizing a 26 item university evaluation tool, the items were rated on a 5-point Likert scale, with 1 being strongly disagree and 5 being strongly agree. All respondents (N=14) indicated that the program had a positive impact on allowing participants to express opinions, stretching their minds, encouraging discussion of viewpoints, and learning from each other. The evaluations while positive, do not describe a correlation between the content learned and application to leadership style and practices. Johnson and D Argenio (1991) conducted a non-experimental study, based on Situational Leadership theory, to measure the effectiveness of a management training program on the leadership behavior of a group of 11 nurse mangers. The Leadership Effectiveness and Adaptability Description (LEAD) instrument was completed by the nurse manager prior to 68 hours of management education, 6 months following, and 12 months after the education was completed. In addition, the nurse manager s staff completed the same instrument. Mean scores demonstrated that pre-training nurse managers perceived two dominant leadership styles. These included high task/high relationship (5.7) and low task/high relationship (4.7). Mean scores from the staff pre-training included the same two, but also included low task/low relationship which was statistically significantly different than the nurse managers( p<.05). At six months posttraining, the nurse managers mean frequencies remained the same and the staff s mean scores did not reflect low task/low relationship style. There were no changes in the mean scores for nurse managers or staff at 12 months. These results indicated short term changes in leadership behaviors but the results were not sustained at 12 months. Wolf (1996) utilized the LEAD instrument with 144 nurses, pre and post attendance at a four day leadership training. Fifty

11 Leadership Education 10 percent of the participants (n=72) identified the primary leadership style pre-training as high task/high relationship. Fifty three percent (n=76) identified the primary leadership style post training as low task/high relationship. Changes in leadership style adaptability were measured utilizing t-tests for paired samples. The data revealed a significant increase in leadership adaptability following the four day training (t=4.67, df=143, p.0001). The mean scores for adaptability demonstrated an increase of a moderate degree of adaptability. There was a low correlation (r=0.29) of pre and post test scores indicating that the pre-test was not predictive of the post-test. The findings demonstrated a significant change in participants perceived leadership style, but did not look at long term effects of the program. The comparisons were informative for further refining the program. These results demonstrate that change in leadership behaviors are possible following educational programs, however, many variables contribute to making the transition from classroom to the practice setting. Santiano and Daffurn (2003) evaluated the perceived level of registered nurses competence level following completion of a specialist graduate certificate. Questionnaires, developed by the authors, were sent to participants who graduated less than 2 years from the course and graduates greater than 2 years from completion of the course. The purpose was to ascertain the extent to which the educational objectives had been achieved. Thirty nine graduates responded for a 69% response rate. Findings indicated that graduates perceived the course enhanced their knowledge and skills in the performance of defined competencies. Recognizing own abilities and level of competence was rated the highest while engagement in research activities was rated the lowest. Graduates were able to apply what they had learned in the training to their defined work areas. This study supports leadership training to improve competency level of managers.

12 Leadership Education 11 The use of a 360 degree appraisal system has been utilized as a tool to identify leadership strengths and developmental needs, assess competency level, and provide feedback to leaders. (Bradley, Maddox & Spears, 2008; Flowers, Sweeney & Whitefield, 2004). The tool provided a baseline assessment of the individual s leadership competency level and can be used to develop a plan to capitalize on strengths and improve in areas of weakness. The use of preceptors, mentoring, and orientation programs has also demonstrated success for new nurse leaders. Conley, Branowicki and Hanley (2007) described the process of conducting a needs assessment to determine necessary competencies to be included in a nurse manager orientation program. The new program resulted in favorable comments because the new managers were aware of the skills and expectations associated with their role. The sample size however, was small because there were only five new nurse managers in two years. Robbins, Bradley and Spicer (2001) conducted a qualitative study to develop a 52 item competency assessment tool based on technical skills, industry knowledge, analytic and conceptual reasoning, and interpersonal and emotional intelligence. The development of the tool was the first step toward linking education with practice. The authors suggested the tool be used by students for career planning, managers for evaluation of developmental objectives, and academic leaders to match the educational programs objectives with the needs of the practice setting. The need for ongoing mentoring and continuous self improvement supports the need for these types of tools following completion of an educational program. Incorporating new knowledge and skills into daily practice required mentoring, evaluation and ongoing assessment processes. Public health personnel became very interested in leadership development in the 1990s after the Institute of Medicine s report on the Future of Public Health was released. The Centers for Disease Prevention (CDC) and the University of California Public Health Leadership

13 Leadership Education 12 Institute conducted a retrospective study to determine if there was an improvement in participant s skills and effectiveness as leaders following education at the Public Health Leadership Institute (Woltring, Constantine & Schwarte, 2003). A valid survey instrument was sent to alumni of the program by mail. Two hundred and ninety seven participants returned the survey for a 67% response rate. The findings indicated that the leadership education had a positive impact on leadership effectiveness at the personal, organizational, and community level. At the personal level, 82% reported an expanded view of their role as a leader, 77% reported using new approaches to meeting challenges, and 34% reported gaining balance between personal and professional commitments. At an organizational level, 69% reported increased skills in assessing need for change, 67% in accomplishing the organization s core functions, 57% created functional teams within the organization. On a community level, 68% reported developing coalitions and collaborative working relationships with community organizations. Chi-square analysis demonstrated that state government, followed by local government employees, had the highest percentage of skill level improvement. Saleh, Williams and Balougan (2004) also demonstrated improved skill levels in 15 competencies derived from the ten essential public health services, following leadership education. The greatest improvements were in the ability to cope and lead changes (mean score improved from 3.0 to 4.0 p<.001), and the use of media to inform and educate and empower people about health issues (mean score improved from 2.7 to 3.7 p <.001). Leadership education was positively supported through these studies. Bradley (2003) discussed the difficulty in demonstrating the association between individual competency attainment and subsequent job performance. She suggests that many factors influence performance and that it is difficult to define competency based on the use of

14 Leadership Education 13 different terminology. In order to establish that competencies are correlated with job performance researchers need valid and reliable measures of performance and research that adjusts for confounding factors. Competency attainment can be influenced by personal attributes of the student, organizational variables such as supervisor s experience or culture of the organization, and patient outcomes. The Yale Health Management Program provides competency based education in the technical, human, and conceptual domains. Bradley suggested that in the absence of clear evidence, self assessment of perceived growth in a skill set, preceptor assessment, feedback one to two years after education, and ongoing communication to the learner about changing skills that are needed, would provide a defensible argument for the need for leadership education. Leadership is influenced by many factors. Synthesis of the literature demonstrated changes in perceived leadership in eight of the fourteen sources reviewed. Two sources demonstrated that group learning provided a supportive environment that allowed for networking and teamwork. Four of the sources described tools to assess development of leaders but did not show correlation to competency level. The literature demonstrates the complexity of measuring learning outcomes as it relates to leadership effectiveness. Nurse leaders are challenged to develop skills and competencies that will prepare them to meet the complex healthcare environment. Assessing self perception of competency level provides one measure of the link between education and performance. Theoretical Framework Patricia Benner s theory of novice to expert provided the framework for this evidence based project (Benner, 1984). This framework has been widely used to explain clinical nurses skill acquisition as they move through five levels of proficiency. Since nurses have little

15 Leadership Education 14 education in leadership skills, the same concepts can be applied to nurses new to a leadership position. The five levels of proficiency include novice, advanced beginner, competent, proficient, and expert. The novice nurse leader has little background in leadership skills. They may have been an expert clinical nurse but different competencies are required in the leadership role. The advanced beginner may be exposed to more leadership experiences but still needs guidance and mentoring. The competent leader may have been in the nurse manager role for a number of years and haved gained management skills and knowledge. Application of management/leadership skills in complex situations may be limited at this level. The proficient leader is able to examine the entire work environment and determine where priorities should be focused. The proficient leader evaluates evidence and research and uses experience to guide administrative practices. The expert nurse leader demonstrates extensive leadership background and experiences to guide practice. Nurses enter the leadership role with limited knowledge and experience. Leadership education allows nurses to gain additional knowledge and practice new skills to enhance their competency level as they move from novice to expert. Design of the Intervention A team, led by the project coordinator, with representatives from nursing administration, the business school, the University s Center for Global Development, and continuing nursing education comprised the planning team for the educational program. A leadership education program (ilead) was created based on an identified organizational need for nurse leadership education. The ilead program was designed based on the AONE Nurse Executive Competency Model. The model identifies five leadership domains with specific competencies in each domain essential for effective leadership. Content for the leadership education program (Appendix C) was developed based on identified competencies in the AONE model. Effectiveness of the

16 Leadership Education 15 evidence based leadership education intervention was evaluated based on the difference in self perceived competency level of the nurse leaders before and after completion of the program and participant evaluation of the program objectives and faculty. Stakeholders The stakeholders identified for the leadership education include the registered nurse participants, hospital and nursing administration, the staff who will be provided leadership by the participants, and ultimately the patients. Participants benefit from new knowledge and skills gained in their leadership roles while administrators benefit by the increased knowledge and skills of their nurse leaders. In addition, nurse leaders may view the support from administrators, for leadership education, as a positive benefit. Application of the knowledge and skills to the work environment promotes healthy and safe care for patients. Implementation and Evaluation The program was offered twice during this project period. The content was delivered to 29 participants over 14 sessions, each two to four hours in length, by faculty from nursing administration, nursing informatics, business school, risk management, hospital finance, and the medical director of quality and safety. The educational sessions provided new information, video examples of leadership styles, case studies, and individual and group exercises to reinforce concepts and skills. An example of individual tools used during the program to assess personality and leadership behaviors were the Meyers Briggs and Thomas-Kilmann Conflict Mode Instruments. An assumption was made that nurse leaders will utilize the knowledge gained by applying the knowledge to their practice setting. Expert application of the knowledge and skills requires a commitment on the part of the nurse leader to recognize his/her own limitations and take steps to enhance his/her professional development. An additional assumption is that nurse

17 Leadership Education 16 leaders will be honest in completing the self assessment. Financial resources needed for the program were limited. The Executive Center for Global Development provided a small stipend to the University Faculty through a grant received for promoting professional development. The rooms for the sessions were free of charge and coffee was provided to the participants at the hospital s expense. Participants attended on work, paid time. Methodology A quasi-experimental study with separate group sample pre test/post test design was used to determine the self perceived competency level of nurse leaders before and after attendance at the ilead program. The advantage of this design is the elimination of pre-test/post-test sensitization and reduction of threats to internal validity. The dependent variable was the self perceived competency level of nurse participants. The independent variables were communication and relationship building, knowledge of the healthcare environment, leadership, professionalism, and business skills. The confidential data collected from this evidence based project was without identifiers. All data were reported in aggregate form and not individual data was shared to maintain confidentiality and protect anonymity. All completed assessment tools and consent forms were kept in a locked file cabinet and will be destroyed after six years. None of the participants were supervised by the project coordinator Sample The sample was comprised of registered nurses (N=29) in leadership positions or aspiring nurse leaders in the acute care and ambulatory care clinics of a Midwest academic healthcare center. These job categories might include Nursing Directors, Assistant Nursing Directors, Clinic Managers, Lead Nurses, Administrative Coordinators, and Nurse Educators. Participants

18 Leadership Education 17 were required to attend at least ten of the fourteen sessions and could not miss more than three critical sessions. The critical sessions included leading and developing yourself, leading through ethical decision making, leading with power and influence, leading change and organizational improvement, and creating a vision through service quality. All participants met the inclusion criteria. Measurement Self Perceived Competency. The AONE Nurse Executive Competency Assessment Tool (Appendix D) was used to collect data on participants self perceived competency level. The competencies were self assessed and rated on a scale from 1-5 with 1 being novice and 5 being expert, in the five leadership domains. Permission for use of the tool was granted by AONE. The AONE Nurse Executive Competencies Assessment Tool was designed as a self assessment tool that nurse leaders could use to rate themselves and then develop a plan for personal improvement. The competencies could also be used to plan personal careers or guide job descriptions and curriculum development. The tool has not been reported as a measurement tool. However, based on the breadth of the competencies identified, the tool provides content and face validity. Even though modification of the assessment tool was discussed with the Director of Professional Practice at AONE (Meadows, M.T., personal communication August 5, 2009), permission was not obtained to modify the tool and the tool was required to be used in its entirety. All of the competencies identified in the AONE tool are not addressed in the leadership education program. Therefore, to more specifically examine items germane to this project, a subset of the competencies are identified in Appendix E. Demographic Characteristics.

19 Leadership Education 18 Number of years as a nurse, number of years in a leadership position, highest degree earned, national certification obtained, and gender were collected using a self developed questionnaire (Appendix F). This information was used to provide descriptive statistics of the sample group. Program Evaluation. Each participant completed an evaluation of the program including meeting the objectives and rating of the faculty (Appendix G). Space was provided for any additional comments. Procedures Informed Consent Process. Approval was obtained from the Institutional Review Board (IRB) prior to the start of the project. The project coordinator met with each participant to explain the project, answer questions, and obtain written consent, utilizing the approved IRB consent form. Nurses consenting to participation were included in the project. No participants refused to participate in the project. Consenting participants were randomly assigned to either the pre-education or posteducation groups. Administration of the Survey Tools. Participants assigned to the pre-education group were provided a copy of the AONE Nurse Executive Competency Tool two weeks prior to the first class. An envelope was provided to each participant with instructions to return the completed tool to the project coordinator prior to the first ilead class. Participants assigned to the post-education group completed the tool following the last ilead class. Names were not required. Completion of the tool took

20 Leadership Education 19 approximately 30 minutes. Participants in both groups were asked to complete the ilead Demographic Inventory Tool and the program evaluation. Statistical Analysis Data obtained from the assessment tools were analyzed using the Statistical Package for the Social Sciences, 16.0 (SPSSCorp, Chicago, IL) computer program. A nonparametric, two independent sample test, (Mann Whitney U) was conducted to determine a difference between the perceived competency levels pre and post education in the 5 leadership domains. The Mann- Whitney U compares two independent samples. This test is analogous to the independent t test but is used when the dependent variable (self perceived competency level) yields an ordinal level of measurement (Norman & Streiner, 2008). In this project the Likert scale resulted in ordinal data. There was no evidence available that indicated the Likert scale had been validated as an interval level measurement. To further explain, one could not be certain that the interval between Novice and Advanced Beginner was the same as between Proficient and Expert, thus assigning numbers to categories does not automatically make them interval level data. (Norman & Streiner, 2008). It was unclear whether the educational sessions would in fact influence the participants perception of competence, therefore a two-tailed test of significance was chosen. If the educational sessions made no difference, there would be no difference between the two independent groups. In a research study this would be the equivalent of a null hypothesis. Based upon the laws of proof, if one can falsify a statement, in this case no difference between the group that completed the AONE competency assessment tool before the course and the group that completed it after the course, then one has to accept the opposite: that the sessions did result in a statistically significant change. An alpha level of.05 was used for all statistical tests. Descriptive statistics were used to describe nominal data collected on the ilead Demographics

21 Leadership Education 20 Inventory Tool. The mean, median, standard deviation, minimum, and maximum values were calculated for number of years as a nurse and number of years in a leadership position. Frequency distributions were calculated for highest degree attained, national certification, and gender. A summary of the program evaluations was conducted to determine if the objectives of the program were met, the rating of the faculty, and any additional comments from the participants. Results Demographic Characteristics. Table 1 described the frequency distribution data related to the participants in both groups. The groups consistent of 89.7% female (n=26) and 10.3 % male (n=3). The highest degree attained consisted of 44.8% BSN (n=13), 27.6% Associate degree (n=8), 17.2% MSN (n=5), 6.0% other Master s degrees (n=2), and 3.4% Diploma (n=1). Most of the participants did not have national certifications. Only 20.7% (n=6) answered Yes to having a certification. Table 1 Frequency Distribution for Gender, Highest Degree Attained, and National Certification Gender Variable Frequency N=29 Percent Male Female Highest Degree Attained Frequency Percent Diploma Associate Degree BSN

22 Leadership Education 21 Table 1 Frequency Distribution for Gender, Highest Degree Attained, and National Certification Frequency Variable N=29 Percent MSN Master s Degree other National Certification Frequency * Percent Yes No *Only those who responded are included in the analysis Table 2 described the data related to years as a nurse and years in a leadership position. The number of years as a nurse ranged from 4 to 33 years, with a mean of years (SD=8.35). The number of years in a leadership position ranged from 1.5 to 24 years with a mean of 6.04 years (SD=5.52). Table 2 Descriptive Statistics Related to Years as a Nurse and Years in Leadership Position Variable Mean Median Std. Dev. Min. Max. Years as a Nurse Years in Leadership Position Self Perceived Competency Level. The outcome measurement of the educational intervention was the self perceived competency level of participants in the evidence based project. Table 3 provides the leadership domains where a statistically significant difference (p=.05) in the self perceived competency level of the nurse leaders is found following completion of the leadership education program. A

23 Leadership Education 22 Mann-Whitney U was conducted for each competency in each of the five leadership domains of communication and relationship building, knowledge of the healthcare environment, leadership, professionalism, and business skills and knowledge. In the communication and relationship building domain a statistically significant difference was noted in the post group for three of the 16 competencies (18.75%). These included the ability to assert views in a non-threatening, non judgmental way (p=.034), engage staff and others in decision making (p=.045), and promote decisions that are patient centered (p=.014). No statistically significant differences were noted in the other 13 competencies. In the knowledge of healthcare domain five of the 22 competencies (22.72%) demonstrated a statistically significant difference. The competencies included ability to articulate various delivery systems and patient care models and the advantages and disadvantages of each (p=.003), serve as a change agent when patient care/work flow is redesigned (p=.007), understand and articulate individual organization s payer mix, case mix index and benchmark database (p=.021), support the development and implementation of an organization-wide patient safety program (p=.004), and design continuum of care options for managing patient throughput (long term care units; urgent care centers; admission/discharge units, etc.) (p=.030). In the leadership domain eight of the 12 competencies (66.67%) demonstrated a statistically significant difference in the post group. The competencies included address issues, beliefs or viewpoints that should be given serious consideration (p=.017), recognize one s own method of decisionmaking and the role of beliefs, values and inferences (p=.001), serve as a professional role model and mentor to future nurse leaders (p=.019), develop a succession plan for one s own position (p=.009), utilize change theory to plan for the implementation of organizational changes (p=.002), serve as a change agent, assisting others in understanding the importance, necessity, impact and process of change (p=.002), recognize one s own reaction to change and strive to

24 Leadership Education 23 remain open to new ideas and approaches (p=.007), and adapt leadership style to situational needs (p=.004). No statistically significant changes were noted in the remaining four competencies in the leadership domain. Two of the eight competencies (25%) in the professionalism domain demonstrated a statistically significant difference. The competencies included ability to articulate the application of ethical principles to operations (p=.021) and ensure that nurses are actively involved in decisions that affect their practice (p=.047). No statistically significant difference was noted in the remaining six competencies. In the fifth domain of business skills and knowledge a statistically significant difference was noted in the post education group in five of the nine competencies (55.55%). These competencies included the ability to create opportunities for employees to be involved in decision-making (p=.022), identify clinical and leadership skills necessary for performing job related tasks (p=.006), utilize hospital database management, decision support, and expert system s programs to access information and analyze data from disparate sources for use in planning for patient care processes and systems (p=.039), participate in system change processes and utility analysis (p=.017), and participate in evaluation of information systems in practice settings (p=.003). No statistically significant differences were noted in the remaining four competencies in the business skills and knowledge domain. Table 3 Statistically Significant Competencies Post Leadership Education Competency Communication and Relationship Building Assert views in non-threatening, non-judgmental ways Engage staff and others in decision-making Promote decisions that are patient centered Mann- Whitney U Z value P value

25 Leadership Education 24 Table 3 Statistically Significant Competencies Post Leadership Education Competency Knowledge of Health Care Articulate various delivery systems and patient care models and the advantages/disadvantages of each Serve as a change agent when patient care work/workflow is redesigned Understand and articulate individual organization s payer mix, CMI and benchmark database Support the development and implementation of an organization-wide patient safety program Design continuum of care options for managing patient throughput (long term care units; urgent care centers; admission/discharge units, etc.) Leadership Address issues, beliefs or viewpoints that should be given serious consideration Recognize one s own method of decision-making and the role of beliefs, values and inferences Serve as a professional role model and mentor to future nurse leaders Develop a succession plan for one s own position Utilize change theory to plan for the implementation of organizational changes Serve as a change agent, assisting others in understanding the importance, necessity, impact and process of change Recognize one s own reaction to change and strive to remain open to new ideas and approaches Adapt leadership style to situational needs Professionalism Articulate the application of ethical principles to operations Ensure that nurses are actively involved in decisions that affect their practice Business Skills and Knowledge Create opportunities for employees to be involved in decision-making Identify clinical and leadership skills necessary for performing job related tasks Utilize hospital database management, decision support, and expert system s programs to access information and analyze data from disparate sources for use in planning for patient care processes and systems Participate in system change processes and utility analysis Participate in evaluation of information systems in Mann- Whitney U Z value P value

26 Leadership Education 25 Table 3 Statistically Significant Competencies Post Leadership Education Competency Mann- Whitney U Z value P value practice settings Statistical significance: alpha =.05 Program Evaluation. Process and outcome measures were evaluated by the overall program evaluation tool. Forty program objectives were identified related to the course content. All participants indicated that they were able to meet the objectives of the program. Ten faculty members participated in the program. Teaching effectiveness of faculty was rated as poor, average, above average, and excellent. Eight faculty members were rated at average, above average, or excellent. Two faculty members received ratings of poor by three participants. Additional comments included very nice program, helpful, informative and relevant, great program, I learned a lot, and I can take a lot from this and implement in day to day practice. Further suggestions by participants included the addition of human resource management issues and interviewing techniques. Utilization of Rosswurm and Larrabee s model to guide the organization of this evidence based project helped to identify statistically significant outcome measures in the five AONE leadership domains. These results provided further evidence of the link between leadership education and the nurse leaders self perceived competency level. Discussion The results of this study show that leadership education can increase the nurse leaders self perceived competency level. A statistically significant difference was found in 23 of the 67 identified competencies (34%). All five of the leadership domains demonstrated at least two competencies with a statistically significant difference following education. The leadership

27 Leadership Education 26 domain showed the greatest percentage of change. These leadership competencies were related to understanding one s role as a leader and self development as a leader. In addition, the concepts of change management and adapting one s leadership style to the situation were stressed in the educational sessions on developing self and change management. Group exercises in leadership roles, videos demonstrating leadership styles, and developing self awareness plans may have contributed to the nurses perception of an increase in knowledge and skills in these areas. Participants completed the Meyers Briggs tool to gain a better understanding of their own personality and discussed situational leadership as a theory for adapting leadership skills to different situations. Participants also completed the Thomas-Kilmann Conflict Mode Instrument to assess their individual behaviors in conflict situations. These types of exercises helped participants gain knowledge and insight into their own leadership styles. The business skills and knowledge domain demonstrated the second highest percentage of change in competency level. The competencies that increased significantly were related to identifying clinical leadership skills, using data to make changes and evaluating systems, and involving staff in decision making. The skills were stressed throughout the educational sessions in areas of ethical decision making, using power and influence, and change management by using the two minute drill technique. Participants were given clinical situations and provided group time to discuss solving the issue from a deontological or teleological base using a rights, results, reputation or relationship perspective. Information was provided on the need for information technology and information management to implement rapid fire, two minute drill change projects. For many participants this was new information and having the opportunity to work in groups and practice during the educational sessions provided new knowledge and application of the skill.

28 Leadership Education 27 The third domain with an increase in self perceived competency was knowledge of the healthcare environment. These competencies reflected the content associated with designing healthcare delivery models, using evidence based practice to support clinical changes, serving as a change agent, and understanding budget and revenue concepts. While these topics did not provide many practice sessions, participants were introduced to new websites related to evidence based practice, patient safety and quality monitoring, and transforming care at the bedside. The finance session introduced budget reports and how reimbursement affects revenues. The median years in a leadership position for this sample was 4.5 years so many nurse leaders had never been educated about the healthcare environment and although they may have participated in their own budgets, they were not aware of how case mix index and payor mix affect overall revenues for the organization. Communication and relationship building and professionalism were the final two domains with a significant increase in perceived competency level. Only three competencies in communication and two in professionalism demonstrated an increase. These competencies also focused on applying ethical principles to decisions, involving staff in decisions, being nonjudgmental and non-threatening, and making patient centered care decisions. One explanation for not seeing an increase in more of the competencies in these areas may be related to nurse leaders belief that they are professionals and therefore already have a high level of professionalism. In addition, much of the nurse s role is in communication and building relationships with patients, physicians, staff, and other disciplines. It is possible that many nurses may perceive they already possess skills in these areas. The areas which did not demonstrate a significant difference included compliance with standards, using research, performance improvement, risk, conflict and communication, building

29 Leadership Education 28 teams, accountability, mentoring, professional organizations, and developing business plans. Nurses participating in the program had a wide range in years as a nurse and years in a leadership position, which may have impacted the areas where no significant difference was seen. Generally nurses rated with more years of experience or more years in a leadership position rated themselves in the advanced beginner to competent range. These nurses may have perceived they already had skills in these areas. Although there was not a significant difference noted, nurses reported a gain in knowledge in these areas. For professional organization membership, participants either rated themselves as a novice if they did not belong to a professional organization and an expert if they did belong. The small percentage of nurses with Master s degrees in nursing (17.2%) and national certifications (20.7%) may have contributed to fewer participants being members in professional organizations and fewer utilizing research in practice. Nurses who rated themselves in the competent range have experience in the daily management tasks and are currently involved in performance improvement and risk management activities. They routinely deal with conflict situations and may have felt they had already mastered some of these skills. The development of business plans was not an area where participants felt competent in either the pre or post group, as this skill was felt to take longer to master than the time allotted in the program. Comments by the participants strongly supported the need and desire for education in the area of leadership. Positive comments included building relationships with other leaders, identifying support and resources for managing leadership issues, and identifying areas needed for continued personal leadership growth. All participants agreed that the content was appropriate for meeting the objectives and identified the need for a more formal mentoring process to be developed.

30 Leadership Education 29 Limitations Several limitations were identified with this evidence based project. First, research related to the evaluation of the relationship between leadership education and competency level is limited. Measuring leadership skills is problematic due to the difficulty in demonstrating a cause and effect relationship between the education and the competency level. Leadership development is complex and affected by many variables. The educational program may not be the only variable affecting a change. Other variables might have included outside readings, other formal education, mentorship, or type of leadership position held. Self perception of competency may not necessarily reflect the ability of the nurse leader to perform in the clinical setting. Just because the nurse leaders perceives themselves as competent, does not mean that they are performing and applying the knowledge gained. A follow up to this project could look at the subordinates perception of a change in leadership as a result of the educational intervention. A second limitation was the length of time for implementation. Effects of the leadership education intervention may not be evident after four months. A third limitation is the length of the AONE Nurse Executive Competency Tool. The tool incorporates many skills not applicable to the content being taught in the ilead program. This could have led to confusion for the post study group when completing the assessment tool. In addition, the tool does not have established reliability and validity because it has not been used as a measurement tool. A fourth limitation is the small sample size may not be representative of all nurse leaders. The groups are from a Midwest academic medical center and may not represent nurse leaders in other geographical locations. Concerns related to external validity may be raised about generalizing the findings to groups other than Midwest nurse leaders in academic medical centers. Finally, because the data

31 Leadership Education 30 collected was ordinal data, the tool may not have been sensitive enough to detect small changes in leadership and it did not measure changes over time. Integration and Maintenance of Change Implications for Practice. This project provided an evidence based evaluation of the nurse leaders self perceived competency level following an educational intervention. The outcome measures supported the evidence that education can be linked to increased competency of registered nurse participants. The additional program evaluations demonstrated positive comments by participants related to the program. AONE supports leadership education as a means to promote a safe and healthy work environment. With the complexity of healthcare it is essential to not only provide leadership education to current managers, but also prepare our future leaders with skills and knowledge to be successful. The AONE Nurse Executive Competency Model provided a comprehensive list of the competencies needed for successful leadership in five domains. Self perceived competency was evaluated against categories ranging from novice to expert utilizing the AONE tool. The outcomes for leadership education support Benner s theory that as new nurses must acquire new skills and gain knowledge to become more proficient, so also must new nurse leaders. Nurse leaders need the knowledge and skills necessary to perform successfully in their leadership role. Rosswurm and Larrabees evidence based model was useful in assessing the need for change, selecting outcome measures, synthesizing the evidence, designing the educational intervention, and evaluating the outcomes. The model provided steps in the change process for evaluating the organization s limitation in leadership education, identifying leadership needs of nurse leaders, and systematically appraising the evidence. Administrative support for the

32 Leadership Education 31 program and involvement in the evidence based change process contributed to the success of the project. Communication of the outcomes of the project has resulted in the decision to continue to provide leadership education for nurse leaders through a certificate program at the university. Nursing administrators faced with creating healthy, safe work environments must incorporate leadership education into the development of nurse leaders who will then be able to use their new skills and knowledge to transform the culture of the work environment. A lack of preparation and education of nurse leaders leadership skills contributes to ineffective leadership and dissatisfaction in the work environment. The investment of resources to educate current and aspiring nurse leaders will enhance the skills and knowledge level of nurses so that changes in the healthcare environment can be realized. This project contributes to evidence based practice by providing further evidence that an educational intervention affects the perceived competency level of nurse leaders. This is important as nurse leaders are required to move from transactional to transformational leaders, while producing positive outcomes for patients, staff, and the organization. Leaders who are successful contribute to a healthy work environment, which leads to positive outcomes for both staff and patients. In addition, nurse leaders who are educated will be more satisfied in their role. On the basis of evidence provided by this project, education influences competency in leadership knowledge and skills. This outcome provides support for Benner s theory that nurses must acquire leadership skills and knowledge to become proficient and move along the continuum from novice to expert nurse leaders. Communication of Outcomes The results of this evidence based project demonstrated that the self perceived competency level of nurse leaders was positively influenced following completion of the ilead

33 Leadership Education 32 program. The evaluation of the effectiveness of the ilead program will be shared with Nursing Administration and the University s Executive Center for Global Development to support continuation of leadership education in promoting leadership growth and development. While this project was focused on nurse leaders, it is also applicable to middle manager development in the academic medical center. Continuation of the program is essential in transforming the work environment and preparing nurse leaders for their role. Dissemination of the results of this project will also be shared at the Midwest Nursing Research Society Conference and the University of Toledo Research Day through poster presentations. Dissemination of the results may also be shared through preparation of a manuscript for publication. Interested journals might include The Journal of Nursing Administration, Nursing Management, and Nursing Administration Quarterly. The findings will be valuable to both researchers and nurse administrators interested in using the evidence to guide further research or implement similar changes in their organization. Conclusion Leadership is complex and influenced by many variables. Evidence based leadership practices are needed to promote leadership development and a culture of safety. Based on the results of this project, leadership education prepares the nurse leader with the knowledge and skills necessary to excel in leadership roles. Rosswurm and Larrabees evidence based practice model and Benner s model from novice to expert provided the guide and theoretical framework for this evidence based leadership education project. Leadership education is successful to the extent that nurse leaders utilize the skills and knowledge gained in the practice area to become more proficient in their leadership role. Further evaluation is needed to determine long term effects of the leadership education on application of the skills learned. The ilead program offers

34 Leadership Education 33 one approach to leadership education for an academic medical center s nursing leaders. Nursing administrators faced with the complexity of the healthcare environment can use this evidence to support the need for leadership education and provide the necessary resources.

35 Leadership Education 34 AUTHOR Johnson & D Argenio (1991) Wolf (1996) Robbins, Bradley & Spicer (2001) Appendix A Synthesis Table Review of the Literature SAMPLE LEVEL & QUALITY PURPOSE MEASUREMENT FINDINGS 11 nurse managers III Non-experimental study to Leadership Effectiveness and Short term changes in leadership C measure effectiveness of Adaptability Description behaviors 6 months after but not management training on (LEAD) before, education, 6 sustained at 12 months/ leadership behavior and 12 months after. Same tool 144 nurses III B Not applicable Upenieks (2002) 16 nurse leaders III A Bradley (2003) Not applicable V B Santiano & Daffurn (2003) 39 registered nurses (69% response rate) III B III B Measure change in perceived leadership style Qualitative study to develop a competency assessment tool Qualitative, descriptive study to understand types of organizational structures that create nurse exec job effectiveness and leadership success Describes the use of the 360 degree appraisal system. Also looks at difficulty in showing association between competency attainment and job performance. Perceived level of competence following education and the extent to which educational objectives were achieved completed by manager s staff. Leadership Effectiveness and Adaptability Description (LEAD) pre and post four day leadership training 52 item competency assessment tool Interviews following specific protocols Not applicable Questionnaires developed by authors Significant change in perceived leadership style, but did not measure long term effects Incorporated technical skills, industry knowledge, analytic and conceptual reasoning, and interpersonal and emotional intelligence. 88% validated access to information, opportunities, and resources produce climate for leadership effectiveness. These environments create supportive and productive climates to enhance success. Strong central beliefs. business intelligence, and teamwork were vital attributes. Used as a tool to identify leadership strengths and developmental needs, assess competency, and provide feedback to leaders. Use to develop a plan to address areas of weakness. Need for reliable and valid measures that take confounding factors into consideration Graduates perceived the course enhanced knowledge and skills. Recognizing own abilities and level of competence was rated the highest, while research was rated the lowest.

36 Leadership Education 35 AUTHOR Woltring, Constantine & Schwarte (2003) Flowers, Sweeney & Whitefield (2004) Saleh, Williams & Balougan(2004) SAMPLE LEVEL & QUALITY PURPOSE MEASUREMENT FINDINGS 438 Alumni of the PHLI III Retrospective survey to Self report questionnaire 67% return rate. Positive impact on A determine effectiveness of leadership effectiveness at all Public Health Leadership levels. Areas emphasized included Institute education on personal, expanded view of role, new organizational, and community approaches used to meet levels challenges, balanced personal and professional commitments, increased skills in handling change and creating teams with 33 Registered Nurses, midwives, and Senior Therapists 297 participants (67% response rate) Duffield (2005) 17 Nurse Mangers III C Conley, Branowicki & Hanley (2007) III C III A 5 Nurse Managers V C Gallo (2007) Not applicable V B Bradley, Maddox, & Spears (2008) Not applicable V B Development of leadership modules based on 15 competencies on leadership and business skills. Retrospective study to determine if there was an improvement in skills and effectiveness as leaders following leadership education Measure learning following Master class in leadership development Use of a needs assessment to identify competencies to include in nurse manager orientation 360 appraisal and program evaluation of modules collaborative relationships. Positive feedback from participants. Demonstration of effective leadership behaviors and skills. Internal survey Improved skill level in 15 competencies. Greatest improvement in the ability to cope and lead change, use of media, and empowering people about health issues. Internally developed tool Used 6 months after completion of program Internally development needs assessment Positive impact on expressing opinions and stretching minds but did not show a correlation between the content learned and application to practice. Favorable comments from participants based on awareness of skills and expectations in role. Small sample size Defines leadership development Not applicable systematic process that immerses the new nurse manager in the role through formal managerial education and informal learning, multirater (360 degree) feedback, exposure to executives, action learning and mentoring programs Describes use of the 360 degree appraisal tool Not applicable Tool used to identify a leader s strengths or developmental needs, assess competency or provide feedback.

37 Leadership Education 36 AUTHOR Cummings, Lee, MacGregor, Davey, Wong, Paul, & Stafford (2008) SAMPLE Systematic review of 24 Pre/post design in 9 of the studies related to effectiveness of educational interventions on behavior LEVEL & QUALITY PURPOSE MEASUREMENT FINDINGS III A Review of factors contributing to nursing leadership. Reported effects at 3, 6, and 12 months. Leadership Practice Inventory, Multifactor Leadership Questionnaire, leader Behaviour Descriptive Questionnaire, Leadership Effectiveness and Adaptability Description, and researcher developed tools. All studies reported increase in skills and competencies when rated by self or others. Suggest leadership qualities can be developed. Weak designs

38 Leadership Education 37 Appendix B Definitions of Level and Quality of Evidence * Strength of Evidence Level I: Level II: Level III: Level IV: Level V: Experimental study/randomized controlled trial (RCT) or meta analysis of RCT Quasi-experimental study Non-experimental study, qualitative study, or meta-synthesis Opinion of nationally recognized experts based on research evidence or expert consensus panel (systematic review, clinical practice guidelines) Opinion of individual expert based on non-research evidence (Includes case studies; literature review; organizational experience e.g., quality improvement and financial data; clinical expertise, or personal experience) * Quality of the Evidence A High Research Consistent results with sufficient sample size, adequate control, and definitive conclusions; consistent recommendations based on extensive literature review that includes thoughtful reference to scientific evidence. Summative Reviews Well defined, reproducible search strategies, consistent results with sufficient numbers of well defined studies, criteria-based evaluation of overall scientific strength and quality of included studies; definitive conclusions. Organizational Well defined methods using a rigorous approach; consistent results with sufficient sample size; use of reliable and valid measures. Expert Opinion Expertise is clearly evident. B Good Research Reasonably consistent results, sufficient sample size, some control, with fairly definitive conclusions; reasonably consistent recommendations based on fairly comprehensive literature review that includes some reference to scientific evidence. Summative Reviews Reasonably thorough and appropriate search; reasonably consistent results with sufficient numbers of well defined studies, evaluation of strengths and limitations of included studies, fairly definitive conclusions. Organizational Well defined methods; reasonably consistent results with sufficient numbers, use of reliable and valid measures; reasonably consistent recommendations. Expert Opinion Expertise appears to be credible. C Low quality or Research Little evidence with inconsistent results, insufficient sample size, conclusions cannot be drawn. major flaws Summative Reviews Undefined, poorly defined, or limited search strategies; insufficient evidence with inconsistent results; conclusions cannot be drawn. Organizational Undefined, or poorly defined methods; insufficient sample size; inconsistent results; undefined, poorly defined or measures that lack adequate reliability or validity. Expert Opinion Expertise is not discernable or is dubious. Newhouse, R.P., Dearholt, S.L. Poe, S.S., Ouch, L.C. & White, K.M. (2007). John Hopkins Nursing Evidence-Based Practice Model and Guidelines. Sigma Theta Tau International. Indianapolis, IN. Pg 198.

39 Leadership Education 38 Appendix C Topical Content of the ilead Program Four Month Program Session Topic Length Speaker Session 1 Leading and Developing Yourself 4 hours Professor, Business Session 2 Session 3 Session 4 Leading and Developing Yourself (continued) Leading Through Ethical Decision Making Leading Through Ethical Decision Making (continued) 4 hours Professor, Business 4 hours Professor, Business 4 hours Professor, Business Session 5 Leading with Power and Influence 4 hours Professor, Business Session 6 Session 7 Session 8 Session 9 Leading with Power and Influence (continued) Leading Change and Organizational Improvement Leading Change and Organizational Improvement (continued) Creating a Vision Through Service Quality 4 hours Professor, Business 4 hours Professor, Business 4 hours Professor, Business 4 hours Professor, Business Session 10 Evidence Based Practice 2 hours Chief Nurse Executive Patient Care Delivery Models 2 hours Chief Nurse Executive Session 11 Information Technology 2 hours RN Director of Informatics Session 12 Risk Management 2 hours Risk Manager Session 13 Healthcare Financing 2 hours Hospital Finance Director Session 14 Patient Safety 2 hours Medical Director Utilization Review 2 hours Medical Director

40 Leadership Education 39 Appendix D AONE Nurse Executive Competency Tool

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