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1 Collegian (2016) 23, Available online at ScienceDirect j ourna l h omepage: ocate/coll Strengthening the capacity of nursing leaders through multifaceted professional development initiatives: A mixed method evaluation of the Take The Lead program Deborah Debono, RN, RM, BA Psych (Hons) a,, Joanne F. Travaglia, PhD a,b, Adam G. Dunn, PhD c, Debra Thoms, RN, MNA, FACN(DLF) d, Reece Hinchcliff, PhD a, Jennifer Plumb, MSc, PhD a, Jacqueline Milne, PhD a, Noa Erez-Rein, BA, MSc e, Janice Wiley, MBBS, MHM, MPH a, Jeffrey Braithwaite, PhD, MIR, MBA a a Centre for Clinical Governance Research, Australian Institute of Health Innovation, University of New South Wales, Australia b School of Public Health and Community Medicine, University of New South Wales, Australia c Centre for Health Informatics, Australian Institute of Health Innovation, University of New South Wales, Australia d Australian College of Nursing, Canberra, Australia e University of New South Wales, Australia Received 18 November 2013; received in revised form 26 August 2014; accepted 19 September 2014 KEYWORDS Nursing leadership development; Nursing Unit Manager; Midwifery Unit Manager; Summary Background: Effective nursing leadership is necessary for the delivery of safe, high quality healthcare. Yet experience and research tells us that nursing leaders are commonly unprepared for their roles. Take The Lead (TTL), a large-scale, multifaceted professional development program was initiated in New South Wales, Australia, to strengthen the capacity of Nursing/Midwifery Unit Managers (N/MUMs). The aim of this study was to examine the effects of TTL on job performance, nursing leadership and patient experience. Corresponding author at: Centre for Clinical Governance Research, Australian Institute of Health Innovation, University of New South Wales, Kensington, NSW 2052, Australia. Tel.: address: d.debono@unsw.edu.au (D. Debono) / 2014 Australian College of Nursing Ltd. Published by Elsevier Ltd.

2 20 D. Debono et al. Role clarification; Peer support; Networking; Take The Lead Methods: Nursing/Midwifery Unit Managers (n = 30) and managers of N/MUMs (n = 30) who had completed the TTL program were interviewed between August and December The semi-structured interviews included a combination of open-ended questions and questions that required respondents to rate statements using a Likert scale. Data from the open-ended questions were thematically analysed to identify and categorise key concepts. The responses to the Likert items were analysed via descriptive statistics. Results: Nursing/Midwifery Unit Managers participation in TTL engendered improvements in job performance and leadership skills, as well as some improvement in patients experiences of care. The program facilitated role clarification and helped foster peer-support and learning networks, which were perceived to provide ongoing professional and personal benefits to participants. Conclusions: Our study revealed a consensus about the beneficial outcomes of TTL among those involved with the program. It supports the significant and ongoing value of widely implemented, multifaceted nursing leadership development programs and demonstrates that participants value their informal interactions as highly as they do the formal content. These findings have implications for delivery mode of similar professional development programs Australian College of Nursing Ltd. Published by Elsevier Ltd. 1. Background In Australia, and elsewhere, Nursing/Midwifery Unit Managers (N/MUMs) have overall responsibility for the coordination of patient services, unit management and nursing staff management (Hawes, 2009). The role has evolved considerably over the last forty years, from an initial emphasis on clinical leaders amongst equals towards a greater focus on professional management and extensive administrative duties (Duffield, Kearin, Johnston, & Leonard, 2007). Significant challenges have accompanied this transformation. Studies have identified confusion among N/MUMs regarding the boundaries and expectations of their role, exacerbated by insufficient professional development mechanisms. In some cases, this has resulted in N/MUMs feeling ill-equipped to carry out their assigned tasks (Duffield, Kearin, et al., 2007; Hawes, 2009; Paliadelis, 2005; Queensland Government, 2008). The lack of role clarity and preparation can impair efficiency, satisfaction and staffing levels (Duffield, Kearin, et al., 2007; Garling, 2008; Paliadelis, Cruickshank, & Sheridan, 2007; Queensland Government, 2008). This has the potential to impede the development of effective nursing leadership, a critical feature of safe, well-managed healthcare services. Associations between effective nursing leadership and attributes of a well-functioning health system are well established. These include patient safety and satisfaction (Cummings, Midodzi, Wong, & Estabrooks, 2010; Duffield, Roche, et al., 2007; Squires, Tourangeau, Spence Laschinger, & Doran, 2010; Tregunno et al., 2009; Wong & Cummings, 2007); improved staff retention (Anthony et al., 2005; Duffield, Roche, Blay, & Stasa, 2011; Duffield, Roche, O Brien-Pallas, Catling-Paull, & King, 2009; Fennimore & Wolf, 2011); use of best practice guidelines (Cummings et al., 2010); higher productivity and organisational commitment (Chiok Foong Loke, 2001; Cummings et al., 2010); better student placement experiences (Andrews et al., 2006); and healthier work environments (Pearson et al., 2007). Despite such reported benefits of effective nursing leadership, there is broad acknowledgement of shortcomings in leadership development, skills and role clarity among unit-level nurse managers in Australia (Paliadelis, 2005); New Zealand (McCallin & Frankson, 2010); South Africa (Pillay, 2011); the United Kingdom (Gould, Kelly, Goldstone, & Maidwell, 2001; Kleinman, 2003); Ireland (Casey, McNamara, Fealy, & Geraghty, 2011); and Finland (Bondas, 2006). In recent years, recognition of the detrimental impacts of deficient nursing leadership on patients, staff and organisations has focussed greater policy attention on developing nursing leadership skills (Bondas, 2009; Casey et al., 2011; Fennimore & Wolf, 2011; Gould et al., 2001; Kleinman, 2003; Loo & Thorpe, 2004; McCallin & Frankson, 2010; Paliadelis, 2005; Pillay, 2011). The principal mechanisms to achieve this have been the instigation of professional development, formal mentoring and administrative assistance programs (Garling, 2008; Hawes, 2009; Queensland Government, 2008). Increasingly, discrete educational programs have been packaged into complex leadership bundles (Abraham, 2011; MacPhee, Skelton-Green, Bouthillette, & Suryaprakash, 2012; Martin, McCormack, Fitzsimons, & Spirig, 2012), comprising participative leadership training (George et al., 2002) and transformational leadership education (Duygulu & Kublay, 2011; MacPhee & Bouthillette, 2008; MacPhee et al., 2012). The increasing use of these multifaceted educational programs attests to the complexity of nursing leadership, and the challenge of systematically facilitating its development. One such initiative is Take The Lead (TTL), a program used in publicly funded health services in the state of New South Wales (NSW), Australia, to enhance nursing leaders by clarifying, standardising, developing and facilitating the leadership role of N/MUMs. The Nursing and Midwifery Office of NSW Health, the responsible Ministry, designed the program following stakeholder consultation (Hawes, 2009). The three components of the program were a conceptual framework describing the purpose and core roles of N/MUMs (N.S.W. Health, 2010a), mechanisms to reduce N/MUMs administrative load, and five professional development modules. These modules targeted communication, lean thinking, financial management, rostering and leadership (N.S.W. Health, 2008). Links to these modules are available on the NSW Health Website (N.S.W. Health, NDS).

3 Strengthening the capacity of nursing leaders through multifaceted professional development initiatives 21 Due to its multifaceted design and statewide implementation, TTL provides a unique research opportunity to examine the impact of broad nursing educational programs. To help build the evidence base and inform the design and implementation of comparable programs, this study aimed to examine the effect of TTL on N/MUMs job performance, leadership skills and the experiences of their patients. 2. Methods 2.1. Study design and data collection methods This evaluation used a mixed methods approach (Johnson & Onwuegbuzie, 2004). Data were collected using telephone interviews, which have been shown to be comparable to face-to-face interviews in terms of the quality of data collected (Cook, White, Stuart, & Magliocco, 2003; Lyu et al., 1998; Rogers, 1976). Telephone interviews with N/MUMs (n = 30), and the supervising managers to whom N/MUMs report (N/MUMs managers) (n = 30), were conducted between August and December Interview times ranged between 30 and 90 min. The researchers recorded responses by hand during the interviews and these notes were entered into an Excel spread sheet following the interviews. The interview approach was semi-structured, allowing for both the examination of a defined area of interest and exploration of interviewees ideas and experiences that may have been unanticipated at the outset of the study (Britten, 1995; Liamputtong, 2010). The interview schedule was structured according to broad domains of potential program impact such as job performance, leadership ability and the experience of patients (Øvretveit, 2002). Our approach to data collection reflected the study s dichotomous objects of inquiry confirmation and exploration (Denzin & Lincoln, 2005). Firstly we sought to confirm that the pre-defined goals of the program had been met. Study participants were asked to rate statements reflecting program aims (n = 26 (N/MUMs); n = 25 (N/MUMs managers)) on a five-point Likert scale which gauged the level of impact of the program (from 1 = improved/increased significantly to 5 = worsened/decreased significantly). For example, Thinking about you since you did the TTL modules has: Your overall job performance: one improved significantly, two improved somewhat, three stayed the same, four worsened somewhat or five worsened significantly? Following each Likert item or set of items, participants were asked if any of the changes or lack thereof were attributable to their participation in TTL. Open-ended questions were used to explore participants responses to the Likert items, elicit their reflections on and experiences of TTL, and to expose unexpected effects of TTL Sampling strategy At the time of the study, there were 1610 N/MUMs in NSW who had participated in the TTL programme (Travaglia et al., 2011). The parameters of the evaluation were such that only N/MUMs who had completed all five professional development modules were eligible for inclusion in this study (n = 186). There was potential for confounding factors to result from differences between Area Health Services (AHS geographical entities responsible for care, similar to National Health Service (NHS) acute trusts). To mitigate any such effects, and to increase the generalisability of the study findings, we ensured representation from across all eight NSW AHSs and two state-wide services by sampling three N/MUMs from each. Nursing/Midwifery Unit Managers who were eligible to participate were grouped according to their AHS or state-wide service and were each assigned a number. Each unit manager (N/MUM) was identified using a random number generator and contacted in the order of their random ranking until three had been interviewed from each AHS. There were 20 eligible N/MUMs who did not participate because they were on leave (n = 11); had changed jobs (n = 4); were unable to be contacted (n = 4); or due to workload (n = 1). Managers of N/MUMs were also eligible for enrolment if any of their staff had participated in the TTL program. To ensure that managers of N/MUMs were evaluating the effects of TTL specifically rather than an N/MUM s individual performance, managers of N/MUMs were excluded if they directly supervised a N/MUM who had been interviewed as a part of this study. Once the N/MUMs had been selected for participation, the random ranking of NUMs was used to identify managers of N/MUMs who were eligible to be included in the study Ethical considerations Our sampling method, was designed to ensure that no managers of N/MUMs were interviewed who were direct supervisors of N/MUM participants in the study, reducing the likelihood of potential conflicts or ethical problems. Participants were contacted directly by the research team. Written consent was gained prior to interview. Participants were able to withdraw from the study at any time, but none chose to do so. The Human Research Ethics Committee at the University of New South Wales approved the study (HREC (PI)/Panel ref: ) Data analysis Descriptive statistics were used to analyse the responses to Likert statements and demographic data. Missing data were coded as 0. Two researchers (DD, JT) independently conducted preliminary thematic analysis of the qualitative interview data from each of the open-ended questions. They compared emergent themes across, and within, the two participant groups (i.e. N/MUMs, and managers of N/MUMs) (Creswell, 2003). Researchers compared results to identify and confirm categories. No additional major categories emerged, and minor differences in coding were resolved through discussion. Results are organised by key evaluation questions. Qualitative data are used to explore responses in greater depth.

4 22 D. Debono et al. 3. Results 3.1. Sample characteristics There were sixty participants (seven males (11.7%) and 53 (88.3%) females) who participated in the study; this approximates the ratio of males to females in the nursing workforce. Among these, the N/MUMs (three males, 27 females) had worked in healthcare (since graduation) for between eight and 40 years (mean = 24 years; median = 28 years). They had occupied a N/MUM role for between 18 months and 20 years (mean = six years; median = five years) and had been in their current N/MUM role for between six months and 15 years (mean = five years; median = three years). The managers of N/MUMs (four males, 26 females) had between eight and 45 years experience in healthcare post graduation (mean = 27 years; median = 29 years). They had been in the role of managing N/MUMs for between several months and 26 years (mean = eleven years; median = 10 years). The managers of N/MUMs held the following positions: Director of Nursing (n = 10); Deputy Director of Nursing (n = 3); Assistant Director of Nursing (n = 2); Assistant Deputy Director of Nursing (n = 2); Nurse Manager (n = 11); and Health Services Manager (n = 2) Perceived impact of TTL on N/MUMs job performance, leadership skills and patient experience We divide our findings on the impact of TTL into three sections: N/MUMs job performance; leadership skills; and patient experience. In each section, we present the confirmatory findings ( what effect ) followed by the qualitative exploratory findings (e.g. how, why, when ). Figs. 1 and 2 present N/MUMs and N/MUMs managers responses to statements, rated according to a five point Likert scale. Statements addressing N/MUMs job performance and leadership skills (including staff performance) are marked with JP and LS respectively, and those relating to patient experience with PE. Time spent on administrative tasks is indicated by AD. In both figures, questions are ordered according to the aggregated mean response. From the left, the responses are segmented: worsened/decreased significantly (red), worsened/decreased somewhat (pink), through no change (grey), to improved/increased somewhat (light green), and improved/increased significantly (dark green) on the right. There was a positive response overall regarding changes in N/MUMs job performance and leadership skills after their participation in TTL (JP and LS). A decrease was reported in relation to numbers of adverse events and patient complaints (PE), and time spent on administrative tasks (AD) Impact on job performance Interviewees commonly suggested that participation in TTL had enhanced N/MUMs job performance. As illustrated in Figs. 1 and 2, there were 21 of 30 N/MUMs (70%) and a greater majority of managers of N/MUMs (25 of 30; 83%), who reported positive changes in overall job performance since TTL. Of these, a small number of participants, four of thirty N/MUMs (13%) and five of thirty managers (17%), asserted that they could not attribute the improvements in job performance entirely to TTL or that they were unsure of the contribution of TTL to the changes. When asked to elaborate, N/MUMs reported that they learnt skills during TTL that were needed to perform the N/MUM role but that previously had not been taught formally. Through participation in TTL, Figure 1 Survey responses on a 5-point scale for Nursing and Midwifery Unit Managers for 26 questions. Questions are ordered by the aggregated mean response across the two groups.

5 Strengthening the capacity of nursing leaders through multifaceted professional development initiatives 23 Figure 2 Survey responses on a 5-point scale for the managers of the Nursing and Midwifery Unit Managers for 25 questions. Questions are ordered by the aggregated mean response across the two groups. some N/MUMs gained insight into what N/MUMs should do and what the role entailed: Some subjects covered things that you are often expected to learn on the job expected to develop certain skills but are never actually taught them... Historically it has been vague but focusing on these particular aspects of the job helped to clarify the role. (N/MUM 20) I didn t know a lot of things nor the expectations of NUMs or ability required... You come into the role without knowledge and expectations of role of NUM. (N/MUM 16) In going to TTL, [my] insight to the job is greater. Mostly how NUM approaches things, how she should do things. (N/MUM 28) The TTL modules that addressed lean thinking and communication were considered the most valuable of the five modules, with participants describing benefits to job performance and changes that they had made following TTL. For example: Lean thinking made me realise I could let go of the hard copy. It helped to deal with things straight away, for example, empty IN tray. Now I only have one tray on my desk eliminates double handling. Sharing of ideas and taking back to use in unit made life easier... [the] Manual was radically revised because of different aspects of TTL, e.g.; introduction of a communication book for questions and ideas for discussion, improvement etc. (N/MUM 5) Managers of N/MUMs also described the positive effects of TTL on N/MUMs job performance. A common theme to their responses was that following participation, the N/MUMs were able to think more laterally, increasingly bring practical solutions back to the ward, and became more confident in managing problems and making decisions themselves, rather than escalating them. Managers identified a specific improvement in problemsolving and decision-making skills amongst participating N/MUMs. Managers also reported that N/MUMs ability to manage finances had improved following participation. N/MUMs [are] confident to manage problems themselves rather that coming straight to ADON... N/MUMs [are] making more decisions at [an] appropriate level. N/MUMs can now think more laterally bring practical solutions. (Manager 13) Both groups of participants noted benefits of attending the training modules that went beyond skills acquisition. Networking opportunities and peer support offered by attending courses with staff from other services had an additional positive impact on job performance. Networking was seen to have fostered collaborative articulation of N/MUMs role expectations across NSW, with role clarification via networking influencing job satisfaction. I have more job satisfaction because there is more clarity in what I should be doing. If you know what your goals are it is easier to know when you are doing a good job and this leads to improved satisfaction...ttl helped me develop confidence in my own skills. I got ideas from other NUMs. There were themes in their ideas and then I could run with these and develop my own ideas that suit my ward. (N/MUM 20) I don t feel as isolated others are doing the same thing... staff are more aware of the role and appreciate it more. I find it more rewarding. (N/MUM 21) The best learning mixing with other NUMs, asking them about specific people management problems to benchmark against them and make sure I am on the right track. (N/MUM 7) Strengthening the N/MUM role through such interactions for N/MUMs was reassuring, therefore strengthening (N/MUM 4). They experienced increased confidence

6 24 D. Debono et al. [which] has led to increased competence (N/MUM 21), and felt the benefit of ongoing support: I get asked more for help by other NUMs. An network has been set up (N/MUM 15), the social networking was good. Have kept in touch with other NUMs in NSW exchanging ideas etc (N/MUM 25). The generally positive interview findings were tempered by a small number of participants who argued that there were no visible changes attributable to improved job performance following TTL. Reasons given for this included local context and culture, workload, and a perception that no change was needed. Initially gained increased enthusiasm for the role, but back to feeling the role is too big. [N/MUM 30] Some NUMs haven t been able to make changes because they simply haven t had the time. (Manager 28) Another ward... wanted to make the changes, but hesitated, due to the fact that there is a different culture in the unit. The staff there are more threatened by change and resist it. (Manager 17) Additionally, there were 12 N/MUMs who reported that at least one professional development module in the nursing leadership program fell short of their needs. Two participants stated that the skills learnt in some modules were not transferable to the workplace because these tasks were out of their control (e.g. rostering and financial management are not done at ward level). Others suggested that TTL may have been more helpful for less experienced N/MUMs than for those with postgraduate degrees with management and leadership components: It is wonderful for young NUMs and NUMs who are keen to learn, develop and move up the ladder. From what I saw, the NUMs who had a lot more experience were not so keen and did not think it was worth it. (N/MUM 20) While some N/MUMs stated that while the content was not new for them, there was still a positive effect of participation in TTL particularly as a result of networking. N/MUMs described a sense of renewed enthusiasm (N/MUM 6), and benefits from experience meeting and learning from other N/MUMs... hearing their solutions (N/MUM 22) Impact on leadership skills The program was generally seen by N/MUMs and their managers to have helped make them more confident leaders and to have improved their communication skills. One fifth of respondents thought that there had been no impact, but the majority of N/MUMs (22 of 30 responses; 73%) and their managers (23 of 29 responses; 79%) reported an improvement in N/MUMs ability to lead since TTL (Figs. 1 and 2). A small number of participants in each group specified that an improvement in leadership ability was not due to TTL (1 N/MUM, 1 manager), or that change was partly due to TTL or that TTL had uncertain impact (1 N/MUM, 1 manager). Nursing/Midwifery Unit Managers often noted a decrease in their anxiety about managing their staff and more proactive approach to change, demonstrated by improved staff feedback, morale, and motivation. Managers also attributed improved leadership skills to increased confidence in the N/MUMs who had attended TTL. I am a more confident leader. I can explain why I make changes. I am less reliant on my managers. My communication has improved. Lean thinking has sorted out the new ward. I am a better leader. My financial management is better and I understand why. (N/MUM 22) It raised their level of their confidence seen in their leadership skills in particular honed leadership skills. (Manager 1) Self-confidence has improved in some of them. Getting out on the ward and being involved. They feel they are more confident in getting out there and talking to staff about more issues and putting forward ideas. Better communication and leadership skills. (Manager 28) Nursing/Midwifery Unit Managers offered instances of changes in their leadership skills and relationships with their staff following their participation in TTL. For example, the staff looked to them for leadership and were more likely to ask them for advice and problem solving. The following sample of data excerpts illustrate the variety of changes reported to have occurred as a result of N/MUMs improved leadership skills following TTL. Trying to encourage staff, especially RNs [in] taking a leadership role on the ward and that they are the leaders not the ENs (Enrolled Nurses). (N/MUM 16) Rather than getting people on the day to attend different committee meetings, I now ask for expressions of interest to join each committee this has increased ownership among the staff. (N/MUM 21) My relationships with my staff have improved because I am now confident and understand why and I can build the staff understanding of why. Being able to say I learnt this at TTL gives it more credibility and credence and therefore my managers are more supportive. (N/MUM 20) One N/MUM claimed that as a result of TTL she can negotiate with staff and management better, and has fostered in staff an appreciation of equipment and cleared away clutter. Furthermore she now s staff with education material and has found that other staff now want to attend learning and development classes, staff approach her more about workplace issues, and the workplace is a more positive place (N/MUM 19). Nursing/Midwifery Unit Managers managers supported these views, identifying that as a result of participation in TTL, N/MUMs were better able to manage staff, staff morale had improved and they were proactively seeking opportunities and enabling change. The NUM had to deal with some resistance there and needed to communicate that in the big picture the focus is excellent patient care, provide a service. She was able to convince the resistant staff. (Manager 17) When asked whether the identified improvement in staff morale was attributable to TTL, Manager 2 explained:

7 Strengthening the capacity of nursing leaders through multifaceted professional development initiatives 25 Yes, having a NUM on the floor has made them more accessible they are feeling that you are one of us the NUM is their NUM. This is part of the TTL culture change the NUM sees it as my ward. (Manager 2) The managers of N/MUMs were more readily able to identify specific changes in N/MUMs confidence and leadership abilities than N/MUMs themselves. They reported that N/MUMs were better at performance management and that they had improved morale and motivation (Manager 20). In addition, due to increased confidence in their role, N/MUMs demonstrated stronger leadership on the ward and were motivated to further develop leadership skills Patient experience There is some evidence that TTL improved patient experience. Patient satisfaction was reported to have increased since TTL by 12 of 30 N/MUMs (40%) and 11 of 29 managers (38%) (Figs. 1 and 2). One N/MUM and one manager clarified that this improvement could not be directly attributed to TTL, while others (one N/MUM and three managers) quantified that they were unsure or unable to attribute all of the improvement to TTL. Conversely, around one third of respondents (9 of 28 (32%) N/MUMs and 9 of 30 (30%) managers) identified that patient complaints had decreased since TTL (Figs. 1 and 2). Of these, two N/MUMs and one manager explained that they were unsure or could not attribute changes solely to TTL. The qualitative data supports these Likert statement results. TTL was perceived to have improved the experiences of participating N/MUMs patients patient care... improved (N/MUM 3). Both N/MUMs and managers reported improved patient flow following TTL. New processes and checklists introduced following TTL facilitated nurses capturing information faster and improved the experience for patients by streamlining patient flow. [Patient flow] around the hospital has improved. NUMs are taking more ownership (e.g. they now use the transit lounge in order to increase patient flow, which they initially resisted). This changed after TTL. NUMs are more proactive liaise with patient flow coordinator (even the one that was obstructive). (Manager 28) One N/MUM reported that the positive effect of TTL on patient experience was evident in increased positive feedback from patient: we have had increased compliments and thank-yous. They know who to talk to (N/MUM 21). Managers held similar views, with one arguing that TTL: has improved their leadership skills, their group communication skills. There is greater interaction with the patient. There is increased ownership of care in their units. Their visibility to staff and patients has increased, emphasised the patient as the centre of care it is all about the patient. (Manager 2) There were 7 of 30 N/MUMs (23%) and 5 of 30 managers (17%) who reported that the number of adverse events had decreased since TTL. One manager argued that TTL had decreased adverse events because N/MUMs were more confident and decisive, proactively preventing adverse events. For example: They are more in tune, particularly the one that completed the program. There is a reduction in falls in his department. He has a big ward to run... Staff morale has improved and there are better patient outcomes. Staff are smiling and they re happy. Patient outcomes have improved tracked number of falls and medication errors. There are less complaints. (Manager 11) However, a number of N/MUMs and managers attributed decreased adverse events to TTL in combination with other factors (1 N/MUM; two managers), observing that TTL facilitated the implementation of other initiatives, which decreased adverse events. One N/MUM asserted that while they perceived that adverse events had decreased since TTL, it was not because of TTL. 4. Discussion The results show that N/MUMs and their managers perceived a substantial strengthening of the N/MUM role due to participation in the TTL program, particularly for those who were new to the role. Specific improvements were perceived in job performance and leadership skills. These findings extend the results of an earlier preliminary examination of TTL (Clarke et al., 2012). We see that increased confidence in, and ownership of, their role empowered N/MUMs to implement more efficient processes, engage and communicate with staff and support change, which was reported to have improved patient experience. Despite the positive impacts identified, interviewees generally could not directly attribute changes in patient experience to TTL alone. Concurrent quality improvement projects, the time lag between commencing and completing TTL, and health system inertia (Coiera, 2011) offer possible alternative explanations. However, previous research establishes the link between effective nursing leadership and the attributes of a well functioning health system including patient safety and satisfaction (Cummings et al., 2010; Duffield, Roche, et al., 2007; Squires et al., 2010; Tregunno et al., 2009; Wong & Cummings, 2007). It follows that through strengthening the N/MUM role, TTL has contributed to improving health care and patient outcomes. While the content of TTL modules offered a vital contribution to strengthening the role of N/MUMs through skills development, participants identified that by-products of attending the courses, such as networking, also had considerable positive impacts. In particular, these by-products were seen to have shaped, clarified or reinforced the N/MUM role. In this way, the program allowed N/MUMs to identify and understand the expectations of their role and empowered them to own the leadership aspects of that role, with related positive outcomes. This finding is supported by prior research that demonstrates the importance of role definition (Sangster-Gormley, Martin-Misener, & Burge, 2013), positive associations between role clarification and team performance (Klein et al., 2009) and how role ambiguity engenders negative consequences for individual employees and their organisations, including lower job satisfaction and productivity (Rizzo, House, & Lirtzman, 1970). Networking occurring via TTL also provided the N/MUMs with opportunities to learn and locally implement tips and tricks from other N/MUMs. The program was instrumental

8 26 D. Debono et al. in reducing feelings of isolation and in providing the reassurance that comes from shared experience. The importance of informal networks in supporting and strengthening the role of N/MUMs has been identified in earlier research (Paliadelis et al., 2007). This study adds to a further body of work to support those findings and echoes the recommendation that organisations should actively foster such naturally occurring networks (Braithwaite, Runciman, & Merry, 2009). 5. Limitations TTL was implemented across one publicly funded health jurisdiction and it is possible that these findings may not be generalisable elsewhere. However, this is a large, diverse health system serving seven million people in Australia, and the mechanisms contributing to the positive impact of TTL in strengthening the role have been demonstrated in other studies; for example, regarding networking (Paliadelis et al., 2007); role clarification (Rizzo et al., 1970); and skills development (Davis, Manktelow, Bohin, & Field, 2001). As with other qualitative studies (e.g. Clarke et al., 2012), a potential limitation of this study is that changes attributable to TTL were based on the N/MUMs self-reports. However, our novel approach moves beyond most existing work which was restricted to the self-reported views of participants in training programs. By additionally incorporating the views of participants managers in our assessment, the authors are able to better gauge the impact of the TTL program on the way N/MUMs worked and the degree to which participation in TTL produced change, which was noticeable to another key stakeholder group. This study evaluated a real world intervention. This study captures participants perceptions of the impact of TTL and how it was linked with improving patient experience. Qualitative findings, such as these, particularly regarding TTL impacts on patient experience, could be strengthened in future work through pre-post evaluation of process and outcome indicators, such as incident reports, patient length of stay, patient complaints, compliments and satisfaction surveys. However, there are attribution problems with such research, and given the length of time between starting and completing the TTL modules, it would be difficult to control for the influence of confounding variables, such as developments in methods of capturing incident data. The roll out of the TTL program meant that participants completed individual modules at varying times during the eighteen months prior to the study. While the study could have been strengthened by pre-course measures, as with all forms of training, it is virtually impossible to distinguish the full impact of the formal educational session with the impact of organisational change strategies that occur at the same time (Cambon, Minary, Ridde, & Alla, 2012). Numerous patient safety initiatives have been introduced in recent years (Bellomo et al., 2004; Cahill et al., 2011; Clinical Excellence Commission and N.S.W. Health, 2010; N.S.W. Health, 2010b). It is possible that changes to the N/MUM role and patient experiences may reflect the halo effect influence of initiatives other than TTL. However, mitigating this, we attempted to minimise this potential limitation by asking and reporting when and whether participants were unsure if, or did not believe, changes were attributable to TTL. 6. Conclusions Effective nursing leadership is critical to patient safety, yet N/MUMs often report feeling unprepared and unsure of the expectations of their role. This study triangulated the views of TTL participants and their managers, confirming the results of recent studies demonstrating the value of employing educational leadership bundles, such as TTL, to systematically strengthen effective nursing leadership and ensure delivery of safe and effective care. This positive impact originates both in the specific content of the program, and the networking and sense-making opportunities that arise from participation. The significance of the faceto-face participation in TTL workshops has implications for the importance of the mode of delivery of similar professional development program. Funding This study was an independent evaluation commissioned and funded by NSW Health. The views expressed are not necessarily those of NSW Health. NSW Health had no role in the data collection, the interpretation of the data, or the drafting of the manuscript for publication. Conflict of interest declaration Debra Thoms was the Chief Nursing and Midwifery Officer at NSW Health at the time of the study, and was involved in the development and roll out of the Take the Lead project. While she made contributions to the conceptualisation and design of the study and the paper, she was not involved in the data acquisition and analysis. Author contributions All authors have agreed on the final version of the paper and meet at least one of the following criteria: substantial contribution to conception and design, acquisition of data, or analysis and interpretation of data; drafting the paper or providing revisions of content. 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