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10 NURSING LEADERSHIP: PERSPECTIVES AND INSIGHTS

Abstract The Dorothy Wylie Health Leaders Institute is a Canadian success story, providing leadership development to over 2,600 nurses and healthcare professionals since its inception in 2001.The authors describe the original design and intent of the Institute and its evolution over the last 18 years as both the context for leadership and leader- ship requirements have evolved. The Institute’s framework, key features, principles, concepts and streams of learning are outlined along with summaries of research on personal and organizational impact. Lessons learned and recommendations are included in the areas of program design, registrant selection and organizational support. This paper will be of interest to those who wish to better understand how the context of leadership in healthcare is evolving and how leadership attributes and behaviours can be developed to meet current and new challenges.

Building Healthcare Leadership Capacity: Strategy, Insights and Ref lections Julia Scott, RN, MBA1

Dorothy Wylie Health Leaders Institute Toronto, ON

Beverley Simpson, RN, MSc Dorothy Wylie Health Leaders Institute Toronto, ON

Judith Skelton-Green, RN, PhD Dorothy Wylie Health Leaders Institute Toronto, ON

Sue Munro, RN, MScN Dorothy Wylie Health Leaders Institute Toronto, ON

Introduction When the Dorothy Wylie Nurse Leaders Institute (DWNLI) was first conceived in the early 2000s, the healthcare system was in flux. Complexity, systems thinking, mental models and team/organizational learning were being discussed

1. The authors are the founders, designers and facilitators of the Dorothy Wylie Health Leaders Institute.

(Senge 1990; Wheatley 1999). We were, in short, entering what has come to be called a VUCA world: volatile, uncertain, complex and ambiguous (Impact International 2012; Horney et al. 2010).

At that time, little focus was placed on leadership development in educational programs. Masters of Health Administration and some nursing masters programs focused on administration; however, the subtle art of leadership was rarely explored in any great depth. Healthcare leaders often enrolled in MEd and MBA programs in search of the advanced skills they needed for career progression.

It had become apparent that there was an immediate and pressing need for leader- ship development opportunities for nurse leaders, so that they could better under- stand and apply concepts such as engaging and motivating professionals, develop- ing human capacity, building learning communities, leading self-managed work teams and instigating practice change (Simpson et al. 2002).

In the winter of 2001, the Ontario Ministry of Health and Long-Term Care (through the sponsorship of the Nursing Secretariat) provided seed funding to establish a nursing leadership institute in Ontario. From 2002 to 2008, the DWNLI was offered twice yearly. As early as 2002, non-nurses began to attend, stating that there was no comparable program available to them. Accordingly, in 2005, the principals designed and began developing the Health Leaders Institute (HLI). In 2009, as more healthcare organizations recognized the need for interprofessional education and collaboration (D’Amour and Oandansan 2005), the two institutes were combined to become the Dorothy Wylie Health Leaders Institute (DWHLI).

Since the Institute’s inception, the following key features have held constant:

• an (albeit evolving) evidence-based conceptual framework, • consistent expert facilitators (the authors), • current and relevant guest faculty (see www.healthleaders.ca for details), • an experiential learning design, • team registration (a minimum of two partners from a given organization), • organizationally based change initiatives and • a four-to-five-day residential session, with reinforcing activities over several

months.

Between 2001 and 2018, 30 Institutes have been held, involving over 2,600 health professionals from sponsoring organizations across almost all Canadian provinces and territories. Sponsoring organizations have benefitted from 1,195 locally rele- vant change initiatives. Evaluations, from individual participants, from sponsoring organizations and from impartial observers, have been consistently positive.

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In late 2015, the DWHLI formed a partnership with the Canadian Nurses Association with the goal of extending the Institute’s reach, exploring new learn- ing approaches and using technology to enhance participation.

Original Intentions and Rationale We viewed leadership development as an important component of a complex strategy to develop individuals who can lead through health system challenges and as both an investment in the present (by helping the system adapt quickly to new requirements and challenges) and in the future (by engaging a new cadre of talent for succession purposes). We wanted to create something unique, a different kind of learning opportunity: a concentrated, engaging learning experience where nurses in any role and at any age or career stage would be able to participate fully, learn and grow in their comfort and confidence as leaders. We committed to creat- ing a highly interactive and engaging experience where participants were partners in learning. Serendipitously, we were able to secure a progressive residential venue that specialized in experiences geared to active learners.

Principles and Streams of Learning A number of key principles were selected to guide the development and conduct of the Institute (Simpson et al. 2002). Since its inception, the DWHLI has held true to the principles of experiential learning, linking theory and practice, collabo- rative self-reflection and a challenging and stimulating experience for participants. Learning has consistently been interwoven through three key areas: the concep- tual framework: the key areas upon which healthcare leaders must focus; change leadership: supporting participants to put their learnings into practice through an organizationally based change initiative; and personal leadership development: frameworks and tools for personal development of leadership characteristics.

Conceptual Framework and Related Content The principals believed strongly that an integrated conceptual framework was important for participants to understand key concepts central to healthcare lead- ership and also to guide the selection of content and exercises. Over the years, as our audience and the healthcare leadership literature evolved, so too did the framework. The original conceptual framework can be found in Simpson et al. (2002). The current framework is illustrated in Figure 1.

In sessions related to the conceptual framework, participants are grouped with diverse colleagues whom they are unlikely to have met and engaged in collabora- tive exercises to apply learning. Over the years, some content has changed to align with updates in leadership theory. However, a number of key core sessions have remained relatively constant.

13Building Healthcare Leadership Capacity: Strategy, Insights and Reflections

Use of self has two major components – emotional intelligence (EI) and self-care. The work on EI is anchored in the work of Goleman and colleagues (Goleman 2005; Lash 2018), which identifies four interconnected aspects of EI: self- awareness, self-management, awareness of/empathy for others and relationship management. Sessions on self-care include content and exercises on courage, vulnerability, resilience and personal leadership development. The work on leader- ship practices is anchored in Kouzes and Posner’s five practices of exemplary lead- ers (Kouzes and Posner 2017b.) Their long-standing, evidence-based leadership model, with 30 years of research behind it, states that leaders model the way, inspire a shared vision, challenge the process, enable others to act and encourage the heart.

Collaborative relationships – a key component of excellence in practice – builds on The Neuroscience of Leadership: The Evolution of Performance. By outlining the three critical components of the Performance Evolution Pyramid, Paucha (2018) assists participants to get a deeper sense of how an inspiring vision (Boyatzis et al. 2015), creating an approach culture through reducing threats to change (Rock 2008) and adopting an organizational growth mindset (Dweck 2017) are founda- tional elements to build strong, sustainable collaborative relationships needed for high performance in complex environments.

Use of Self Leadership Capability

Excellence in Practice

Optimal Health Outcomes

Lea din

g Ch ang

e & Inn

ova tion

in Complex Environments

Figure 1. Current DWHLI conceptual framework

14 Nursing Leadership Volume 31 Number 4 • 2018

Person-centred care – another key component of excellence in practice – builds on provincial, national and international evidence that engaging people and their families in their healthcare results in better outcomes (Baker 2014; Balik 2015; Fooks et al. 2015; Hoffmann et al. 2014) and on the important link between patient and staff experience in IHI’s Joy in Work (Perlo et al. 2017). Using stories, videos and exercises, we discuss leading practices and explore opportunities, strat- egies and approaches. Other aspects of the program have evolved as we learned about new concepts and approaches to leadership, organization development and facilitation. At various times, we have included work on empowerment, innova- tion, ethical leadership, team dynamics, complex adaptive systems and mindful- ness. Learning modalities have included open space, knowledge cafes, appreciative inquiry, meditative exercises and liberating structures.

Change Leadership The second major focus of the DWHLI involves participants’ working with colleague(s) to lead a change project at their organization. An evidence-based framework with three core elements – being strategic, engaging people and imple- menting the project – grounds this work. This framework has been updated regu- larly as knowledge and evidence about successful change leadership has evolved (Skelton-Green et al. 2007; Perlo et al. 2017). Before attending the Institute, partic- ipants work with a corporate sponsor to select a project that is strategically aligned within their organization, has the support of key stakeholders and is of a manage- able size and scope. During the Institute, participants receive coaching support to develop a SMAART goal, an engagement strategy and an implementation strategy. During follow-up sessions, they present their project experience to other partici- pants, highlighting successes and lessons learned.

Personal Leadership Planning The third major stream of learning – personal leadership planning – is reinforced throughout the residential part of the Institute. Participants are regularly encour- aged to reflect on what the content and exercises of the moment mean for them as individual leaders. In addition, participants complete two self-assessments, one on EI and one on the five leadership practices (Kouzes and Posner 2017a). Then in a dedicated session, they are encouraged to identify a leadership practice or aspect of EI that they would like to strengthen, to name specific behaviours they want to demonstrate more frequently and to identify specific actions they will under- take to advance this goal. To support this session, the principals have compiled an extensive listing of ideas and exercises into a topic-related resource booklet.

Impact Participants Over 18 years and 30 Institutes, participants have spanned the Canadian health- care industry in terms of roles, sectors and geographic location. Approximately 80% of graduates are nurses; the remaining are clinical and administrative profes- sionals. In total, 40% are in first-level manager roles, with others holding middle/ senior management, education/professional/advanced practice and front-line roles. Moreover, 70% work in acute care, with the remainder from mental health, long-term care, first nations, government, rehabilitation/complex care, education or community/public health. Also, 75% live and work in Ontario.

Participants provide input on speakers and topics during the on-site sessions and are encouraged to offer structured ratings via online surveys twice during their program. Evaluations are consistently very positive about the venue, the speakers, the facilitation and the opportunities presented for experiential learning. We use evaluation responses to continually improve the program.

Projects The almost 1,200 projects completed fall into four main categories including care delivery (models of care, pathways, etc.), healthy workplace (values and culture, retention, etc.), personal/professional team development (role development, orientation, mentoring, etc.) and business of healthcare (information technology, evaluation, etc.). Many of these projects have had a significant impact, both inter- nally and system-wide. Numerous presentations at local, provincial, national and international conferences have been undertaken by alumni. Employers regularly highlight the value-add of this component of the program.

Sponsoring organizations By far, the majority of participants are sponsored by their employers to attend. Sponsoring organizations span the full range of healthcare providers, from tertiary and quaternary hospitals to small long-term, community care and public health organizations. As a testament to perceived “value-add,” once an organiza- tion has sent participants, it often does so for many years.

Bursaries and studentships Since its inception, the institute was designed to run as a not-for-profit venture. Where possible, sponsors were secured to support key aspects of the program. Nonetheless, with careful fiscal management – and with support from the Canadian Institutes of Health Research/Canadian Health Services Research Foundation (CIHR /CHSRF) Health Human Resources Chair, Johnson & Johnson

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Medical Products, the Professional Practice Network of Ontario and the Nursing Leadership Network of Ontario – we were able to develop bursary and student- ship funds. Over the years, these funds have provided almost 100 bursaries and studentships, for a combined value of nearly $400,000.

Credits and alliances From the outset, we worked to support and assist alumni to gain advanced credit at various organizations for their attendance at the DWHLI. Historically, several universities provided transfer credits for the Institutes. Over time, as these univer- sities strengthened their internal leadership courses, they no longer granted credit. In 2006, we entered into a formal strategic alliance with Canadian College of Health Leaders (CCHL), which provides incentives for alumni who are members of CCHL to pursue their Certified Health Executive (CHE). We have also worked closely with CCHL to ensure that our conceptual framework is aligned with CCHL’s LEADS in a Caring Environment framework (CCHL 2018, Dickson 2010.)

External evaluations In 2004, Tourangeau et al. conducted a study to determine changes in leadership competencies and burnout from the perspective of the leader, supervisor and peers. Although DWHLI participants did not perceive any change, both managers and peers reported improvements in the use of leadership practices after partici- pation in the Institute. In a “downstream” comparison of selected national leader- ship initiatives, Snell (2010) conducted a qualitative study of DWHLI alumni to understand their experiences back in their home organizations. Program design features reported to be advantageous to learning included the venue and program structure, networking among novice and expert participants, group activities, leadership assessment tools and conversations with high-calibre speakers. The most important leadership skills developed were overall confidence as a leader, improved listening skills and learning the language of leadership.

In 2016, an evaluation study was conducted by Purdy to understand the perceived influence of the Institute on the professional lives and careers of alumni over time. The majority of alumni (50–68%) rated the impact of the Institute as significant or very significant on seven of eight intended leadership outcomes. For 73–78% of alumni, the Institute had a recurring or profound positive impact on their professional lives as leaders and personal careers. Alumni who reported the greatest impact of the program on their knowledge, skills and confidence as leaders also had higher levels of career satisfaction and work engagement. Design elements that impacted their development included the theoretical and concep- tual content, interactive and experiential structure and mentoring (Purdy 2016.)

Lessons Learned and Discussion We have often been asked, “What have you learned/What do you recommend about leadership development?” In a 2011 paper, we published our learning about leadership development in three key areas: (a) insights regarding the individual (the leadership aspirant or learner), (b) insights related to the organization’s role in supporting leadership development and (c) insights related to leadership program design (Simpson et al. 2011). In the section following, we consolidate these insights, and other lessons learned since then, into five key recommenda- tions and offer some discussion points.

Grounding the program in solid and current theory, and creating opportunities to practice that theory, enables participants to more readily apply new learning in their work environments A core commitment of the DWHLI is to ground its programs in solid and current theory. A comprehensive and theoretically grounded framework serves a number of important purposes: it frames the challenge of leadership for learners, iden- tifying the key areas of growth and development they may need to undertake; it serves as a filter to guide the selection of content and learning experiences; and it illustrates for participants why certain elements have been included, how they connect with one another and how they will assist them to be more complete and capable leaders. Purdy (2016) noted that the theories and related concepts presented as part of the DWHLI curriculum contributed to the positive impact on the alumni’s professional and personal leadership development. When people are considering new ideas or challenging traditional thinking, the credibility of the person introducing the new material is critical. It is therefore extremely impor- tant that guest faculty be up to date and have the ability to relate to the real world of learners. This applies to not only the material that they present, but also how skilful they are in delivering it. We have learned that we must work closely with faculty not only on the what but also the how of their sessions – tying the content to the conceptual framework, negotiating an experiential rather than a didactic approach, designing exercises that are engaging and relevant to the audience and ensuring that all learning aids are effective. The consistent use of expert facilitators is invaluable in ensuring that learning experiences are on time, on topic and add value.

Use of adult learning principles and practices to guide program design is necessary and appropriate for an audience of real-world practitioners We knew that we needed to attend carefully to adult learning principles (Knowles 2005) in designing our program. Accordingly, we committed early on to the consistent use of an experiential learning design. “Experiential education first immerses learners in an experience and then encourages reflection about the experience to develop new skills, new attitudes, or new ways of thinking”

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(Lewis and Williams 1994). In the DWHLI, we carefully limit “sage from the stage” time in favour of diverse opportunities for testing new ideas. We also spend a significant amount of time creating diverse table groups that will stretch partici- pants’ thinking and build their networks. Purdy (2016) noted that a large number of alumni commented on the value of the interactive design. Knowles (2005) states that adult learners thrive in collaborative relationships with their educators. We believe that “the answers are in the room,” and have committed to the princi- ple that the DWHLI will be a learning community, where faculty, facilitators and participants are partners in learning.

We were initially surprised to discover that many participants did not have confi- dence in their ability to lead, despite the fact that many had been in leadership roles for several years. Schein, cited in Marshak (2016), reinforces this finding in his discussion of learning anxiety. This supports the premise that leaders are made, not born and that leadership is a learnable set of skills available to anyone who is willing to learn and improve (Kouzes and Posner 2016, 2017). Purdy (2016) found that one of the most significant and lasting effects noted by DWHLI participants was an increase in their confidence as leaders.

Use of multiperson registration will promote co-mentoring and transferability of learning We are sure that all readers have experienced the frustration of attending an uplifting conference or workshop and a return to work excited by new ideas, only to be discouraged to find little understanding or support. In an attempt to offset this risk, we require multiperson registration. Initially, we asked organizations to send dyads of established and emerging leaders, in the hope that this would foster mentoring relationships of benefit to both parties and would assist in succes- sion planning. While this approach was successful (Purdy 2016), we also learned that there is value in registering team members who are working on a shared goal in the organization (e.g., professional practice leaders from various disciplines who share the goal of developing an interprofessional practice council). In short, multiperson registration not only fosters cooperation and co-mentoring, but also supports the transferability of new learning to the home setting.

A residential design and “learner-friendly” venue will greatly enhance learning In the earliest stages of planning for the DWHLI, we sought to create a leadership development experience that removed participants from day-to-day responsibili- ties and distractions (both work and personal) and immersed them in a positive learning milieu.

We believed in, and have borne witness to, the many benefits of a residential setting, as we regularly witness examples of non-programmatic learning that occurs when participants are together in a residential learning environment.

We have been exceedingly fortunate to be able to hold all our Institutes at the Bank of Montreal’s Institute for Learning in Scarborough, Ontario. Particular features of this venue include a somewhat isolated yet aesthetically appealing site, a wide range of learning spaces (with state-of-the-art audio-visual technology and support), staff who understand and are committed to supporting learning, comfortable accommodations, excellent food and service, fitness facilities and space for gathering.

Assisting sponsoring organizations to select participants carefully, and to engage fully with them on their leadership journeys will add value for all parties We have learned that if an individual is to begin a leadership development jour- ney, he or she must first develop a self-perception as a leader. For many people, this means an invitation to leadership and support from an admired leader or mentor. Our experience shows that leadership growth is enhanced if individuals self-select to a development program at a time that is right for them. Our experi- ence also supports senior leaders using encouragement – not coercion – for indi- viduals to participate in a leadership program and entering into a formal or infor- mal accountability agreement regarding the expectations of their participation.

There are a number of employers who have been sending participants to the DWHLI since its inauguration. Over time, these “repeat” organizations have become very strategic in how they use the DWHLI to advance their organizational goals. Many require interested staff to compete for the privilege of attending, ensure that the projects will advance organizational priorities and assign execu- tive sponsors to guide the projects and encourage participants’ ongoing leadership development. Some deliberately create a community of leader-learners, to gain synergy and alignment and to foster leadership succession.

Conclusion Leadership is crucial to the success of healthcare organizations as they strive to meet increasingly complex challenges. It is also critical to the successful evolution of Canada’s cherished public healthcare system. Our understanding of leader- ship development is much broader today than it was when we began the DWHLI in 2001. Historically, leadership was viewed as a formal position with a title and specific management accountability. Today, leadership is understood to be a requirement of all professional roles and positions. It involves understanding, influencing and challenging human systems dynamics; role modelling values and culture; enabling, encouraging and engaging others; building capacity, generat- ing and supporting leadership in others; learning to lead and thrive in uncertainty and complexity; and promoting successful change and innovation, being adaptive, courageous, authentic and resilient and actively embracing self-care (Jeffs 2018; Eoyang and Holladay; 2013, Anderson et al. 2009; Bowles 2009; Heifetz et al. 2009).

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Since the inauguration of the DWHLI, numerous other non-graduate-level programs have been established (a few examples include the CCHL’s – LEADS in a Caring Environment, McMaster University’s Health Leadership Academy and the British Columbia Institute of Technology’s Advanced Certificate in Health Leadership). Notwithstanding the number and quality of current offerings, the work is not nearly done; thousands more Canadian health professionals need a better understanding of their roles, responsibilities and relationships as leaders, as well as the concepts and tools to lead in volatile, uncertain, complex and ambigu- ous situations. All health professionals have an important leadership role to play in the necessary transformation of the Canadian healthcare system that is under- way. We are pleased to have played a small part in this important endeavour and gladly share our learning to support the work of others taking this forward.

Correspondence may be directed to: [email protected]

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Building Healthcare Leadership Capacity: Strategy, Insights and Reflections

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