Foundations and Essentials for the Doctor of Nursing Practice

Educational Innovations

ABSTRACT Background: The social change model (SCM) promotes

equity, social justice, self-knowledge, service, and collabora- tion. It is a relevant framework for extracurricular leadership development programs that target students who may not self-identify as leaders. Method: Application of the SCM in a leadership development program for prelicensure nursing students from underresourced or underrepresented back- grounds is described. Students’ opinions about leadership for social change were explored through a focus group and a pilot test of an instrument designed to assess the values of the SCM. Results: Students lack the experience required to feel comfortable with change, but they come into nursing with a sense of commitment that can be nurtured toward leadership for social change and health equity through best practices derived from the SCM. These include sociocultural conversations, mentoring relationships, community service, and membership in off -campus organizations. Conclu- sion: Nurse educators can cultivate inclusive leadership for social change using the SCM as a guide. [J Nurs Educ. 2016;55(3):164-167.]

Leadership competence, which is essential for all nurses and required in prelicensure nursing curricula (American Association of Colleges of Nursing, 2008), is a lifelong

developmental process that should be guided by a comprehen- sive conceptual framework (Scott & Miles, 2013). Participation in extracurricular leadership development programs can build a student’s confi dence, provide experiences, and set the stage for a lifetime of meaningful activities. However, these programs must be accessible to all with attention to addressing the challenges of inclusivity (Read, Vessey, Amar, & Cullinan, 2013). The polish- ing diamonds approach, where self-identifi ed student leaders or those with high grade point averages are targeted for opportuni- ties, will never result in the development of a diverse cadre of professionals who can truly lead the way toward health equity. This article describes an extracurricular leadership development program for underrepresented and underresourced nursing stu- dents and introduces the social change model (SCM; Higher Education Research Institute, 1996) as its framework. The SCM, often used in non-nursing higher education settings, is especially relevant for nursing leadership in a diverse society.

Social Change as a Framework for Student Leadership Development

Student leadership development programming and inclusivity became increasingly intentional in the authors’ generic baccalau- reate nursing program after being awarded a Nursing Workforce Diversity Grant from the Health Resources and Services Admin- istration in September 2009 for an initiative called Keys to Inclusive Leadership in Nursing (KILN). It had been long since recognized that many students, especially those from underrep- resented and underresourced backgrounds, did not participate in activities that were typically viewed as leadership building, such as undergraduate research, semester abroad, service-learning opportunities, committee participation, networking events, and others. The KILN program, now funded by a private founda- tion with support from the university, provides resources and mentorship to 55 students each academic year. Participants are selected based on information from the university fi nancial aid offi ce that verifi es high need and a student essay that describes how he or she qualifi es as underrepresented or underresourced. For example, participants are typically fi rst-generation college students who speak a language other than English at home and whose families have a limited ability to provide fi nancial and other supports. Participation in leadership-building activities has

Social Change: A Framework for Inclusive Leadership Development in Nursing Education Catherine Y. Read, PhD, RN; Debra M. Pino Betancourt, MA; and Chenille Morrison, BS, RN

Received: January 22, 2015 Accepted: December 3, 2015 Dr. Read is Associate Professor, and Ms. Pino Betancourt is Associate

Director, Keys to Inclusive Leadership in Nursing Program, Boston College William F. Connell School of Nursing, Chestnut Hill, Massachusetts; and Ms. Morrison is Clinical Nurse, Adult Emergency Department, Yale-New Haven Hospital, New Haven, Connecticut.

Dr. Read and Ms. Pinoi Betancourt received fi nancial support for the Boston College “Keys to Inclusive Leadership in Nursing” program from the Health Resources and Services Administration (Nursing Workforce Diver- sity Grant D19HP14617), and all authors received a grant from the Price Family Foundation.

The authors thank Allyssa Harris, PhD, WHNP-BC, and Mitchell Li, BS, RN, for providing focus group assistance.

The authors have disclosed no additional potential confl icts of inter- est, fi nancial or otherwise.

Address correspondence to Catherine Y. Read, PhD, RN, Associate Pro- fessor, Boston College William F. Connell School of Nursing, 140 Common- wealth Avenue, Chestnut Hill, MA 02467; e-mail: [email protected].

doi:10.3928/01484834-20160216-08

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now become a typical characteristic of KILN participants, and the authors believe that the adoption of the SCM as a unifying framework has contributed to these outcomes.

The SCM Because social responsibility has become increasingly

viewed as an important college outcome, the SCM has been identifi ed as the model most often applied in college leadership development (Dugan, Bohle, Woelker, & Cooney, 2014; Owen, 2012). The SCM model was developed by the Higher Educa- tion Research Institute (1996) of the University of California Los Angeles (UCLA) for college students who want to learn to work effectively with others to create positive social change over their lifetimes. The SCM asserts that leadership is a col- laborative, service-oriented, values-based process that is about effecting change on behalf of society. The seven values of the SCM cluster across individual (consciousness of self and oth- ers, congruence, commitment), group (collaboration, common purpose, controversy with civility), and societal (citizenship) domains. The model posits that leadership includes individuals in positional and nonpositional roles, views leadership as a pro- cess rather than a position, and promotes equity, social justice, self-knowledge, service, and collaboration.

Relevance of Social Change for Nursing The centrality of nursing in the intertwined areas of health

care leadership and the promotion of social justice is a focus of contemporary discourse within the profession. Nursing’s Social Policy Statement (American Nurses Association, 2010) charac- terized nursing as an evolving discipline, with a responsibility to serve the interests of society through active and enduring lead- ership in public and political determinations about health care. The Institute of Medicine (2010) highlighted the need to educate nurses who can meet the present and future demands of health care—a goal that requires preparation for leadership roles in the redesign of the system. There is movement toward replacing the traditional focus on individualized behavioral health promotion strategies with a social justice agenda that would more effec- tively reduce the health inequities resulting from structural and other social determinants of health (Reutter & Kushner, 2010; Mohammed, Cooke, Ezeonwu, & Stevens, 2014). In nursing education, support is building for an “emancipatory nursing” approach that “seeks to address social and structural factors that infl uence health and that seeks social justice for all as a direct path to health and well-being” (Chinn, 2014, p. 487). Thus, the need for insightful nurse leaders with diverse backgrounds has become increasingly important.

Research on Leadership Development Programs The development of students as socially responsible leaders

is a purpose commonly found in university mission statements that has been a prominent area of study over the past two decades, especially in liberal arts settings (Dugan et al., 2014). In 1999, Burkhardt and Zimmerman-Oster conducted one of the fi rst multifaceted formal evaluations of funded leadership development programs and examined the impact of participa- tion in leadership activities on measures such as understanding of self, ability to set goals, sense of personal ethics, willingness

to take risks, civic responsibility, multicultural awareness, com- munity orientation, and a variety of leadership skills. Findings revealed that participants in formal leadership programs were much more likely to report signifi cant changes on those out- comes, compared with nonparticipants.

Avolio and Lester (2012) presented evidence that leadership development has both inborn and situational infl uences and sug- gested interventions that can increase leadership self-effi cacy in young emerging leaders. Leadership development should be viewed as an ongoing journey throughout the lifespan, where the individual utilizes self-refl ection and experience to create a positive leader self-concept that results in leadership behav- iors. This process can be facilitated by (a) instilling the mes- sage to emerging leaders that they have personal control over their development; (b) exposing emerging leaders to successful leaders for observational and social persuasion; (c) providing opportunities for service in leadership positions, where emerg- ing leaders can experience both success and failure and build their leader self-effi cacy; and (d) giving developmental feedback and encouragement that builds leadership self-effi cacy.

Dugan, Kodama, Correia, and Associates (2013) synthe- sized evidence-based best practices that refl ect the values of the SCM and build leadership capacity across various demographic groups, using data from more than 250 colleges and universi- ties that participated in the Multi-Institutional Study of Leader- ship Development, launched in 2006. The data gathered from that study also addressed some challenges of college leadership development programs, such as the need to increase collabora- tions across departments and to make better use of evaluation data for strategic planning (Dugan & Komives, 2007; Owen, 2012). In addition, Dugan et al. (2011) concluded that leader- ship programs have a narrow breadth of impact because 65% of senior students reported never participating in an individual leadership experience.

Although specifi c student leadership experiences, such as positional roles, can cultivate leadership self-effi cacy, a criti- cal lens must be applied when those roles are primarily occu- pied by students from dominant groups (Dugan et al., 2013). This has particular relevance in nursing and health care because health equity is at stake. A climate of inclusivity within a uni- versity is the key to the success of underrepresented and under- resourced students and sets the stage for program initiatives to be effective. Creating such culture change requires intentional embracement of a broad defi nition of diversity and open discus- sions about defi nitions of labels, underlying assumptions about student aptitudes, and strategies for ensuring student success (Read et al., 2013).

Adopting the SCM: Pilot Research Findings From the KILN Program

Initial steps toward adoption of the SCM as a framework for the KILN program involved a pilot test of the Socially Re- sponsible Leadership Scale-Revised Version Two (SRLS-R2; National Clearinghouse for Leadership Programs, 2013; Tyree, 1998) and a follow-up focus group. After obtaining approval from the university’s Offi ce of Research Protections, the 68- item SRLS-R2 was administered to 17 juniors and seniors (age range = 19 to 21 years) enrolled in the KILN program. This

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instrument uses a set of statistically valid and reliable scales constructed to measure the seven critical values identifi ed in the SCM, plus an eighth construct that measures comfort with change. Items are scored on a 5-point Likert scale, where a higher score indicates greater socially responsible leadership capacity. The purpose of this pilot study was to enable review of this proprietary instrument and solicit students’ opinions about whether the SRLS-R2 constructs could be used to evaluate the long-term goals of the KILN program. Although no statisti- cal inferences could be made based on the small sample, the SRLS-R2 pilot revealed that students scored highest on the con- struct of commitment (six items, mean = 4.67) and lowest on the construct of comfort with change (10 items, mean = 3.85).

The authors of the current study conducted a follow-up focus group to explore students’ opinions about the SRLS-R2 con- structs and the desired long-term outcomes of the KILN pro- gram. Eight junior and senior nursing students who had com- pleted the SRLS-R2 participated. All students in this racially diverse group qualifi ed as fi nancially underresourced by univer- sity guidelines. The audiotaped 1-hour session was conducted and analyzed by a faculty member who had expertise in focus group methodology and familiarity with the SRLS-R2 and the KILN program.

Students in the focus group conversed comfortably about their perceptions of the attributes of an admirable leader. These attributes included the ability to advocate for self and others, cultural competence, listening, networking and organizational skills, decisiveness, comfort with change and public speaking, open mindedness, well-roundedness, self-awareness, humility, and advanced education. They described socially responsible nursing leadership as a long-term commitment that recognizes disparities and creates avenues for positive change. Socially responsible nursing leadership requires an understanding of one’s own power to make change and a commitment to help those who may not be represented due to sociocultural or health circumstances. Participants credited experiences in the KILN program for increasing their awareness of the relevance of those attributes and reassuring them that leadership development is a lifelong process within a career that may unfold in unexpected ways. Many items on the SRLS-R2 resonated with students, especially those related to a nurse’s responsibility to the com- munity. They all agreed that the SCM was a strong framework for the KILN program that will set the stage for socially respon- sible decision making throughout their careers.

Overall, it was concluded from the SRLS-R2 pilot and the focus group that young prelicensure nursing students lack the experience required to feel comfortable with change, but they come into nursing with a sense of commitment. The change construct in the SRLS-R2 refl ects scores on items such as com- fort with transition, looking for and fi nding energy in new ways of doing things, and the ability to work well in new environ- ments. These attributes likely develop over time and with the confi dence that comes with success. However, commitment may be an internal characteristic that is fairly well-developed in high school and may have contributed to these students’ choice of nursing as a career and a religious-based nursing program in particular. Items related to the commitment construct on the SRLS-R2 include willingness to devote time and energy to

things that are important, following through on promises, and focusing on one’s responsibilities.

Identifying and Implementing Practices for Shaping Socially Responsible Leadership

The Multi-Institutional Study of Leadership Development (Dugan et al., 2013) identifi ed high-impact practices that are infl uential in shaping college students’ capacities for socially responsible leadership. The practices fell into four categories, which were used to plan activities for the evolving KILN pro- gram. The four categories and some examples of related KILN activities include:

● Sociocultural conversations: Language and cultural immersion programs, written logs and blog posts, and partici- pation in the school’s diversity advisory board meetings provide opportunities for conversations that address nurses’ advocacy for the vulnerable and underserved to infl uence health and social policy agendas.

● Mentoring relationships: Formal mentoring program with assigned faculty mentors, informal peer mentoring, and other mentorship opportunities on campus, such as research fel- lowships and supervised student organizations.

● Community service: Activities that benefi t the commu- nity, build student self-effi cacy, and foster university and com- munity relationships, such as local health fairs and infl uenza vaccination clinics, service immersion, and clinical placement in nontraditional community settings.

● Membership in off-campus organizations: Local and national nursing organizations provide a way for students to observe and interact with leader role models outside of the uni- versity, make connections for future collaborations, and witness the values of citizenship and controversy with civility that sets the stage for later participation in politically active organiza- tions.

Dugan et al. (2013) also found that it is important to provide experiences that are sequenced to meet students’ developmen- tal needs over time and with sensitivity to specifi c infl uences that may vary by racial and ethnic group. For example, African American/Black, Asian-Pacifi c American, and White students responded more positively to having a faculty mentor than did Latino students, whose leadership capacity was better predicted by having a peer mentor. Individual differences in students’ backgrounds and experiences challenge educators to provide support systems that are relevant to a diverse student population and to use sociocultural conversations to inform those efforts.

Discussion The literature presented in this article reveals that the devel-

opment of socially responsible leaders is a goal of many college programs that is often underpinned by the SCM. Evidence-based practices can facilitate the achievement of this goal. Nursing programs have yet to adopt a conceptual model or report on long-term outcomes of extracurricular leadership development initiatives, yet the need to prepare nurses as leaders with a social justice lens is broadly accepted. In a multicultural society affl icted with health disparities, the tenets of the SCM resonate.

Building and sustaining a leadership development program for nursing students works best when the university’s vision and

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mission are congruent with the goals of the program. The devel- opment of leadership capacity should be valued as an important aspect of the social dimension of student formation. A faculty leadership structure for the program needs to be implemented, university and community resources need to be leveraged, and external funding should be sought to enhance the initiative. Pro- grams must extend beyond didactic content and into co-curricular and extracurricular activities that are supervised or mentored by faculty and nurse leaders. The conceptual framework selected for the program should ideally be adopted throughout the insti- tution, and students of all abilities and backgrounds should reap the benefi ts of full participation in such programs.

Specifi c, measurable outcomes that would demonstrate the long-term effectiveness of socially responsible leadership development programs need to be identifi ed. Those outcomes should refl ect the participants’ activities that are aimed at reduc- ing health disparities, promoting social justice, and contributing to the betterment of society. We have begun such an evaluation through an alumni survey that includes items related to work in an underserved area, participation and leadership in com- mittees and professional organizations, mentorship activities, community service, leadership self-effi cacy, and attitudes about sociocultural issues. Despite the diffi culties inherent in obtain- ing long-term, follow-up data from alumnae and alumni, such a study could provide valuable information about best practices that could ultimately contribute to positive social change.

Conclusion Social justice and health equity are essential aspects of the

mission of nursing. Social change is an active, long-term pro- cess that begins with insight and is realized through skills that can be taught and developed in a nursing program and carried forward in one’s career and as a citizen of society. Nurse edu- cators are in a prime position to cultivate leadership for social change through intentional student programs that recognize the developmental nature and need for inclusivity in student forma- tion.

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