Leadership Assessment

Development of the Leadership Influence Self- Assessment (LISA©) instrument

Casey R. Shillam, PhD, RNa,*, Jeffrey M. Adams, PhD, RN, NEA-BC, FAANb, Debbie Chatman Bryant, DNP, RN,FAANc, Joy P. Deupree, PhD, RN, WHNP-BCd,

Suzanne Miyamoto, PhD, RN, FAANe, Matt Gregas, PhDf a School of Nursing, University of Portland, Portland, OR

b Jeff Adams, LLC, Belmont, MA c College of Nursing, Medical University of South Carolina, Charleston, SC d University of Alabama, Birmingham School of Nursing, Birmingham, AL

e American Association of Colleges of Nursing, Washington, DC f ITS Research Services, Boston College, Chestnut Hill, MA

A R T I C L E I N F O

Article history: Received 4 July 2017 Revised 28 October 2017 Accepted 30 October 2017 Available online November 15, 2017.

Keywords: Leadership Influence Instrument development Self-assessment Professional development

A B S T R A C T

Purpose: This study aims to describe the development and psychometric evalua- tion of the Leadership Influence Self-Assessment (LISA©) tool. Background: LISA© was designed to help nurse leaders assess and enhance their influence capacity by measuring influence traits and practices and identifying areas of strength and weakness. Methods: Concepts identified in the Adams Influence Model and input from content experts guided the development of 145 items for testing. Administered to 165 nurse leaders, the assessment was subjected to exploratory factor analysis (EFA). Findings: EFA yielded a four-factor solution that comprised 80 items. Cronbach’s alpha for factors ranged between 0.912 and 0.938. All factor loadings were >0.4; the smallest factor contained 14 items. Items grouped together in the theoreti- cal model also clustered together in the EFA. Conclusions: Preliminary psychometric testing supports validity and reliability of the LISA© and its potential use as a tool to assess influence capacity for pur- poses of leadership development and research. Cite this article: Shillam, C. R., Adams, J. M., Bryant, D. C., Deupree, J. P., Miyamoto, S., & Gregas, M. (2018, MARCH-APRIL). Development of the Leadership Influence Self-Assessment (LISA©) instrument. Nursing Outlook, 66(2), 130–137. https://doi.org/10.1016/j.outlook.2017.10.009.

Acquiring influence and knowing how to use it ef- fectively are fundamental competencies for health- care leaders (American Organization of Nurse Executives (AONE), 2015; National Center for Healthcare Leadership (NCHL), 2006). The importance of influence for nurse leaders has been highlighted by multiple organiza-

tions that are charged with improving health-care quality and safety. The American Nurses Credentialing Center (ANCC, n.d.) and Joint Commission (Governance Institute, 2009) have called on nurse leaders to use their influ- ence and professional nursing expertise to transform organizations to better meet the needs of patients and

Funding sources: This work was supported by the Robert Wood Johnson Foundation Executive Nurse Fellows program. * Corresponding author: Casey R. Shillam, 5000 N. Willamette Blvd., MSC 153, Portland, OR 97203.

E-mail address: [email protected] (C.R. Shillam). 0029-6554/$ — see front matter © 2017 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.outlook.2017.10.009

Available online at www.sciencedirect.com

N u r s O u t l o o k 6 6 ( 2 0 1 8 ) 1 3 0 – 1 3 7 www.nursingoutlook.org

staff, and the Institute of Medicine (2011) has urged nurses to expand and use their influence to help rede- sign the U.S. health-care system.

For emerging nurse leaders, the emphasis on influ- ence is complicated by a lack of understanding of how influence works and how to strengthen one’s capacity to influence. Although influence as a concept and process has been examined in depth by a variety of dis- ciplines (French & Raven, 1959; Kacmar, Carlson, & Harris, 2013; Katz & Kahn, 1966; Kipnis, 1976; Kipnis & Schmidt, 1988; Martin, 1995; Mowday, 1978; Yukl & Falbe, 1990), the focus within nursing has historically been on its role in promoting change and desired outcomes (Bradley, 2014; Brady & Cummings, 2010; Laschinger & Smith, 2013; Lunaigh & Hughes, 2016; Shirey, 2013) rather than on how it is acquired and best used.

Influence, generally described as the ability to per- suade or convince others (National Center for Healthcare Leadership (NCHL), 2006), is of increasing importance in today’s highly collaborative health-care markets. Lead- ership influence impacts workforce performance, motivation, and perceptions of interprofessional col- laboration. Further, influence guides and directs strategic decisions and changes at the organizational and system levels (Musselwhite & Plouffe, 2012; Newton, 2016).

Much of the definitive research on influence has been conducted within the psychology, business, and orga- nizational studies disciplines (French & Raven, 1959; Katz & Kahn, 1966; Kipnis, 1976; Kipnis & Schmidt, 1988; Martin, 1995; Mowday, 1978; Yukl & Falbe, 1990) and in many cases has focused on influence as it relates to physical products and marketing. Although the re- search was conducted outside the traditional health- care arena, it offers important and useful insights about the influence process. Further, its findings can be readily extrapolated to interpersonal influence, which is the type of influence most relevant to health-care leaders and person-oriented disciplines such as nursing.

Interpersonal influence refers to influence that occurs within the context of a relationship involving two or more people (Bell, 1975; Pentony, 1981): an influence agent (Allen & Porter, 1983), or the person seeking to in- fluence, and an influence target. Although an individual might be considered generally influential and able to exert influence in multiple domains, a person’s capac- ity to influence frequently varies depending on the issue (Dutton & Ashford, 1993).

Conceptual Framework

The study of influence within nursing was recently ad- vanced by the introduction of the Adams Influence Model (AIM) (Adams & Natarajan, 2016), which de- scribes the attributes, factors, and process of influence in relation to nurse leaders, and identifies key con- cepts that impact a nurse leader’s influence capacity. The AIM (Adams & Natarajan, 2016) was used to un- derstand the factors, attributes, and process of influence.

According to Adams (2009), influence is the ability of one person to sway another person or group based on a set of defined factors (authority, communication traits, knowledge-based competence, status, and time and timing) and corresponded attributes as identified in Table 1.

The AIM is a dyad model with an Influence Agent (Agent) and Influence Target (Target) consisting of in- teraction between an individual or a group and existing within open social, interpersonal, and personal systems (Figure 1). Both the Agent and the Target possess each of the influence factor and attribute characteristics to varying degrees and titrate and use them differently given each influence issue or scenario. Each character- istic is associated with a set of attributes that further describe the characteristic and how it is manifested in practice. At the core of the AIM is the iterative interac- tion process of influence whereby the Agent draws on her or his perception of the Target and chooses an in- tervention or tactic. The influence agent may use a variety of tactics, from forming a coalition of like- minded individuals to employing rational persuasion or an inspirational appeal (Kipnis, Schmidt, & Wilkinson, 1980; Yukl & Falbe, 1990; Yukl & Tracey, 1992). In turn, based on the intervention or tactic chosen by the Agent, the Target updates her or his perception of the Agent and provides feedback. Then either influence is achieved or the Agent may relent or modify the selected tactic so the process can begin again.

The AIM is unique in the influence literature as it was developed specifically for nurse leaders and describes the influence process particularly as it relates to nurse leadership (Adams & Ives Erickson, 2011; Adams & Natarajan, 2016). The model was developed through an iterative process that drew on influence research, in- sights from nursing theory, input from expert reviewers, and the results of pilot and validation studies (Adams & Natarajan, 2016). The AIM approximates a camera shutter, signifying the model’s focus and perspective on a single issue and particular moment in time (Figure 1). Through this singular focus, the AIM distinguishes in- fluence from power, which within the context of the AIM is the cumulative result of being able to influence mul- tiple issues.

Although the AIM provides guidance for understand- ing the influence components and process of influence in relation to nurse leadership roles, the responsibility remains with individual nurses to translate its con- cepts to their own leadership practice. Tools to help leaders gain insight into their influence style (e.g. ra- tionalizing vs. negotiating) are widely available (Discovery Learning International, n.d.). In contrast, there is a paucity of tools to aid leaders in assessing and strength- ening their capacity for influence.

In this article, the authors describe the develop- ment of a self-assessment instrument called the Leadership Influence Self-Assessment (LISA©) that is de- signed to fill this need. By measuring a nurse leader’s influence traits and practices, the LISA© helps leaders gauge their capacity to influence and identify strengths

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and areas for improvement. The study team describes the process of item development, instrument admin- istration, and psychometric evaluation and discusses how the LISA© may be used to help nurse leaders in diverse health-care arenas enhance their influence ca- pabilities to effect meaningful change.

Methods

The study team used the AIM as a conceptual frame- work when developing the LISA©. Concepts contained within the AIM provided a framework for item

Table 1 – The Adams Influence Model: Definitions of the Influence Factors and Attributes

AIM Influence Factors Definitions AIM Influence Attributes

Definitions

Knowledge-based competence

The quality of being adequately or well-qualified intellectually so as to meet or exceed standards of performance

Empirical knowledge

The application of theories of science; factual knowledge of nursing, the scientific body of nursing knowledge

Personal knowledge Providing the means to become more aware of culture, customs, beliefs, and emotion

Aesthetic knowledge

Envisioning desired outcomes to respond with appropriate action; knowing how to be creative, open, empathetic, and holistic

Ethical knowledge The capacity to make choices regarding moral judgments within situations; expressed in codes, standards, and ethical frameworks

Sociological knowledge

Areas that affect the health of the population such as class structure, poverty, sexism, and racism

Authority The right to take actions to responsibility

Accountability The state of being liable or answerable Responsibility The social force that binds a person to the

courses of action demanded by that force

Access to resources Ability to manage or oversee finances, information, or goods that are needed or valued by others

Status Having high standing or prestige Hierarchical position

An organized body of officials in successive ranks or order

Key supportive relationships

An emotional or other connection between people

Reputation A favorable and publicly recognized name or standing for merit, achievement, and reliability

Informal position An assumed or appointed role and the related pattern of expected interpersonal behaviors associated with the role

Communication traits

The proficiency or dexterity with which one person relates or interacts with other people

Message articulation

The shape or manner in which things come together and a connection is made

Emotional involvement

To engage interests, emotions, or commitment

Persistence The act of persevering, continuing or repeating behavior

Confidence Belief in oneself and one’s power or abilities

Physical appeal— self

The attractiveness of the individual

Physical appeal— environment

An expected order to one’s surroundings

Presence Being with another physically and psychologically

Use of time and training

The understanding of both the interval in which action is available to be taken and the optional judgment and delivery of when an action is taken

Amount of time to sell an issue

A limited period or interval, as between two successive events

Timing to deliver the issue

The selecting of the best time or speed for doing something to achieve the desire or maximum result

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development and for the initial hypothesized factor structure for psychometric analysis. As part of this psy- chometric analysis, the study team planned an exploratory factor analysis (EFA). The details of this plan are further highlighted in the following sections.

Instrument Development

Providing background for item development, each member of the study team interviewed three nurse leaders from academic, practice, policy, or philanthro- py settings. Each of the five team members was charged with interviewing three nurse leaders (a total of 15 nurse leaders). Each interview consisted of four standard- ized questions identified by team member consensus. The questions were as follows:

1. What kind of leaders do we need in the health-care system now and in the future?

2. What skills do these leaders possess? 3. Do you know of nurses now who have these skills

and in what positions are they serving? 4. Based on the conversation we have had, is there any-

thing that stands out for you that you think may be helpful as we move forward?

Qualitative narrative analysis of the interviews re- sulted in several common themes (Table 2). The synthesis of the skills and qualities identified by the interviews closely reflected the five AIM factors: competence, au- thority, time and timing, status, and communication, with all skills found in the details of each of these factors and the subsumed attributes (Table 1). The interviews

Figure 1 – The Adams Influence Model (Adams & Natarajan, 2016). Used with permission.

Table 2 – Qualitative Interview Themes

Skills Identified by Leaders in Academic/ Practice Settings (Chief Nurses, Deans, etc.)

Skills Identified by Leaders in Public Sectors (Government, Policy, etc.)

Overlapping Skills

Influence as emotional intelligence Servant leadership Sense of micro and macro focus Strong communication/negotiation skills Authentic leadership Informed risk-taker (opportunistic)

Emotional intelligence Negotiation Skills Authentic Leadership Risk-takers Integrity, Fearless, Confident, Timing

Emotional Intelligence Negotiation Skills Authentic Leadership Risk-takers

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further validated the AIM’s relevance to nurse leader practice and also provided content that informed the development of items for testing.

The team then drew on topics and content from the interviews and personal experiences as nurse leaders to develop an initial set of 192 instrument items. Each item addressed one of eight hypothesized compo- nents or domains addressed by the AIM: influence, power, perceptions, and the five influence factors or char- acteristics that nurse leaders titrate as influence agents and targets. Each instrument item was worded as a pos- itively directed, closed-ended question and asked about the respondent’s experience with, or use of the target domain. Item responses were captured through a Likert scale that ranged from 1 (“not at all”) to 6 (“total/complete”).

The face and content validity of the 192 items was assessed by a panel of 12 content experts. The panel in- cluded leaders from nursing and other health-care disciplines who represented academic, policy, and prac- tice settings. The panelists scored each item with two dichotomous yes/no questions: one question addressed item clarity and the other question addressed repre- sentativeness of the target construct. A third question asked for qualitative feedback if the panelist answered “no” to either question. Several items were removed or reworded with minor changes to the item text based on the expert panel feedback. The review process yielded a test instrument with 145 items and eight hypoth- esized components or subscales.

Sampling and Data Collection

Approval for instrument administration and testing was obtained through the University of Alabama at Birming- ham (UAB) Institutional Review Board. Study data were collected and managed using REDCap (Research Elec- tronic Data Capture) electronic data capture tools hosted at UAB (Harris et al., 2009). REDCap is a secure, web- based application designed to support data capture for research studies, providing (a) an intuitive interface for validated data entry, (b) audit trails for tracking data ma- nipulation and export procedures, (c) automated export procedures for seamless data downloads to common sta- tistical packages, and (d) procedures for importing data from external sources.

To identify potential survey participants, the members of the study team drew on their associations with pro- fessional networks, which included nurse leaders in patient care services, nursing education, and email dis- tribution lists from several national and regional professional nursing organizations. The study team sent introductory e-mails with the REDCap survey link to po- tential participants in May 2016. The email explained the purpose of the study, invited recipients to com- plete the survey, and also invited them to participate in snowball sampling by forwarding the email message and survey link to their own professional networks and colleagues. Data collection was closed in June 2016, after the receipt of 201 surveys.

Data Analysis

Data from the surveys were entered into SPSS (IBM SPSS Statistics version 24; IBM Corp., Armonk, NY) and evalu- ated for completeness. Although the total percentage of missing data was small (less than 2%), the missing values were distributed over many subjects and only 80 subjects had complete data. Multiple imputation (Rubin, 1996) was used to estimate the missing values, result- ing in a total analysis sample size of 165 participants. Frequencies and descriptive statistics indicated that all items showed sufficient variability to be included in an EFA. Five imputed datasets were obtained; an EFA was performed on each dataset and results were com- pared for consistency.

Maximum likelihood was used as the extraction method for the EFA. Direct oblique rotation was used with the value of delta = 0. This produces a rotation that need not be orthogonal and does not constrain factors to be uncorrelated. The number of factors was deter- mined primarily through the examination of scree plots.

Findings

The final sample (n = 165) was 92.8% female (Table 3). Subjects, on average, were 53 years of age (standard de- viation [SD] 9.8), had been in their current administrative roles for 9 years (SD 8.83 years), and had 27 (SD 39.53) direct reports. The scree plots from all imputed datasets were similar and suggested a four-factor solution. An item was loaded onto a factor if the following condi- tions were met:

1. The item loading was greater than 0.4 on all five of the imputed datasets.

2. The item loading was greater than 0.415 on four of the imputed datasets.

3. The item loading was greater than 0.425 on three of the imputed datasets.

4. The item loading was greater than 0.435 on two of the imputed datasets.

5. The item loading was greater than 0.445 on one of the imputed datasets.

6. Items that did not meet any of the above criteria were dropped.

Under this rubric, a total of 80 items were assigned to one of the factors; all factor loadings were greater than 0.4, and there were no cross-factor loadings. A review of the items assigned to each factor indicated that items that were grouped together in the theoretical model also clustered together in the EFA.

After the EFA was complete, an expert panel examined the resulting factors to define the construct represented by each factor and ensure each item’s in- clusion was both scientifically and theoretically justified. The four factors (Table 4) were labeled as Status (18 items, Cronbach’s alpha = 0.932), Authority (25 items,

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Cronbach’s alpha = 0.938), Strategy (14 items Cronbach’s alpha = 0.916), and Integrity (23 items, Cronbach’s alpha = 0.912). Of note, the Cronbach’s alpha for each factor was calculated from the same data used to create the factor, which may have resulted in a slight infla- tion of its value.

Limitations

The limitations of the study include the use of a con- venience sample that may not be representative of all nurse leaders. Additionally, the ratio of the number of items to the number of responses was low, and tradi- tional metrics such as the Kaiser-Meyer-Olkin test suggested the EFA results should be viewed with some caution, probably because of the small sample size.

Discussion and Recommendations

In a study conducted by Gallup for the Robert Wood Johnson Foundation (RWJF) in 2010 (Robert Wood Johnson Foundation and Gallup, 2010), opinion leaders representing a broad range of sectors were asked to identify who would influence health reform in the United States in the next 5–10 years. Listed last, after government officials, insurance executives, pharma- ceutical executives, healthcare executives, doctors, and patients, were nurses. Barriers identified as inhibiting nurses from exerting influence included the percep- tion that nurses lacked strategic vision, were not important decision makers relative to physicians, and had limited opportunities to advance into leadership positions. Although some may argue that in the last 7 years, great progress has been made on many fronts, there is still much work to be done. Even without a more current data point, influencing health reform and transformation still remains a priority for the nursing profession.

Table 3 – Survey Sample Characteristics

Characteristic N %

Gender Female 152 93 Male 12 7

Employment status Full-time 155 94.5 Part-time 6 3.60

Temp per diem (<20 hr) 3 1.80 Race

African American 2 1.20 Asian 1 1.00 Pacific Islander 8 4.80 White 156 94.5

Hispanic Yes 4 2.5 No 158 97.5

Highest level of education Doctoral 75 41 Masters 83 50 Baccalaureate 11 7 None of the above 2 1

Likely to retire within 3 years Yes 19 12 No 131 79 Unsure 15 9

Magnet status of current employer Not pursuing magnet accreditation 41 36 On the journey 39 34 Application submitted 7 6 Magnet accredited 21 18 Unknown 7 6

Characteristic Mean SD

Age 52.88 9.82 Years with current employer 11.53 9.01 Years in current role 8.98 8.83 Number of direct reports 27.41 39.53 Number of reports within span 279.2 674.44 Number of beds overseen by

respondent 834.4 5,841.71

SD, standard deviation.

Table 4 – LISA© Factors

Factor Operational Definition Number of Items Cronbach’s Alpha

Status Having high standing or prestige. The professional standing a person holds in an organization, group, or system.

18 0.932

Authority The right, or ability to take actions, make decisions, give orders, or rightfully use sources of support, supply, or aid.

25 0.938

Strategy Considers external and internal factors to create a plan of action; builds relationships to advance an agenda; negotiates when agendas do not align; determines appropriate tactics to implement a plan of action or agenda depending on the audience.

14 0.916

Integrity Trustworthy, reliable, and morally sound in adherence to ethical principles and honesty; holds a reputation as a favorable and publicly recognized name who stands for merit, achievement, and reliability; able to adapt responses and change priorities to meet urgent needs in a timely way that consistently reflects the shared vision of the organization and maintains a commitment to upholding ethical standards.

23 0.912

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The LISA© assesses many of the areas that impact nurse influence as described by the RWJF study, includ- ing decision making, leadership opportunities, and strategic vision. The preliminary data evaluating the LISA©’s performance demonstrate the instrument’s re- liability and validity and support its potential as a self- assessment tool for nurse leaders. Although the ratio of the number of potential items to sample size was small, multiple criteria suggest a stable factor analy- sis, including the number of items assigned to each factor, the factor loadings (all greater than 0.4), and the lack of cross-factor loadings. Further support is provid- ed by the item groupings, which match those “predicted” by the theoretical model.

It is important to note that the Leadership Influ- ence over Professional Practice Environment Scale (LIPPES) (Adams, Nikolaev, Ives Erickson, Ditomassi, & Jones, 2013) was also developed using the AIM to guide the item development. The LIPPES was specifically de- veloped to explore acute-care nurse leader manager self- perceived influence over practice environments and the relationship to workforce and patient outcomes (Ducharme, Bernstein, Padilla, & Adams, 2017). The LISA© expounds on this concept to purposefully assess a leaders’ influence as an exercise regardless of the setting or role.

Going forward, the study described here should be replicated and confirmatory factor analysis was con- ducted on the LISA© with the goal of further decreasing the number of items and producing a more stream- lined and user-friendly instrument. In 2017, the American Academy of Nursing Expert Panel on Building Health Systems Excellence have identified “influence of nursing” as a priority for their collective work, several doctoral students are using the LISA© in their capstone or dis- sertation work, and the authors themselves have plans for follow-up studies to further this line of research. Based on the results of this preliminary analysis, we expect future versions of the LISA© will provide nurse leaders with an effective mechanism for assessing their influence capacity and focusing their professional de- velopment efforts on strengthening their ability to impact organizational culture and effecting meaning- ful change. The LISA© holds promise in support of concerted efforts to understand and enhance individ- ual and a collective nursing influence across policy, practice, research and within undergraduate, gradu- ate, and continuing education.

Conclusion

Findings from this study offer preliminary support for the LISA© as a reliable and valid instrument that can be used to assess nurse leader influence capacity and identify strengths and areas for improvement. The tool holds promise as a self-assessment tool, which can be used for leadership development purposes. It is antici- pated that the LISA© instrument will be useful to

nursing and health services researchers seeking to un- derstand mechanisms through which nurse leaders impact organizational strategy, culture, and change.

Acknowledgments

This study was supported through a Robert Wood Johnson Foundation—Executive Nurse Fellowship grant. The authors thank Linda Cronenwett, Susan Dentzer, Bill Drath, Judith Hibbard, and Susan Lawler for their team leadership and instrument development advise- ment; Michael Anderson, Mary Beth Bigley, Susan Birch, Rebecca Engelman, Kelly Espinoza, Jane Kirschling, Kath- leen Ladner, Joanne Olsen, Pat Reid Ponte, Lois Skillings, Julie Sochalski, and Jackie Somerville for their experi- ential leadership insight; Stacey Boatright for survey software management; and Beth Kantz for editorial support.

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