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Section 1: Nature of the Project
The current health care landscape requires leaders to drive toward higher quality
and improved patient experience at a lower cost (AONE, 2016; Collins & Collins, 2007).
Contemporary nurse leaders require advanced knowledge and competencies to
successfully lead in this complex and challenging health care environment (Stefl, 2008).
Progressive leadership abilities are required to meet these demands. Nurse leaders must
be flexible and agile to adapt to continuous change, be skilled at communication and
relationship building, and demonstrate sharp business acumen. Porter-O’Grady (2015)
described these new skills as “predictive” and “adaptive” (p. 23). Predictive leadership is
visionary and enables the leader to foresee future needs based on current trends (Plsek,
2010). Adaptive leadership requires the ability to manage rapid change within the
organizational culture (Porter-O’Grady & Malloch, 2010). The increasing rate of nurses
planning to retire has generated more urgency to create leadership development and
succession programs for nurse leaders ("Baby-boomer nurse retirement," 2018).
MacDonald (2017) found that 73% of baby boomers plan to retire in 3 years or less. Due
to this impending shortage of nurse leaders, organizations need to educate and mentor
future nurse leaders on the progressive and adaptive leadership skills required for today’s
health care landscape (Porter-O’Grady, 2015).
Talented and knowledgeable health care leaders are necessary for organizations to
improve the patient experience and promote population health in a fiscally responsible
manner (Carriere, Muise, Cummings, & Newburn-Cook, 2009). Advanced leadership
skills require experiential learning cultivated over time (MacMillan-Finlayson, 2010).
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Visionary, strategic health care organizations need to foster these skills in their leaders
(Blouin, McDonagh, Neistadt, & Helfand, 2006; Collins & Collins, 2007). Developing
internal candidates for promotion opportunities ensures future organizational leaders will
have an understanding of the history and culture of the organization and be better
prepared to move the organization forward (Collins & Collins, 2007; Pedersen et al.,
2018). A structured, advanced nursing leadership education program that focuses on
evidence-based, advanced leadership competencies can provide a pool of adept and
skilled nursing leaders prepared for future organizational leadership roles. Providing
leadership development for nurse leaders supports positive social change by developing
and preparing them for executive health care leadership positions. By creating an
advanced nursing leadership academy (NLA), one southcentral Pennsylvania health care
system can methodically and strategically prepare nurse leaders for advanced health care
leadership roles and ensure tactical and effective succession planning strategies.
Problem Statement
Strategic and intentional succession planning is a characteristic of visionary
organizations (Collins & Porras, 1997). However, nurse leader selection is often based on
clinical expertise and education level without consideration of leadership ability
(Davenport, 2015; Fennimore & Wolf, 2011; Sanford, 2011; West, Smithgall, Rosler, &
Winn, 2016). Expertise in bedside clinical nursing skills does not necessarily translate
into business acumen and skilled leadership. Often, technically talented nurses fail to
meet the leadership expectations held by the organizational leadership due to the lack of
formal leadership education and training (Collins & Collins, 2007). Conversely, nurses
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who possess leadership skills may not be promoted to leadership roles because the
organization’s leaders are unaware of their leadership capacity (Davenport, 2015).
The health system at the project site identified developing an engaged health care
team as part of their 2017-2018 strategic plan. A defined tactic to meet this part of the
strategic plan was to develop an advanced nursing leadership educational program
designed to prepare frontline and mid-level nurse leaders to move into executive nursing
and health care leadership positions. This health care system did not have a formal
succession plan in place, and the health care system did not provide formal education or
mentoring for frontline and mid-level nurse leaders to prepare them for upper- and
executive-level health care leadership roles. With no formal advanced nurse and health
care leadership preparation, this health care system was at risk for experiencing a lack of
internal candidates capable of filling leadership roles. Skilled and knowledgeable internal
candidates who transition into upper level leadership positions can provide stability for
the organization during leadership transitions (Blouin, McDonagh, Neistadt, & Helfand,
2006). Implementation of an advanced NLA would provide the organization with the
ability to develop leaders capable of moving the organizational strategic plan forward and
providing stability in an unstable time.
Significance to the Field of Nursing Practice
Health care organizations are transitioning from single-entity acute-care hospitals
to multifacility systems that include the continuum of care from inpatient to ambulatory
to home care. Leading a health care organization in an increasingly complex health care
reform environment requires advanced leadership skills and competencies (AONE,
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2016). An advanced NLA may promote the development of advanced leadership
competencies in the organization’s current nursing leadership workforce. Acquisition of
advanced leadership competencies and knowledge may yield a stronger pool of
candidates able to assume strategic leadership roles throughout the health care system in
the coming years.
This project, the development of an advanced NLA to prepare nurse leaders for
executive positions, may be replicated in other health care organizations to broaden the
pool of advanced nurse leaders. The advanced NLA may also fulfill the call by the
Institute of Medicine (IOM, 2010) to “prepare and enable nurses to lead change to
advance health” in all levels and all sectors of health care (p. 43). Unlike other members
of the health care team, nurses are present during all phases of care and bring a unique
and valuable perspective and expertise to the table.
Purpose
The purpose of this project was to prepare current nurse leaders to assume
executive-level health care leadership roles. Skilled and knowledgeable nurse leaders are
necessary to lead the health care system and ensure the workforce continues to provide
high-quality, efficient, effective, patient-centered care (Porter-O’Grady, 2015). By
identifying leadership potential in the current frontline nursing leadership ranks and
providing advanced leadership education and training to those selected, the project site
organization can ensure a cadre of prepared leaders able to assume advanced leadership
positions as the need arises.
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There was no formalized leadership preparation program to develop nurse leaders
at the project site, and the organization recognized a gap existed for advanced nursing
and health care leadership preparation (Vice President of Nursing, personal
communication, Summer, 2017). To address this gap, the health care system set a goal to
develop an advanced NLA. In response to this organizational goal, I developed the
following practice-focused question for this project: “How will an advanced nursing
leadership education program affect the knowledge level and competencies of nurse
leader participants?”
The purpose of the project was to develop an advanced NLA including didactic
classroom instruction based on the American Organization of Nurse Executive (AONE)
leadership competencies combined with leadership activities and projects aimed at
preparing current nurse leaders to move into advanced health care leadership positions
and ensure organizational sustainability. The project included assessment of the AONE
competencies prior to the advanced NLA, after the 4-day intensive, and at the completion
of the 1-year advanced NLA. These assessments would provide data to determine
whether the knowledge and skill gap was narrowed as a result of the NLA.
Nature of the Doctoral Project
The IOM (2010) made a recommendation to prepare nurses to “lead change to
advance health” so they can take on advanced leadership roles in public, private, and
governmental sectors and at every leadership level from management to executive level
and board positions (p. 14). To address this recommendation, nurse leaders need to
develop executive level competencies. The AONE, in conjunction with the American
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College of Healthcare Executives, the American Association for Physician Leadership,
the Healthcare Financial Management Association, the Healthcare Information and
Management System Society, and the Medical Group Management Association identified
five core competency domains: communication and relationship management, knowledge
of the health care environment, leadership, professionalism, and business skills and
acumen (AONE, 2015). The source of evidence for this project was the AONE nurse
executive competencies. These competency domains provided the framework for the
advanced NLA. Each competency domain includes specific competencies and skills
required of an executive-level transformational leader.
In conjunction with the competency domains, the AONE (2011) developed an
assessment tool to evaluate the competency level of nurse leaders, ranking each
competency and related skill from novice to expert. The AONE competency assessment
provides a self-assessment of current nurse executive competencies. The assessment was
completed prior to the start of the advanced NLA to provide baseline measurements, a
second time after the 4-day intensive, and will be completed a third time at the conclusion
of the advanced NLA to measure professional growth.
When implementing a program, especially one that bears significant cost, it is
important to monitor the program’s return on investment (MacNally & Lukens, 2006).
The costs to implement the program included cost of speakers, presentation materials,
securement of venues, and productivity time of the nurse leaders away from their day-to-
day roles. One measurement of success is the engagement scores of nurse leaders, as well
as the employee engagement scores of their teams (Trepanier & Crenshaw, 2013).
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Research indicated that employees with skilled and effective leaders have a higher level
of engagement compared to those with ineffective leaders (Davenport, 2015). The
Advisory Board Company (2014), an international health care consulting firm, identified
seven drivers of employee engagement with the greatest opportunity for improvement.
Two of those drivers relate directly to executive leadership actions: “the actions of
executives in my organization reflect our mission and values” and “executives at my
organization respect the contributions of my unit/department” (Advisory Board
Company, 2014, p. 19). Financial gain will be measured by a decrease in employee
turnover and the associated costs with replacing employees. The direct impact that
leadership has on employee engagement cannot be stressed enough and must be a
consideration for inclusion in advanced leadership education (Carriere, Muise,
Cummings & Newburn-Cook, 2009; Collins & Collins, 2007; Trepanier & Crenshaw,
2013).
Turnover of nurse leaders is an important data point to consider. There is a
paucity of information in published literature related to the cost of nurse leader turnover.
Sherman (2014) estimated the cost to replace a perioperative director to be between
$132,000 to $228,000 and more if the process takes longer. Supplying nurse leaders with
skills to help them move into advanced nursing leadership roles can translate into nurse
leader retention (Trepanier & Crenshaw, 2013).
The percentage of program applicants who complete the program will be another
measure of success. The hope is that all participants will find value and complete the
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program. If the program design does not prove valuable to the participants, the program
will not be continued.
A final data point that will be monitored is the number of nurse leaders in the
advanced NLA cohort who transition into advanced leadership positions or are given
oversight of system-level projects within the health care system over the next 5 years.
The purpose of the advanced NLA is to improve the knowledge and competencies of
nurse leaders by providing them with didactic theoretical content and real-life
experiences with executive health care leaders. The increase in advanced leadership skills
and competencies may enable nurse leaders in the cohort to be better prepared to take on
advanced leadership positions and provide leadership for system-level projects.
Significance of the Project
The significance of the project was defined as the impact the project has on the
stakeholders. The organization’s executive leadership devised an organizational strategy
to develop an engaged health care team. One part of this strategy is the development of
an educational program to prepare frontline and mid-level nurse leaders to move into
executive nursing and health care leadership positions. The executive leadership team
was identified as stakeholders who will provide the authority to lead this organizational
initiative. The system chief nurse executive served as the executive sponsor of the NLA,
thereby providing the necessary driving force behind the initiative.
The organization’s executive leadership may benefit from a successful NLA as
the graduates are better prepared to serve in executive health care roles and have a
smoother and more efficient transition from middle management to executive-level
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positions. Chief nursing officers from each entity and the system chief nurse executive
were asked to select the NLA candidates, with assistance from human resources
leadership. Chief nursing officers and human resource leaders may benefit as the NLA
provides a succession plan to fill chief nurse and other advanced leadership roles. NLA
participants may benefit from the knowledge and skills gained through the academy.
Even if the participants do not transition to a higher-level leadership position, they may
use their advanced NLA experience to improve performance in their current leadership
role and may share insights with their colleagues. As a member of the project team, I was
a stakeholder who was deeply vested in the success of the program.
This NLA project contributed to the expanded knowledge and competency of
current nurse leaders at the organization. Change in knowledge and competency was
measured using the AONE competency assessment tool. The pool of advanced leadership
candidates enabled a strategic succession planning strategy that may reduce the time
spent filling executive-level positions. The current nursing shortage coupled with the
impending retirement of baby boomers is increasing the number of clinical and leadership
vacancies (Sanborn, 2017). Organizations must educate and train current staff with
identified leadership potential to assume advanced leadership roles (Carriere, Muise,
Cummings & Newburn-Cook, 2009; Lewis, 2009).
Another benefit of the academy that cannot be measured but should not be
underestimated is the development of the relationships among the academy participants
and between the academy participants and the executive leadership team. The
relationships developed between the participants during the NLA proved invaluable in
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future organizational endeavors of the graduates. The mentorship provided by the
organization’s health care executives may have a lasting impact on the nursing and
leadership practices of the academy participants regardless of their future professional
endeavors. The advanced NLA project framework is also transferable to other
organizations.
Transferability of NLS Project
One value of the NLA is its ability to be transferred to other health care
organizations. The curriculum topics and content are based on the AONE nurse executive
competencies and may be replicated in a variety of health care settings. The IOM (2010)
call for an increase in nurse representation on hospital and health care executive
management teams and boards will require nurse leaders with advanced leadership
competencies. Skilled, competent nurse leaders are needed in the public, private, and
governmental health care settings. The advanced NLA may increase the pool of nurse
leaders capable of serving in executive health care leadership roles.
Another opportunity for transferability of the NLA is the implementation of this
program in nonnursing departments. Incorporating nonnursing disciplines in an advanced
leadership academy would create a more diverse pool of potential leadership candidates
and would provide an enriching experience for the interprofessional participants. The
advanced NLA may deepen the leadership talent of nursing and nonnursing leaders, and
may improve health care leadership in the community.
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Implications for Positive Social Change
Promoting positive social change is the mission of Walden University
(https://www.waldenu.edu/about). Contemporary nurse leaders are called to advance
nursing practice and improve health care for the betterment of the community (Blouin,
McDonagh, Neistadt, Helfand, 2006). The American Association of Colleges of Nursing
(AACN, 2006) DNP Essential VIII includes mentoring and developing other nursing
professionals by using conceptual and analytical skills related to organizational practice.
The NLA project aligned with Essential VIII of the DNP curriculum by providing
advanced nursing leadership education. The NLA was designed to promote positive
social change by providing advanced nursing leadership education that will prepare nurse
leaders for executive health care roles.
Summary
The current health care environment calls for nurse leaders with high-level
leadership competencies and knowledge (AONE, 2016; Collins & Collins, 2007; Stefl,
2008). The NLA provides a comprehensive learning opportunity to develop nurse leaders
for future expanded leadership roles. A selected cohort of nurses participated in didactic,
functional, participatory, and experiential learning exercises that exposed them to
challenging health care leadership issues. Successful completion of the academy may
prepare nurse leaders to transition into expanded leadership roles to meet the current and
future leadership needs of the health care system.
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Section 2: Background and Context
Today’s leaders require advanced knowledge and business-oriented competencies
to lead in the complex and challenging health care environment. Nurse leaders must be
flexible and agile to adapt to a changing environment, be skilled at communication and
relationship building, and demonstrate strategic business acumen. Often nurses are
promoted based on their clinical expertise; however, expertise in bedside clinical nursing
skills does not necessarily translate into the competencies required of contemporary
health care leaders. Health care organizations are often good at providing clinical-based
education but are often remiss in providing professional development opportunities such
as advanced leadership education for candidates identified as possessing leadership
abilities (Collins & Collins, 2007; Sherman, et al., 2014). The purpose of this project was
to develop an advanced NLA that prepares nurse leaders to assume advanced and
executive-level health care leadership roles.
This section provides a review and synthesis of the concepts, models, and theories
that supported this advanced nursing leadership education project. The literature
addressing advanced nursing leadership education and nurse executive succession
planning is reviewed as well as the history and current state of nursing leadership
development. Strategies and practices that have been used to address this gap in practice
are outlined to emphasize the local relevance of the advanced NLA.
Concepts, Models, and Theories
Strategic planning and succession planning go hand in hand. The strategic plan
addresses the leadership opportunities necessary to advance organizational goals.
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Succession planning includes organizational practices to identify appropriate candidates
for leadership roles (Rothwell, 2016). Organizations must ensure future leaders are
identified and prepared for executive leadership roles to maintain continuity and support
the organization’s strategic plan and mission. Fayol (1949) suggested that the inadequate
preparation of people to fill vacant leadership positions will result in a dearth of qualified
candidates. Rather than waiting for a qualified candidate, organizations may fill the
position with a candidate who may not be adequately prepared (Fayol, 1949). Fayol
advocated for recruitment and training to ensure employees are in positions that match
their identified strengths.
Succession planning requires identification and selection of potential candidates
for specific roles. Five components to succession planning have been identified to ensure
strategic selection of skilled and knowledgeable leaders (Capuano, 2013):
1. It must be recognized at the board and senior management level as a priority.
2. Systems for succession planning must be developed.
3. The identification of succession leaders must be a part of every leader’s job.
4. Succession leader mentorship and education are essential.
5. Measurement for success is an important and integral component (p. 136).
Leadership skills and abilities are developed through education and experiential
learning, and employees come with varying degrees of leadership skills and abilities. The
skills and abilities accumulated through education, employment, habits, and activities that
make employees valuable and productive are referred to as human capital (Desai,
Lockett, & Paton, 2015). According to human capital theory, investments in such skills
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and abilities can be worth the cost of resources (Desai et al., 2015). Organizations can
identify employees with high leadership potential and invest resources to advance their
knowledge and ability. Organizations invest in human capital to increase productivity and
financial returns (Jones, 2004). This investment in human capital can produce future
benefits for the organization. The NLA developed in the current study required an
investment of resources, including money, personnel, and time. This investment may help
to increase the leadership skills and abilities of the selected candidates and benefit the
organization.
The purpose of the NLA was to provide leadership skill development to ensure a
strategic succession plan. The NLA was based on the AONE (2015) nurse executive
competencies, which include communication, knowledge, leadership, professionalism,
and business skills. Expertise in these competencies will enable nurse leaders to develop
the vision for nursing practice so care is provided in a safe, timely, efficient, equitable,
and patient-centered manner. The AONE competencies are modeled after the Healthcare
Leadership Alliance (HLA) model. The HLA includes six major professional health care
associations: American College of Healthcare Executives, American College of Physician
Executives, American College of Nurse Executives, Healthcare Financial Management
Association, Healthcare Information and Management Systems Society, and Medical
Group Management Association. In response to the demands for better prepared
executive leaders, the HLA developed a list of skills and competencies required of
executive health care leaders to meet the demands of the changing and complex health
care environment.
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The nurse leader candidates selected for the NLA completed an assessment tool to
measure their perceived leadership abilities. Assessment of the nurse leader’s aptitude in
the five competency domains was measured using the AONE nurse executive
competencies assessment tool. This tool is based on Benner’s (1982) novice to expert
theory. Benner identified five stages of development for the professional nurse: novice,
advanced beginner, competent, proficient, and expert. Benner’s novice to expert theory
was adapted from the Dreyfus model of skill acquisition, which outlines the same five
stages in Benner’s model and notes that as skills develop, the individual’s need to rely on
rules decreases and the ability to critically think through a situation increases (Stefl,
2008). This learning and skill development comes from management knowledge,
experience, and practice (Stefl, 2008).
The AONE assessment tool is used to measure competency in each of the five
nurse executive leadership domains: communication and relationship management,
leadership, professionalism, knowledge of the health care environment, and business
knowledge and skills. Each domain includes behaviors specific to that competency.
Using a 5-point novice (1) to expert (5) scale, the nurse leader candidates assessed their
level of competency for each behavior. The nurse leader candidates then discussed the
results of their self-assessment with their direct supervisor and formulated an
individualized action plan for professional development based on identified development
opportunities.
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Relevance to Nursing Practice
The need for development of advanced nursing leadership competencies has
increased in response to the rapid pace of change and increasing complexity of the
current health care environment (AONE, 2016). This climate of disruptive innovation
calls for nurse leaders to be multidimensional clinical leaders with a strategic vision in
health care and business (Boston-Fleischhauer, 2016). Leadership has evolved from being
transactional and management-focused to transformational and strategic, and the required
leadership competencies have evolved as well. Transformational leadership refers to
leaders who motivate and inspire their followers to want to perform at a higher level to
attain common goals (Burns, 1978). Transformational leadership, associated with
improved organizational outcomes and staff engagement, is necessary in the current
health care environment (Tourangeau & McGilton, 2004). In response to a need for better
prepared transformational leaders, Posner and Kouzes (1988) developed a leadership
practices inventory to measure and assess behavioral leadership competencies.
Leadership assessments can be used to evaluate current leadership ability and gain insight
into specific leadership competencies that need to be further developed and refined.
Sherman, Patterson, Schmidt, and Dahl (2014) found that business acumen and
relationship building were the top two competencies required of a nurse leader. The
AONE (2015) also listed business skills and principles as one of five competency
domains. The inclusion of business acumen, leadership, communication, professionalism,
and communication in nurse executive competencies signifies the importance of
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providing these specific professional development opportunities for potential nurse
executive leaders.
Awareness of the level of leadership ability and availability in the current
workforce is a major factor in developing a leadership succession plan. Dolan (2005)
found that only 21% of freestanding hospitals have a CEO succession plan compared to
64% of businesses in the private sector. Health care organizations have traditionally
lagged in this aspect compared to private sector businesses, but the chaotic health care
environment has provided clarity to health care executives who now understand the need
for succession planning (Crawford, Omery, & Spicer, 2017). Considering the current
health care environment, ensuring a seamless transition of leadership when the need
arises is crucial to organizational stability and success (Blouin, McDonagh, Neistadt &
Helfand, 2006; Carriere, Muise, Cummings & Newburn-Cook, 2009; Trepanier &
Crenshaw, 2013) . Astute organizations must be proactive to ensure the development of
current leaders in preparation for executive roles (Blouin et al., 2006). Cultivating leaders
for strategic succession is necessary for successful business operations.
Another reason succession planning needs to be a top organizational priority is the
increased rate of health care labor shortages, especially in the nursing leadership
category. In a national study of chief nursing officers (CNOs), Jones, Havens, and
Thompson (2008) found that 38% of respondents reported having left a CNO position in
the last 5 years, and 61% planned to change jobs in the next 5 years. CNO turnover can
be detrimental to an organization. After a replacement is found, it takes time for the new
CNO to learn the culture and history of an organization and to assimilate into the
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organization’s leadership environment. Research findings highlighted the necessity for
organizations to socialize and prepare future nurse executives via formalized educational
and experiential opportunities (MacMillan-Finlayson, 2010; Perderson, et al., 2018).
Organizational leaders and nurse executives need to have a succession plan in
place to ensure organizational stability. Succession planning and leadership development
are two critical strategic initiatives health care organizations should embrace (Collins &
Collins, 2007). The American Nurse Credentialing Center’s (ANCC, 2014) Magnet
recognition program requires applicant organizations to outline succession planning
strategies for nurse leaders at all levels, including managers, directors, and nurse
executives. Succession planning is also part of the leadership component of AONE’s
(2015) nurse executive competencies. Succession planning includes ensuring that internal
candidates ready for further development are identified, that there is an understanding of
career aspirations and growth within potential candidates, and that there is intentional
facilitation of mentoring between recognized, successful leaders and novice, aspiring
leaders (Trepanier & Crenshaw, 2013). The NLA project provided a formalized nursing
leadership development program that included both didactic and experiential learning
experiences aimed at developing nurse executive leadership competencies.
Strategies and Standard Practices
Strategies identified in the literature included leadership competency assessment
and evaluation of current leader aspirations, but little was found on formal advanced
nursing leadership programs similar to the proposed NLA. Carriere, Muise, Cummings,
and Newburn-Cook (2009) identified eight articles that provided an overview of
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succession planning frameworks; however, most frameworks included mentoring and
coaching strategies and none listed a formal curriculum structure. Baylor Health System’s
succession program includes a five-stage development cycle that consists of
conversations with managers about their aspirations, completion of a 360-degree online
profile by employees and their managers, meeting with the talent development staff
regarding profile results, a day-long talent summit during which executives meet with
those interested in various positions, and creation of a development plan for the next year
(Lewis, 2009). Another organization located in eastern Pennsylvania, Lehigh Valley
Health Network, has made succession planning a priority (Capuano, 2013). Like Baylor,
Lehigh Valley Health Network begins with conversations and competency assessments.
Individuals identified as potential upper-level leaders are given an individualized
development plan that consists of experiential learning and mentorship. The program
includes 3-hour workshops, but most of the development plan is focused on providing
experiences such as leading improvement projects and organizational initiatives outside
the everyday work environment.
The NLA in the current study included identification of potential advanced
leadership candidates based on previous performance and career aspirations. The selected
candidates attended a 4-day leadership intensive provided by internal and external experts
covering topics such as the AONE leadership competencies. Over the course of the year,
there will be several 2- to 4-hour workshops to increase candidates’ knowledge of
leadership, combined with experiential learning and mentorship with selected executive
leaders. The intensive was conducted with a cohort of 23 nurse leaders who shared
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experiences and learned from each other. The relationships developed among the cohort
members further increased the value of the NLA experience.
Local Background and Context
There was no formal succession plan in place for nurse leaders at this six-hospital
health care system. As the health care system grew along with the potential for more
advanced leadership positions, there was a need for a pipeline of internal leaders with the
skills and knowledge to transition into these positions. Candidates selected for the NLA
completed the AONE nurse executive competency assessment. This assessment was
repeated after a 4-day intensive and will be repeated at the completion of the 12-month
NLA to determine growth in leadership knowledge, skills, and attitudes.
Three years ago this organization developed and instituted a physician leadership
academy (PLA) based on a similar format that included a 5-day intensive followed by bi-
monthly 4-hour workshops and various leadership experiential opportunities. There were
already had several physicians in key leadership positions, including chief executive
officer, chief quality officer, and chief informatics officer. The purpose of the PLA was
to develop additional physicians for expanded leadership opportunities. The PLA was a
2-year course and has resulted in several physicians being offered and placed in key
leadership positions. With the success of the PLA, the executive leadership team set a
goal to develop an advanced nursing leadership academy to grow and develop key
nursing leaders to assume various executive and advanced leadership positions either
within the numerous entities or at the system level.
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Role of the DNP Student
My role was project oversight for the development of the NLA with assistance
from the executive sponsor, the chief nurse executive. As the project lead, I assisted with
candidate selection, curriculum development, leadership competency assessments,
development and coordination of experiential opportunities, and pairing of executive
mentors with NLA participants. I assisted with development of the 4-day didactic course,
reviewed evaluations completed by participants after the intensive, and oversaw
workshops and experiences.
Leadership development is a personal passion. I have past experience with
overseeing a nurse manager residency program. The nurse manager residency was a
developmental program for staff nurses who expressed an interest in becoming a nurse
manager and who displayed leadership qualities in their current role. The selected staff
nurses spent 5 days every 2 weeks shadowing a nurse manager and learning the role, as
well as participating in lunch-and-learns focused on leadership topics. After this 1-year
experience, the nurse manager resident had a fairly broad understanding of the nurse
manager role and could decide to pursue a nurse manager position when one became
available. Those who completed the residency experienced a smoother transition and
were successful in the role as they already knew what the nurse manager responsibilities
included and how to perform many aspects of the role. I also have past experience
developing and overseeing a nurse residency program for new to practice registered
nurses. Being able to see nurses grow professionally gives me great satisfaction. I take
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pride in mentoring these nurses as they embrace their new role as a clinical nurse or nurse
manager.
Role of the Project Team
The project team selected for the NLA consisted of a multidisciplinary team
which included me, the chief nurse executive, the hospital chief nursing officers, the
system chief operating officer, leadership from human resources, and the project lead
from the PLA who lent her expertise and insight from previous experience. The project
team met monthly and as needed to ensure continued development and progress of the
program.
Summary
Leadership development and succession planning should be a part of every
organization’s strategic plan. Seamless transitions into executive leadership roles provide
the organization a more stable environment and provide greater continuity in progressing
towards organizational and system goals (Carriere, Muise, Cummings & Newburn-Cook,
2009). Self-awareness of leadership competencies and skills provided valuable insight
into the professional development that was offered through the NLA. The NLA provided
a comprehensive learning opportunity to develop nurse leaders for future expanded
leadership roles within the health care system.
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Section 3: Collection and Analysis of Evidence
Strategic and intentional succession planning can only occur when there are
adequately prepared and skilled nurse leaders ready to step in and assume an advanced
leadership role (Blouin, McDonagh, Neistadt & Helfand, 2006; Trapenier & Crenshaw,
2013). One southcentral Pennsylvania health care system did not have a formal
succession plan in place, and it did not provide formal education or mentoring for
frontline and mid-level nurse leaders to prepare them for upper and executive level health
care leadership roles. With no formal advanced nursing and health care leadership
preparation, the health care system was at risk of experiencing a lack of internal
candidates capable of filling leadership roles. The purpose of this project was to develop
an advanced NLA to prepare current nurse leaders to assume executive-level health care
leadership roles.
In this section, I review the identified gap in practice and the purpose and
importance of creating and implementing an advanced NLA. I also describe the sources
of evidence that will be used to measure the success of the project. This section concludes
with a detailed description of the advanced NLA project.
Practice-Focused Question
The organization did not offer advanced leadership education, which indicated a
gap between current nursing leadership competencies and the level of knowledge and
skill required for executive-level leadership roles. The organization set a goal to develop
nurse leaders so they would be prepared to step into advanced leadership roles. The
practice-focused question for this project was the following: How will an advanced
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nursing leadership education program affect the knowledge level and competencies of the
nurse leader participants?
To address this question, the organization realized a need to develop a formal
advanced nursing leadership education program to prepare nurse leaders with advanced
leadership knowledge and skills so they would be able to transition into upper- and
executive-level health care leadership positions when the need arose. A nurse executive
competency assessment was completed for each nurse leader participant before the onset
of the program and again after the program to measure a change in the level of executive
leadership competency.
Sources of Evidence
Succession planning and development of future nurse executives requires a
proactive strategy to ensure candidates are identified and coached to ensure readiness for
leadership positions as vacancies and organizational needs arise (Carriere et al., 2009).
The growth of health care systems with an increasingly interprofessional team leadership
approach, coupled with health care’s ongoing transition from an acute care focus to a
broader focus on the longitudinal continuum of care spectrum has created a need for
advanced nurse executive education and mentoring (Meadows, 2016). The AONE nurse
executive competencies provided the primary source of evidence for the advanced NLA
project.
Nursing leadership roles have seen an increased span of control in response to the
complexity of health care reform. Health care organizations must develop intentional
succession planning strategies to develop potential executive nurse leaders to be
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visionary, financially astute, and skilled communicators. Health care organizations need
to appreciate the importance of succession planning to ensure continuity. According to a
study by Garman and Tyler (2004), health care organizations noted the top three reasons
succession planning was not an urgency included succession planning was not an
organizational strategic priority, the current CEO was too new, and there was a lack of
internal candidates ready to assume an executive leadership position. These organizations
are placing their strategic plan and mission at risk when underestimating the necessity of
succession planning (Blouin et al., 2006).
Strategic planning and succession planning go hand in hand. Organizations must
ensure future leaders are identified and prepared for executive leadership roles to
maintain continuity and support the organization’s strategic plan and mission. The
strategic plan defines the leadership skills and talent needed in future leaders.
The AONE (2015) developed a comprehensive model of nurse executive
competencies that served as the foundation for this project. Communication and
relationship management, professionalism, leadership, business skills and principles, and
knowledge of the health care environment were the 5 overarching nurse executive
competencies used as sources of evidence in the study. Each competency was further
defined by specific skills and behaviors. I measured the competency level of each of the
skills and behaviors, ranked from novice to expert on the AONE (2011) competency
assessment tool, for each leader candidate prior to participation in the advanced NLA and
after completion of the advanced NLA. The change in competency level was the primary
measure of success for this project to answer the practice-focused question: How does an
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advanced nursing leadership education program affect the knowledge level and
competencies of the nurse leader participants?
The AONE competency assessment tool was used as a self-assessment
instrument. NLA participants and their direct supervisors completed the AONE
competency assessment. To determine the baseline level of the participants’ nurse
executive competencies, the assessment was completed prior to the commencement of the
advanced NLA. To determine the change in level of competency proficiency as a result
of program participation, I asked participants to complete a self-evaluation at the
completion of a 4-day intensive and will ask them to complete a self-evaluation a third
time at the conclusion of the 1-year advanced NLA. The aggregate change in nurse
executive competency proficiency provided a measurement of program success or failure.
Evidence Generated for the Doctoral Project
Participants
There were 23 nurse leaders from across the six-hospital health care system.
Participants included inpatient, ambulatory, frontline, and mid-level nurse leaders.
Participants were selected by the CNO from each entity and the system chief nurse
executive. Criteria for participation in the advanced NLA included administrative
management success as measured by recent employee engagement scores, demonstrated
leadership ability as demonstrated by recent performance evaluation scores, values
congruent with the organization, career duration, and known aspirations to advance to a
higher level of leadership within the health care system. All potential advanced NLA
candidates were vetted by the advanced NLA steering committee, which included the
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CNOs, chief nurse executive, system chief operating officer, vice-president of human
resources, director of organizational learning and development, and the system director of
nursing practice and professional development. The selected candidates were identified
as having the potential to integrate into an advanced leadership role based on their prior
performance and desire to advance. Selected candidates received a formal invitation to
participate in the year-long advanced NLA. Acceptance required their commitment to
participate in and complete defined aspects of the advanced NLA.
Procedures
Each advanced NLA participant, upon acceptance to participate and at the
completion of the 4-day didactic intensive, was asked to complete the AONE nurse
executive competencies assessment tool. The scores of the self-assessment were averaged
for each behavior, and an aggregate score for each section and for the overall tool was
calculated. The data were used to measure change in level of nurse executive
competencies. There was no published validity or reliability measurements for the AONE
nurse executive competency assessment tool.
Completion rate of the advanced NLA participants (number of completions
divided by number of acceptances) was a measure of success. If the advanced NLA did
not prove valuable for the participants, they were allowed to terminate their participation
at any time during the program. If the participants found the advanced NLA valuable,
they were more likely to complete all program requirements. Additional evidence
collected through the human resources department to measure the success of the program
included succession of advanced NLA participants into upper and executive level
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leadership positions in the health care system within 5 years of program completion,
decreased time to fill upper- and executive-level nursing and health care leadership
positions, and increased employee engagement survey scores as measured prior to
participation and after completion of the advanced NLA.
Protections
To ensure protection of human subjects, I submitted this project to the
institutional review boards of the health care organization and Walden University (08-07-
18-0107618). All survey data were secured to maintain participants’ confidentiality.
Published data did not identify any participants. No incentives were offered to the
advanced NLA participants. Participation was voluntary, and informed consent was
obtained prior to survey participation. Advanced NLA participants were allowed to
withdraw from the program at any time.
Analysis and Synthesis
The competency assessment scores were tracked using a password-protected
Microsoft Excel spreadsheet. The spreadsheet enabled me to track completion and
calculate average scores. The advanced NLA participant completion rate was also
monitored using a spreadsheet. The organization’s human resources department collects
data related to turnover and time to fill vacancies via the employee tracking software
system. The employee engagement scores were obtained from the advisory board’s
employee engagement survey used by the organization on an annual basis. The integrity
of the evidence was maintained by having all data double-checked by a member of the
NLA steering committee as well as human resources staff. Participants’ supervisors were
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contacted to encourage participants to complete surveys and attend all sessions and
events.
I asked participants to complete the AONE nurse executive competency
assessment prior to starting the program, as did their supervisor. Scores were averaged at
the individual and aggregate level. The same competency assessment was completed by
all participants at the conclusion of the NLA, and again scores were averaged. The pre-
assessment and post-assessment scores were compared to determine the percentage of
change.
Summary
Development of a successful advanced nursing leadership academy is dependent
on ensuring the selected interventions are evidenced based and aligned with the
organizational mission to “work as one to improve health through exceptional care for all,
lifelong wellness and healthy communities.” This project was aligned with the evidence-
based AONE nurse executive competencies interventions. The advanced NLA included a
4-day didactic nursing leadership intensive, functional didactic lecture, and participatory
and experiential learning. The AONE nurse executive competency assessment tool
provided a means to assess change in knowledge and competency level of the
participants.
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Section 4: Findings and Recommendations
Preparing nurse leaders to assume executive health care leadership roles is
paramount to an organization’s sustainability and success. The project site health care
system had no formalized succession strategy to address future executive vacancies. This
lack of leadership planning placed the organization at risk. This project involved the
development of an advanced NLA. The practice-focused question for this project was the
following: How will an advanced nursing leadership education program affect the
knowledge level and competencies of nurse leader participants? The purpose of this
project was to develop and prepare current frontline and mid-level nurse leaders to
assume executive-level leadership roles within the health care system.
AONE (2015) compiled a list of nurse executive competencies that served as the
evidence-based framework for this project. The AONE nurse executive competency
domains include communication and relationship management, professionalism,
knowledge of the healthcare environment, business skills and principles, and leadership.
In addition to the AONE nurse executive competency framework is a nurse executive
competency assessment. The assessment tool requires the nurse leader to self-assess on
each competency and behavior on a scale from novice (0) to expert (5). NLA participants
were asked to complete an assessment prior to commencement of the NLA, a second time
after a 4-day didactic intensive experience, and a third time at the completion of the 1-
year NLA. The results of the self-assessments were evaluated to determine a change in
level of competency using aggregate mean scores for each competency domain.
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Findings and Implications
Ten candidates out of the 23-member cohort completed the AONE nurse
executive competency assessment prior to commencement of NLA curriculum and a
second time following a 4-day educational intensive, for a participation rate of 43%. The
scores of the respondents were calculated to determine the mean score for each of the five
competency domains for both the first and second assessments. As shown in Table 1,
there was an increase in the level of competency in each of the five domains. The greatest
improvement change (delta) was in the knowledge of health care environment domain,
followed by the communication and relationship building domain. Though the increases
in scores for each domain were minimal, this was anticipated due to the short time frame
between the first and second assessment. Greater improvement in scores was anticipated
at the conclusion of the 12-month NLA.
Table 1
Nurse Executive Competency Assessments
AONE Nurse Exec Competencies
1st
Assessment
(mean)
2nd
Assessment
(mean)
Delta
Professionalism
3.72
3.73
0.01
Leadership
3.31
3.41
0.10
Business Skills
2.82
2.95
0.13
Communication and Relationship Building
3.37
3.60
0.23
Knowledge of Healthcare Environment
2.96
3.22
0.26
Overall Averages
3.33
3.38
0.15
Qualitative data were collected at the conclusion of the 4-day intensive.
Comments from the participants included, “Relationships…opportunity to meet,
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network;” “Thoughtfulness that was put into our development;” “The gift of opportunity
and recognition;” “Appreciate each other’s strengths and characteristics;” and “Helped to
rejuvenate me.” The common theme of appreciation for professional development
indicated positive feedback for the NLA project team.
Unanticipated Limitations and Outcomes
An unanticipated outcome was the lack of immediate availability of the
assessment results from AONE. An apparent firewall issue was blocking the e-mails
containing the results. AONE was contacted several times to e-mail results to the cohort
member, which proved cumbersome and inconvenient. I worked with the organization’s
information services department to resolve the firewall issue. For the second assessment,
there were no issues receiving results in a timely fashion.
An unanticipated limitation of this study was the low response rate of cohort
participants completing the assessments. A desired completion rate indicating a majority
of the cohort was not obtained, despite several e-mail reminders. The low response rate of
43% provided a limited view of the improvement in nurse executive competencies and
knowledge, and prevented generalizability of findings.
Project Implications
The implications of this project extend from the individual to the system. The
cohort participants not only learned the didactic content presented to them, but also
formed relationships within the group that will be beneficial to them in future projects.
Participants developed an understanding of areas outside their specialty. Inpatient leaders
learned about ambulatory care, and ambulatory nurses learned about inpatient care.
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Participants acquired a broader perspective of how one intervention can have far-reaching
implications across the continuum of care.
At the entity and system levels, this project increased the knowledge and
competency of cohort participants, which will likely lead to improved outcomes in staff
engagement, staff turnover, and time to fill entity- and system-level executive positions.
This project also provided networking opportunities and strengthened the cohesiveness of
leaders across all entities. This structured NLA promoted positive social change by
providing advanced leadership education to leaders in the health care system. With
skilled leaders ready to assume executive- or system-level roles, the time to fill these
critical positions will be reduced, which will contribute to the sustainability of the health
care system.
Recommendations
Continuation of the NLA over the next year will lead to a further increase in nurse
executive skills and knowledge. Assessment of cohort participants’ strengths and abilities
over the year will enable current executive leaders to identify skilled and talented leaders
ready to assume key positions to improve organizational sustainability. Development of a
succession plan for key executive and system positions addressed a gap in practice for
this health care system. Evaluations of the 4-day intensive and monthly roundtable
session will enable the project team to make necessary adjustments to the curriculum.
Assessment results will also provide information to determine which nurse executive
competency domains need increased focus.
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Contribution of the Doctoral Project Team
The NLA project team consisted of the system chief operating officer, system
chief nurse executive, entity chief nursing officers, director of organizational learning and
development, and director of human resources. The team lent their executive expertise
and understanding of competencies necessary for system leadership as curriculum was
developed. Some members of this team also served as content experts for the intensive
and roundtable sessions.
The NLA project team members were also active participants in the selection of
NLA cohort participants. The project team had a vested interest in the success of this
cohort and offered insight regarding targeted outcomes to determine NLA success. Future
plans for the NLA include a transition to a clinical leadership academy and extending the
opportunity to health care leaders outside of nursing. Creation of an interprofessional
leadership academy will provide a unique experience and offer the cohort members a
broader perspective of system leadership.
Strengths and Limitations of the Project
The main strength of the NLA was the pool of knowledgeable and skilled
candidates to supplement both system and entity executive leadership succession plans.
Succession plans can help ensure seamless and stable leadership transitions. Other
strengths of the project included an increase in nurse executive skills and competencies,
which can be used in candidates’ current roles and can lead to improved employee
engagement and strengthened relationships among the cohort members both within
entities and across the system.
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Limitations of the project were that cohort participants were limited to nursing
and restricted to 23 members. For a health care system that includes 15,000-plus
employees and approximately 600 leaders, 23 cohort participants represented less than
4% of the leadership team. Limiting the cohort to nursing also narrowed the span of
projects the team would complete. In the current health care environment, most projects
require interprofessional teams because identified opportunities for improvement are
rarely specific to nursing. Future consideration of an interprofessional leadership
academy will be beneficial to the health care system.
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Section 5: Dissemination Plan
Dissemination of findings from an evidence-based practice project is the last step
of the process according to Melnyk’s model and the Johns Hopkins model (Dang &
Dearholt, 2018; Melnyk & Fineout-Overholt, 2015). Dissemination of findings should
involve internal and external audiences. For my project, which involved creating an
advanced nursing leadership academy, my dissemination plan included internal
dissemination as well as submission of an article to a nursing leadership journal and a
poster presentation to a nursing conference.
Internal Dissemination
Internal dissemination within the health care system was another way to share the
success of this project. Presentations to executive leadership within the health care
system, as well as future cohort candidates, may increase the awareness and perceived
value of the NLA. Creating a brochure and posting information on the health care system
recruitment Internet site was another important dissemination strategy. The NLA can be
used as a recruitment tool for potential employees who may see the commitment the
health care system has regarding leadership development.
External Dissemination
It is important to consider the audience when writing the manuscript to ensure
their interest matches the manuscript (Morton, 2013). The appropriate audiences for
dissemination include nursing and health care leadership. The nursing journal I selected
was the Journal of Nursing Administration. This journal focuses on patient care
leadership, and the intended audience includes nurse executives, directors of nursing, and
37
nurse managers in hospitals, community health organizations, and ambulatory care
environments. The audience and focus of the journal closely align with the NLA. The
strengths of publishing a journal article is the broad audience a published article can
reach. The article will be seen by anyone who subscribes to this journal, as well as
anyone searching a nursing database using appropriate search terms that match my
article. I plan to reach out to colleagues who have published articles for their help in
reviewing and critiquing my article to ensure it meets the standards of the journal. If the
journal editors ask for revisions, I will follow their recommendations. If the article is not
accepted, I will submit to another nursing leadership journal such as Nursing
Management.
The conference I plan to submit an abstract to is the American Organization of
Nurse Executives (AONE) annual conference. The framework for the NLA is the AONE
nurse executive competencies, and this conference would be the perfect venue to present
a poster or conduct a podium presentation on developing executive competencies for the
purpose of succession planning and executive leadership development. Strengths of this
format include the ability to present live, answer questions from the audience, and
network with interested professionals. Limitations of this dissemination method are that it
is limited to the audience attending. When presenting at a conference, I make it a habit to
have my contact information available for the audience and a copy of my poster, slides,
or other handouts so the attendee will have my contact information.
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Analysis of Self
This doctoral project provided me with an in-depth insight into the need for
succession planning as part of an organizational strategy. Focusing on the nurse executive
competencies and associated curriculum helped me advance my leadership ability and
expand my leadership potential. Given my desire to move to an executive leadership
position, the NLA project provided me with increased awareness of the talents necessary
for such a position and an understanding of the competencies I need to focus on for
professional development. This project also expanded my knowledge of project
management and working with an executive-level interprofessional team. Performing a
literature search and analyzing evidence helped me learn how to evaluate similar
programs and develop a program that met the needs of the health care system while
honing my evidence-based practice skills. My professional passions include professional
development and evidence-based practice, and the NLA project was the perfect fit.
This project will continue over the next year and will be followed by successive
annual cohorts. Survey results and evaluations from current cohorts will shape future
cohorts to allow for continual program improvement. I will continue to monitor long-
term outcomes related to the NLA, including time to fill key system and executive
positions, employee engagement scores, and number of NLA cohort members who are
promoted to executive- and system-level positions.
Other than the limited participation in the competency assessment survey,
challenges with the project were minimal and mainly related to time commitment from
the cohort members and the executive speakers. I was fortunate to have a project assistant
39
who supported the NLA with overseeing scheduling, sending calendar appointments and
email reminders, and keeping participants on track. For the next cohort, expectations
regarding the survey will be explained from the beginning, and specific completion
timelines will be provided. Another change that will be implemented for the next cohort
is to ask members to provide topics they feel they would like to learn more about. Having
a better understanding of the members’ learning needs will allow us to customize the
NLA curriculum to better meet the needs of the participants.
An unanticipated benefit of the NLA was the relationships that were formed
among the cohort participants. After the 4-day intensive, the group bonded and asked to
be seated together at an organizational leadership conference. Most of the cohort
participants did not know each other prior to the NLA, so this was a wonderful
development.
I learned that nursing professionals are appreciative of the time offered to them
for their professional development. Leaders spend most of their time doing for others,
and when they have the rare opportunity to participate in a program focused on them,
they are humbled and thankful. I am confident that participants will become more skilled
and knowledgeable leaders as a result of this program, and the organization will also
benefit. The health care system will have a pool of executive leadership candidates and a
succession plan to ensure the sustainability and success of the organization, which will
benefit the community. I am hopeful that external dissemination of the NLA and
associated outcomes will further spread the benefits.
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Summary
The current health care environment requires nurse leaders with executive-level
leadership competencies and knowledge. The NLA provided a comprehensive learning
opportunity and developed nurse leaders who are prepared to assume executive- and
system-level leadership positions. This project can be replicated at single-entity health
care organizations or multiple-entity health care systems. Having a pool of potential
executive talent is a valuable asset of health care organizations that cannot be neglected
in today’s competitive health care environment.
