- Email: [email protected]
Crisis Leadership Efficacy of Nurse Practitioners
ORIGINAL RESEARCH
Crisis Leadership Efficacy of Nurse Practitioners
Priscilla Samuel, DNP, FNP, Mary T. Quinn Griffin, PhD, RN, Maureen White, MBA, RN, and Joyce J. Fitzpatrick, PhD, RN ABSTRACT
Leadership is vital to patient safety, particularly in crises. Clinical leadership is an important component of the nurse practitioner (NP) role; expert clinicians are called upon to assure patient safety in crisis situations. The purpose of this study was to describe the self-perceived crisis leadership efficacy of NPs working in acute care settings. The sample included 105 NPs. There was a significant positive relationship between participants’ self-reported familiarity with departmental preparedness to prevent/respond to safety crises/ emergencies and crisis leadership efficacy. Results may inform health care leaders to position NPs for greater impact on patient safety in crisis situations. Keywords: acute care setting, crisis leadership, leadership, nurse practitioners Ó 2015 Elsevier, Inc. All rights reserved.
P
ublic knowledge about widespread medical errors and poor patient outcomes has caused patient safety to become a focal point of what troubles health care systems today. Factors such as interdisciplinary teamwork, collaboration, and effective communication have been identified by various regulatory bodies, such as the Agency for Healthcare Research and Quality,1 as being integral to patient safety. Although patient safety experts observe that cultivating behavioral abilities of the front-line staff could be beneficial in improving patient safety, research on practices and capabilities of clinical leaders and their self-efficacy in managing crises is scarce.
BACKGROUND AND SIGNIFICANCE
The seminal report, published in 2000 by the Institute of Medicine and titled To Err is Human: Building a Safer Health System,2 indicated that up to 98,000 people die each year in hospitals as a result of preventable medical errors. Since that report, various governmental reports have been issued showing compelling evidence that lack of clinical leadership skills, harmful variation in processes, needless complexity, barriers to the flow of critical information, and gaps in teamwork hinder patient safety.3 Leadership is an essential attribute in times of safety crisis/emergencies. Effective crisis leadership is www.npjournal.org
important in attaining quality outcomes in any organization experiencing a safety crisis/emergency. Acute care hospital settings are highly complex and dynamic in nature. The kinetic milieu can rapidly turn unpredictable, especially when patients’ lives are at stake. Ineffectual leadership in safety crises is costly and possibly disastrous.4,5 Clinical leadership and precise execution of clinical judgment are warranted during these times of high stress. The skills and expertise of the clinical leader are in great demand during a crisis. Crucial decisionmaking is based on receipt of pertinent information, which is then critically assessed and analyzed. Information assessment and decision-making have been identified as 2 fundamental behaviors that are important for effective crisis leadership.6-11 Furthermore, a synchronized and seamless flow of information exchange must occur between clinical leaders and pertinent team members under strict time constraints and within stringent protocols and guidelines. Organizations must devote energy to identifying crisis management skills among clinical leaders and persistently invest in resources to further promote and develop clinical leadership. The central role of the nurse practitioner (NP) is to be a clinical leader. There is an identified need to develop leadership skills of NPs to help them achieve their full potential. The Journal for Nurse Practitioners - JNP
1
The pervasiveness of crisis and the prerequisite for effective response have become so vital that crisis leadership is a fundamental competency required by many employers.12 In general, research on crisis leadership has been conceptual or based on various case studies. Not much is known about the details of how leaders respond to a crisis effectively.10,11,13 Very little is also known about how to identify the capabilities of leaders preemptively, that is, prior to their being in a crisis management role.14 STATEMENT OF PURPOSE
The purpose of this research was to examine the selfperceived crisis leadership efficacy of NPs in the acute care setting. The research questions were: (1) What is the crisis leadership efficacy of NPs? (2) What is the relationship between crisis leadership efficacy and each of the background measures among NPs? BACKGROUND
Research conducted on the topic of leadership in crisis management has primarily been in highreliability sectors, such as the aviation industry, with little research literature in health care. Within the research on crisis leadership, crises are considered events that are unpredictable, and that provide a major threat to the organization or group. In the case of a safety crisis/emergency, the threat is to the system and is on a large scale. Given that these largescale safety crises include many complex factors that make alternative outcomes difficult to assess or predict, crisis leader performance is often problematic to define and measure.11 The present review of the literature uncovered case reviews of crisis leadership that emerged during major natural disasters.9,15 The research literature suggests that leaders who manage a crisis effectively tend to be emotionally intelligent.16 They also have the innate ability to think globally and understand the interdependencies and patterns of different components of a larger structure or system. Last, they can synthesize information and communicate imperatives in a timely manner.9,15,16 One of the first studies of nurse leaders in crisis situations was done by Shih and colleagues,16 who studied the experiences of nurse leaders and the 2
The Journal for Nurse Practitioners - JNP
survival strategies employed by them during the SARS epidemic. Based on the data gathered from focus-group interviews and an open-ended questionnaire, the authors identified that nurse leaders are important facilitators of interventions in health disasters. They also recognized that emotional intelligence and sociopolitical and analytical skills are significant to planning and decision-making and to implementing strategies. Hadley et al.11 investigated critical behaviors of leaders (managers from the public health and safety sector) in crisis. Their results show that the important indicator of crisis leadership potential is the aptitude to assess information swiftly and accurately. Higher crisis leadership efficacy was associated with more confidence and ease in making crisis-related decisions. In a case-based study by Higgins et al.,17 factors influencing the abilities of advanced practitioners in carrying out their clinical and professional leadership roles were evaluated. Four factors were identified as having great impact on the practitioner’s ability to perform: professional development; opportunities to function as leaders; tools for sustaining leadership; and personal traits of the practitioners. According to Bandura,18 the level of motivation is dependent on the individual’s self-efficacy to perform a particular task or behavior. Empirical association was noted between leader efficacy and advanced motivation to lead.19 One can infer that high self-efficacy in the implementation of information assessment and decision-making during a crisis is related to motivation to exhibit those skills in a genuine crisis situation.11 Prior research has shown that leadership role-taking in the military is influenced by motivation to lead.20 Crisis leader selfefficacy and motivation to lead in a crisis are both likely to impact the degree to which individuals take on leadership roles in a crisis. Significant gauges of leader performance consist of efficiency of the decision-making, such as the level of effort and selfconfidence that leaders maintain while assessing information and making crisis decisions.11 SUMMARY
The few studies conducted on crisis leadership efficacy have been accomplished outside the realm of the health care setting. There is also minimal research Volume
-,
Issue
-, -/-
2015
regarding the particulars of how leaders respond during crises and how the competencies of leaders can be evaluated prior to a crisis situation. In general, much of the understanding of crisis leadership has been based on analysis of case studies. METHODS Design and Setting
A quantitative descriptive design was used for this investigation. The setting for our study was a large health care system located in northeastern United States. The health care enterprise investigated consists of 15 hospitals inclusive of community, tertiary, and teaching institutions; however, the study setting was acute care hospitals within the local health care system. The health system is one of the largest not-forprofit organizations in the country, with clinical concentrations in emergency medicine, cardiovascular care, pediatrics, neurosciences, internal medicine, psychiatry, and women’s health. Sample
The study population was all NPs practicing in acute care settings in 1 integrated health system in the Northeast. The potential sample was estimated to be approximately 500. All NPs credentialed and privileged to render clinical services and employed in an acute care setting within the integrated health care enterprise were eligible to participate in the survey. NPs who were on voluntary or adjunct status were excluded. Other advanced practice nurses, such as certified nurse anesthetists, clinical nurse specialists, and certified nurse midwives, were not eligible to participate. Instruments
The Crisis Leader Efficacy in Assessing and Deciding (C-LEAD) scale was used to measure crisis leadership efficacy. This instrument was developed by Hadley et al.11 to determine the efficacy of leaders in assessing information and in making decisions while dealing with a safety crisis. The C-LEAD scale forecasts confidence in decisionmaking during a crisis better than a general measure of leadership efficacy. It consists of 9 items and measures 2 critical actions: propensity for evaluating information and decision-making in crisis. It uses a www.npjournal.org
7-point rating scale with scores ranging from 1 (strongly disagree) to 7 (strongly agree). The total C-LEAD score is calculated by taking the mean of all 9 items; possible scores range from 4 to 63. Higher scores represent lesser degree of trouble and more comfort in making decisions in crisis situations. The Cronbach alpha reliability for the C-LEAD measure was previously found to range from 0.81 to 0.88.11 In the present study Cronbach’s alpha was a ¼ 0.917. A background data questionnaire was used to gather pertinent information from participants. The 10 questions included: gender; age; education; years of experience in acute care settings; year of experience in the role; years of experience in the organization; specialty certification; prior crisis training (yes/no); formal leadership position for managing a patient safety crisis (yes/no); and familiarity with departmental preparedness to prevent and respond to safety crises/emergencies (choices included not at all familiar, somewhat familiar, moderately familiar, very familiar). Procedure
Approval was obtained from the appropriate institutional review boards. Several methods were employed for recruitment of participants for this study. In efforts to maximize participation, contact was made with the system-wide NP leadership council for NP recruitment. An electronic mail distribution list of all NPs employed in acute care within the integrated health system was created in partnership with the medical staff services office. E-mail correspondence included a description of the study, its purpose, the importance of voluntary participation, and instructions on completing the survey. The survey was administered via Survey Monkey; biweekly electronic requests were sent to all prospective participants as a reminder to complete the survey. Data Analysis
SPSS software (version 21) was used for analysis. Descriptive statistics were computed including frequency distribution, measures of central tendency, ranges, and standard deviations. Correlational analysis using Spearman’s rho was performed to determine The Journal for Nurse Practitioners - JNP
3
the relationship between the C-LEAD and each of the categorical background measures. RESULTS Sample
One hundred five NPs participated in the survey with a 21% response rate. The majority of participants (89.5%) were female (n ¼ 94). More than half (54.3%) were age 50 or older. Almost half of the participants (45.7%) had > 10 years of work experience as an NP; a small portion of the respondents (15.2%) had > 20 years of work experience as an NP. Nearly half (45.7%) reported tenure with the health system of < 5 years, whereas < 10% (6.7%) had worked for > 20 years in the health system. More than half (53.3%) of the participants were not in a position of formal authority to direct other employees in the event of a patient emergency. Fewer than half (47.6%) reported being “not at all familiar” to “somewhat familiar” with departmental preparedness to prevent and respond to crises/ emergencies. More than half (54.3%) had participated in patient safety emergency training in the last 2 years. All participants held a master’s degree in nursing. A small group (3%) reported having a doctorate degree. Nearly all participants (93.3%) were nationally board certified. Fewer than 4% (3.8%) were trained in acute care; 38.1% were adult NPs; < 25% (23.8%) were family NPs; and < 10% (9.5%) were pediatric NPs. Background data are included in the Table. Possible total scores for the C-LEAD scale range from 4 to 63, with higher scores indicating higher levels of self-reported crisis leadership efficacy. The mean total score for the C-LEAD scale in this study was 48.26 (SD 9.97). Approximately, 50% of the respondents scored > 50, indicating a high level of self-reported crisis leadership efficacy. Spearman’s rho revealed a statistically significant positive relationship between C-LEAD score and familiarity with departmental preparedness to prevent and respond to safety crises/emergencies (rs[105] ¼ 0.355, P < .001). Two-tailed tests were performed to determine the direction of the relationships. No significant relationships were found for C-LEAD with other background characteristics, such as formal 4
The Journal for Nurse Practitioners - JNP
Table. Sample Characteristics (N [ 105) Variable
Number (%)
Age 20-29 years
5 (4.8)
30-39 years
15 (14.3)
40-49 years
28 (26.6)
50-59 years
42 (40.0)
> 60 years
15 (14.3)
Gender Male
8 (7.6)
Female
94 (89.5)
Missing
3 (2.9)
Years as an NP 0-4 years
29 (27.6)
5-10 years
25 (23.8)
11-19 years
32 (30.5)
> 20 years
16 (15.2)
Missing
3 (2.9)
Years as NP at the organization 0-4 years
48 (45.7)
5-10 years
23 (21.9)
11-19 years
24 (22.8)
> 20 years
7 (6.7)
Missing
3 (2.9)
Area of NP specialty Adult
40 (38.1)
Family
25 (23.8)
Geriatric
1 (1.0)
Pediatric
10 (9.5)
Acute
4 (3.8)
Other
22 (21.0)
Missing
3 (2.8)
National board certification Certified
98 (93.3)
Noncertified
4 (3.8)
Missing
3 (2.9)
NP ¼ nurse practitioner.
leadership position for crisis management, previous crisis training, national board certification status, and area of NP specialty. Volume
-,
Issue
-, -/-
2015
DISCUSSION
limitation stems from the use of self-reported data, thus increasing the possibility of self-presentation bias.
The study participants included a convenience sample of 105 NPs employed by an integrated health system in the Northeast. The majority of the NPs within the integrated health system reported high levels of crisis leadership efficacy. This finding was important because most respondents were not in a position of formal authority in crisis management. It is possible that this finding may be directly correlated with the high percentage of well-educated and board-certified NPs in this organization. It may also be a downstream effect of the culture of patient safety embraced by the organization and a result of the high-fidelity‒based simulated patient safety training made available to employees via the corporate learning university. Despite the resources available to the NPs in the organization, 47.6% reported being either “not at all familiar” to “somewhat familiar” with departmental preparedness to prevent and respond to safety crises/ emergencies. This finding is important. It indicates a need for the local setting to explore potential barriers, such as large clinical caseloads, that may prevent NPs from engaging in nonclinical activities, thereby affecting their perception of their own leadership capacity. This finding may also prompt the local organization to understand gaps in preparing and tapping NPs for management and leadership in safety crises/emergencies. In this study we have examined the relationship between NP background characteristics and crisis leadership efficacy. The review of the literature uncovered no prior research on crisis leadership efficacy of NPs. There are similarities, however, with findings obtained by Hadley et al.,11 who found that C-LEAD correlated positively with the level of understanding among public health and safety workers regarding their departmental emergency response protocols. No significant relationships were found for C-LEAD with other background variables, including whether participants were in a leadership position with formal authority for crisis management.
This study revealed that there is a significant relationship between NPs’ level of crisis leadership efficacy and their familiarity with departmental preparedness in preventing and responding to patient emergencies. As organizations struggle to prepare themselves for safety crises/emergencies and safeguard their patients, is important to develop higher levels of crisis leadership efficacy among clinical leaders. The C-LEAD scale can be used to identify the capabilities of a clinical leader (such as an NP) prior to a crisis situation and, ultimately, to develop crisis leadership prototypes for health care and interventions to increase the efficacy of expert clinicians, including NPs, in managing crises. On the national level, there are implications for educational preparation of NPs and other advanced practice nurses. For example, it will be important to include a focus on leadership within safety crises/ emergencies within the leadership components of the doctor of nursing practice degree programs, all of which have leadership content. This research study has both implications and applications within the context of the integrated health system. The literature review indicated that there have been no other studies that have addressed the crisis leadership efficacy of NPs. Although the implications of this study at this stage may be relevant only to the local setting, we have provided an important starting point. Leaders in other health systems may wish to reproduce this study to determine the capabilities of their clinical leaders in managing patient safety‒related crises. We have found that most NPs in the local system perceived themselves as capable of managing a patient safety‒related crisis, even if not in a role of formal authority in managing such an event. This information is valuable to the organization because familiarity with departmental emergency protocols is an attribute organizations can control.
Limitations
Recommendations for Future Research
The study was limited to NPs working in acute care settings within a single integrated health system in the Northeast. The study design limits generalizing the results to other acute care hospital systems. Another study
The current accelerated redesign of traditional care delivery models and the increasing demand for patient safety support the need for continued research in the area of clinical leadership and crisis
www.npjournal.org
Implications for Nursing
The Journal for Nurse Practitioners - JNP
5
management of NPs. Based on our findings, future research is proposed to analyze whether crisis leadership training and NP specialization and preparedness affect the self-efficacy levels of NPs in managing patient safety‒related crises. Future research is also recommended to strengthen the generalizability of the findings of this study. Areas of interest for future research include examining crisis leadership efficacy of NPs across the country and the relationship between crisis leadership efficacy and patient outcomes. An exploration of the crisis leadership efficacy of multidisciplinary clinical leaders is also warranted. Therefore, it may be valuable to replicate this study within diverse health systems and in mixed geographical areas of the US to support and generalize the findings. Also, qualitative research may be an important next step to generate the depth of data needed to fully explore the reasons why NPs adopt certain crisis leadership styles.
A clinical leader, the person directing the immediate management of any patient safety‒related event, could possibly be the most vital stakeholder in ensuring that a life, or many lives, can be saved in the midst of a crisis. Efforts in fostering patient safety through the establishment of clinical guidelines, practice protocols, patient safety goals, and multidisciplinary crisis resource management often result in decreasing patient harm. It is important for organizations to understand the crisis leadership efficacy of clinical leaders, such as NPs, and cultivate their expertise and attributes necessary for efficacious crisis management. The results of our study serve as a stepping stone and may be utilized by NPs, nurse executives, physician collaborators, managers, and administrators to position NPs in a role with greater impact on patient care and patient safety. References
CONCLUSION
The public demand for patient safety and the increasing mandate for quality health care dictate the need for strong clinical leadership. The expanding role of advanced NPs provides institutions the opportunity to achieve insight into the aspects of their practice that support their qualification as clinical leaders. Higgins et al.17 found 4 interceding elements that impact the capability of advanced practitioners in fulfilling their leadership role. These include opportunities for professional development of the role, prospects to act as leaders, support and context for sustaining leadership, and personal traits of the practitioners. As health care moves from tiered leadership to situational leadership, and as team-based care models flourish, it is important for organizations to consider factors that enhance the self-efficacy of their clinical leaders and implement actions to nurture a highly self-efficacious multidisciplinary team to deliver optimal care and foster patient safety. Further exploration of the topic of crisis leadership efficacy is important to health care organizations and patient safety agencies. Many organizations have focused on the strategic components of crisis management rather than understanding the core crisis management leadership abilities of clinicians and clinical leaders. 6
The Journal for Nurse Practitioners - JNP
1. Agency for Healthcare Research and Quality. Team strategies & tools to enhance performance & patient safety. 2006. http://www.ahrq.gov/qual/ teamstepps/. Accessed February 15, 2015. 2. Institute of Medicine. To err is human: building a safer health system. https:// www.iom.edu/w/media/Files/Report%20Files/1999/To-Err-is-Human/To% 20Err%20is%20Human%201999%20%20report%20brief.pdf/. Accessed April 14, 2015. 3. Agency for Healthcare Research and Quality. Patient safety primers. 2015. http://psnet.ahrq.gov/primerHome.aspx/. Accessed May 15, 2015. 4. Mitroff II. Crisis Leadership: Planning for the Unthinkable. Hoboken, NJ: John Wiley & Sons; 2004. 5. Tichy NM, Bennis WG. Making judgment calls. Harvard Bus Rev. 2007; 85(10):94. 6. Boin A, Stern E, Sundelius B. The Politics of Crisis Management: Understanding Public Leadership When it Matters Most. Cambridge, UK: Cambridge University Press; 2005. 7. Coombs WT. Ongoing Crisis Communication. Thousand Oaks, Calif: Sage; 2014. 8. Klann G. Crisis Leadership. Greensboro, NC: Center for Creative Leadership; 2003. 9. Useem M, Cook JR, Sutton L. Developing leaders for decision making under stress: wildland firefighters in the South Canyon Fire and its aftermath. Acad Manag Learn Educ. 2005;4(4):461-485. 10. Wooten LP, James EH. Linking crisis management and leadership competencies: the role of human resource development. Adv Devel Hum Res. 2008;10(3):352-379. 11. Hadley CN, Pittinsky TL, Sommer SA, Zhu W. Measuring the efficacy of leaders to assess information and make decisions in a crisis: the C-LEAD scale. Leadership Q. 2011;22(4):633-648. 12. Coombs WT. Code Red in the Boardroom: Crisis Management as Organizational DNA. Westport, Conn: Greenwood Publishing; 2006. 13. Sweeney K. Crisis decision theory: decisions in the face of negative events. Psychol Bull. 2008;134(1):61. 14. Schoenberg A. Do crisis plans matter? A new perspective on leading during a crisis. Publ Rel Q. 2005;50(1):2-6. 15. Peltz R, Ashkenazi I, Schwartz D, et al. Disaster healthcare system management and crisis intervention leadership in Thailand—lessons learned from the 2004 Tsunami disaster. Prehospital Disaster Med. 2006;21(5): 299-302. 16. Shih FJ, Turale S, Lin YS, et al. Surviving a life-threatening crisis: Taiwan’s nurse leaders’ reflections and difficulties fighting the SARS epidemic. J Clin Nurs. 2009;18(24):3391-3400. 17. Higgins A, Begley C, Lalor J, Coyne I, Murphy K, Elliott N. Factors influencing advanced practitioners’ ability to enact leadership: a case study within Irish healthcare. J Nurs Manag. 2013.
Volume
-,
Issue
-, -/-
2015
18. Bandura A. Self-efficacy. 1994. Wiley Online Library. http://onlinelibrary.wiley .com/doi/10.1002/9780470479216.corpsy0836/full. 19. Chan K-Y, Drasgow F. Toward a theory of individual differences and leadership: understanding the motivation to lead. J Appl Psychol. 2001;86(3):481. 20. Amit K, Lisak A, Popper M, Gal R. Motivation to lead: Research on the motives for undertaking leadership roles in the Israel Defense Forces (IDF). Military Psychol. 2007;19(3):137.
Priscilla Samuel, DNP, FNP, is a nurse practitioner in the North Shore-LIJ Health System in Great Neck, NY. Mary T. Quinn Griffin, PhD, RN, FAAN, is a professor in the Frances Payne Bolton School of Nursing at Case Western Reserve University in Cleveland, OH. Maureen White, MBA, RN,
www.npjournal.org
NEA-BC, FAAN, is a senior vice president and chief nurse executive in the North Shore-LIJ Health System. Joyce J. Fitzpatrick, PhD, RN, FAAN, is a professor of nursing in the Frances Payne Bolton School of Nursing at Case Western Reserve University. She can be reached at jjfitzpatrick@ hotmail.com. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest. 1555-4155/15/$ see front matter © 2015 Elsevier, Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2015.06.010
The Journal for Nurse Practitioners - JNP
7
Crisis Leadership Efficacy of Nurse Practitioners
Priscilla Samuel, DNP, FNP, Mary T. Quinn Griffin, PhD, RN, Maureen White, MBA, RN, and Joyce J. Fitzpatrick, PhD, RN ABSTRACT
Leadership is vital to patient safety, particularly in crises. Clinical leadership is an important component of the nurse practitioner (NP) role; expert clinicians are called upon to assure patient safety in crisis situations. The purpose of this study was to describe the self-perceived crisis leadership efficacy of NPs working in acute care settings. The sample included 105 NPs. There was a significant positive relationship between participants’ self-reported familiarity with departmental preparedness to prevent/respond to safety crises/ emergencies and crisis leadership efficacy. Results may inform health care leaders to position NPs for greater impact on patient safety in crisis situations. Keywords: acute care setting, crisis leadership, leadership, nurse practitioners Ó 2015 Elsevier, Inc. All rights reserved.
P
ublic knowledge about widespread medical errors and poor patient outcomes has caused patient safety to become a focal point of what troubles health care systems today. Factors such as interdisciplinary teamwork, collaboration, and effective communication have been identified by various regulatory bodies, such as the Agency for Healthcare Research and Quality,1 as being integral to patient safety. Although patient safety experts observe that cultivating behavioral abilities of the front-line staff could be beneficial in improving patient safety, research on practices and capabilities of clinical leaders and their self-efficacy in managing crises is scarce.
BACKGROUND AND SIGNIFICANCE
The seminal report, published in 2000 by the Institute of Medicine and titled To Err is Human: Building a Safer Health System,2 indicated that up to 98,000 people die each year in hospitals as a result of preventable medical errors. Since that report, various governmental reports have been issued showing compelling evidence that lack of clinical leadership skills, harmful variation in processes, needless complexity, barriers to the flow of critical information, and gaps in teamwork hinder patient safety.3 Leadership is an essential attribute in times of safety crisis/emergencies. Effective crisis leadership is www.npjournal.org
important in attaining quality outcomes in any organization experiencing a safety crisis/emergency. Acute care hospital settings are highly complex and dynamic in nature. The kinetic milieu can rapidly turn unpredictable, especially when patients’ lives are at stake. Ineffectual leadership in safety crises is costly and possibly disastrous.4,5 Clinical leadership and precise execution of clinical judgment are warranted during these times of high stress. The skills and expertise of the clinical leader are in great demand during a crisis. Crucial decisionmaking is based on receipt of pertinent information, which is then critically assessed and analyzed. Information assessment and decision-making have been identified as 2 fundamental behaviors that are important for effective crisis leadership.6-11 Furthermore, a synchronized and seamless flow of information exchange must occur between clinical leaders and pertinent team members under strict time constraints and within stringent protocols and guidelines. Organizations must devote energy to identifying crisis management skills among clinical leaders and persistently invest in resources to further promote and develop clinical leadership. The central role of the nurse practitioner (NP) is to be a clinical leader. There is an identified need to develop leadership skills of NPs to help them achieve their full potential. The Journal for Nurse Practitioners - JNP
1
The pervasiveness of crisis and the prerequisite for effective response have become so vital that crisis leadership is a fundamental competency required by many employers.12 In general, research on crisis leadership has been conceptual or based on various case studies. Not much is known about the details of how leaders respond to a crisis effectively.10,11,13 Very little is also known about how to identify the capabilities of leaders preemptively, that is, prior to their being in a crisis management role.14 STATEMENT OF PURPOSE
The purpose of this research was to examine the selfperceived crisis leadership efficacy of NPs in the acute care setting. The research questions were: (1) What is the crisis leadership efficacy of NPs? (2) What is the relationship between crisis leadership efficacy and each of the background measures among NPs? BACKGROUND
Research conducted on the topic of leadership in crisis management has primarily been in highreliability sectors, such as the aviation industry, with little research literature in health care. Within the research on crisis leadership, crises are considered events that are unpredictable, and that provide a major threat to the organization or group. In the case of a safety crisis/emergency, the threat is to the system and is on a large scale. Given that these largescale safety crises include many complex factors that make alternative outcomes difficult to assess or predict, crisis leader performance is often problematic to define and measure.11 The present review of the literature uncovered case reviews of crisis leadership that emerged during major natural disasters.9,15 The research literature suggests that leaders who manage a crisis effectively tend to be emotionally intelligent.16 They also have the innate ability to think globally and understand the interdependencies and patterns of different components of a larger structure or system. Last, they can synthesize information and communicate imperatives in a timely manner.9,15,16 One of the first studies of nurse leaders in crisis situations was done by Shih and colleagues,16 who studied the experiences of nurse leaders and the 2
The Journal for Nurse Practitioners - JNP
survival strategies employed by them during the SARS epidemic. Based on the data gathered from focus-group interviews and an open-ended questionnaire, the authors identified that nurse leaders are important facilitators of interventions in health disasters. They also recognized that emotional intelligence and sociopolitical and analytical skills are significant to planning and decision-making and to implementing strategies. Hadley et al.11 investigated critical behaviors of leaders (managers from the public health and safety sector) in crisis. Their results show that the important indicator of crisis leadership potential is the aptitude to assess information swiftly and accurately. Higher crisis leadership efficacy was associated with more confidence and ease in making crisis-related decisions. In a case-based study by Higgins et al.,17 factors influencing the abilities of advanced practitioners in carrying out their clinical and professional leadership roles were evaluated. Four factors were identified as having great impact on the practitioner’s ability to perform: professional development; opportunities to function as leaders; tools for sustaining leadership; and personal traits of the practitioners. According to Bandura,18 the level of motivation is dependent on the individual’s self-efficacy to perform a particular task or behavior. Empirical association was noted between leader efficacy and advanced motivation to lead.19 One can infer that high self-efficacy in the implementation of information assessment and decision-making during a crisis is related to motivation to exhibit those skills in a genuine crisis situation.11 Prior research has shown that leadership role-taking in the military is influenced by motivation to lead.20 Crisis leader selfefficacy and motivation to lead in a crisis are both likely to impact the degree to which individuals take on leadership roles in a crisis. Significant gauges of leader performance consist of efficiency of the decision-making, such as the level of effort and selfconfidence that leaders maintain while assessing information and making crisis decisions.11 SUMMARY
The few studies conducted on crisis leadership efficacy have been accomplished outside the realm of the health care setting. There is also minimal research Volume
-,
Issue
-, -/-
2015
regarding the particulars of how leaders respond during crises and how the competencies of leaders can be evaluated prior to a crisis situation. In general, much of the understanding of crisis leadership has been based on analysis of case studies. METHODS Design and Setting
A quantitative descriptive design was used for this investigation. The setting for our study was a large health care system located in northeastern United States. The health care enterprise investigated consists of 15 hospitals inclusive of community, tertiary, and teaching institutions; however, the study setting was acute care hospitals within the local health care system. The health system is one of the largest not-forprofit organizations in the country, with clinical concentrations in emergency medicine, cardiovascular care, pediatrics, neurosciences, internal medicine, psychiatry, and women’s health. Sample
The study population was all NPs practicing in acute care settings in 1 integrated health system in the Northeast. The potential sample was estimated to be approximately 500. All NPs credentialed and privileged to render clinical services and employed in an acute care setting within the integrated health care enterprise were eligible to participate in the survey. NPs who were on voluntary or adjunct status were excluded. Other advanced practice nurses, such as certified nurse anesthetists, clinical nurse specialists, and certified nurse midwives, were not eligible to participate. Instruments
The Crisis Leader Efficacy in Assessing and Deciding (C-LEAD) scale was used to measure crisis leadership efficacy. This instrument was developed by Hadley et al.11 to determine the efficacy of leaders in assessing information and in making decisions while dealing with a safety crisis. The C-LEAD scale forecasts confidence in decisionmaking during a crisis better than a general measure of leadership efficacy. It consists of 9 items and measures 2 critical actions: propensity for evaluating information and decision-making in crisis. It uses a www.npjournal.org
7-point rating scale with scores ranging from 1 (strongly disagree) to 7 (strongly agree). The total C-LEAD score is calculated by taking the mean of all 9 items; possible scores range from 4 to 63. Higher scores represent lesser degree of trouble and more comfort in making decisions in crisis situations. The Cronbach alpha reliability for the C-LEAD measure was previously found to range from 0.81 to 0.88.11 In the present study Cronbach’s alpha was a ¼ 0.917. A background data questionnaire was used to gather pertinent information from participants. The 10 questions included: gender; age; education; years of experience in acute care settings; year of experience in the role; years of experience in the organization; specialty certification; prior crisis training (yes/no); formal leadership position for managing a patient safety crisis (yes/no); and familiarity with departmental preparedness to prevent and respond to safety crises/emergencies (choices included not at all familiar, somewhat familiar, moderately familiar, very familiar). Procedure
Approval was obtained from the appropriate institutional review boards. Several methods were employed for recruitment of participants for this study. In efforts to maximize participation, contact was made with the system-wide NP leadership council for NP recruitment. An electronic mail distribution list of all NPs employed in acute care within the integrated health system was created in partnership with the medical staff services office. E-mail correspondence included a description of the study, its purpose, the importance of voluntary participation, and instructions on completing the survey. The survey was administered via Survey Monkey; biweekly electronic requests were sent to all prospective participants as a reminder to complete the survey. Data Analysis
SPSS software (version 21) was used for analysis. Descriptive statistics were computed including frequency distribution, measures of central tendency, ranges, and standard deviations. Correlational analysis using Spearman’s rho was performed to determine The Journal for Nurse Practitioners - JNP
3
the relationship between the C-LEAD and each of the categorical background measures. RESULTS Sample
One hundred five NPs participated in the survey with a 21% response rate. The majority of participants (89.5%) were female (n ¼ 94). More than half (54.3%) were age 50 or older. Almost half of the participants (45.7%) had > 10 years of work experience as an NP; a small portion of the respondents (15.2%) had > 20 years of work experience as an NP. Nearly half (45.7%) reported tenure with the health system of < 5 years, whereas < 10% (6.7%) had worked for > 20 years in the health system. More than half (53.3%) of the participants were not in a position of formal authority to direct other employees in the event of a patient emergency. Fewer than half (47.6%) reported being “not at all familiar” to “somewhat familiar” with departmental preparedness to prevent and respond to crises/ emergencies. More than half (54.3%) had participated in patient safety emergency training in the last 2 years. All participants held a master’s degree in nursing. A small group (3%) reported having a doctorate degree. Nearly all participants (93.3%) were nationally board certified. Fewer than 4% (3.8%) were trained in acute care; 38.1% were adult NPs; < 25% (23.8%) were family NPs; and < 10% (9.5%) were pediatric NPs. Background data are included in the Table. Possible total scores for the C-LEAD scale range from 4 to 63, with higher scores indicating higher levels of self-reported crisis leadership efficacy. The mean total score for the C-LEAD scale in this study was 48.26 (SD 9.97). Approximately, 50% of the respondents scored > 50, indicating a high level of self-reported crisis leadership efficacy. Spearman’s rho revealed a statistically significant positive relationship between C-LEAD score and familiarity with departmental preparedness to prevent and respond to safety crises/emergencies (rs[105] ¼ 0.355, P < .001). Two-tailed tests were performed to determine the direction of the relationships. No significant relationships were found for C-LEAD with other background characteristics, such as formal 4
The Journal for Nurse Practitioners - JNP
Table. Sample Characteristics (N [ 105) Variable
Number (%)
Age 20-29 years
5 (4.8)
30-39 years
15 (14.3)
40-49 years
28 (26.6)
50-59 years
42 (40.0)
> 60 years
15 (14.3)
Gender Male
8 (7.6)
Female
94 (89.5)
Missing
3 (2.9)
Years as an NP 0-4 years
29 (27.6)
5-10 years
25 (23.8)
11-19 years
32 (30.5)
> 20 years
16 (15.2)
Missing
3 (2.9)
Years as NP at the organization 0-4 years
48 (45.7)
5-10 years
23 (21.9)
11-19 years
24 (22.8)
> 20 years
7 (6.7)
Missing
3 (2.9)
Area of NP specialty Adult
40 (38.1)
Family
25 (23.8)
Geriatric
1 (1.0)
Pediatric
10 (9.5)
Acute
4 (3.8)
Other
22 (21.0)
Missing
3 (2.8)
National board certification Certified
98 (93.3)
Noncertified
4 (3.8)
Missing
3 (2.9)
NP ¼ nurse practitioner.
leadership position for crisis management, previous crisis training, national board certification status, and area of NP specialty. Volume
-,
Issue
-, -/-
2015
DISCUSSION
limitation stems from the use of self-reported data, thus increasing the possibility of self-presentation bias.
The study participants included a convenience sample of 105 NPs employed by an integrated health system in the Northeast. The majority of the NPs within the integrated health system reported high levels of crisis leadership efficacy. This finding was important because most respondents were not in a position of formal authority in crisis management. It is possible that this finding may be directly correlated with the high percentage of well-educated and board-certified NPs in this organization. It may also be a downstream effect of the culture of patient safety embraced by the organization and a result of the high-fidelity‒based simulated patient safety training made available to employees via the corporate learning university. Despite the resources available to the NPs in the organization, 47.6% reported being either “not at all familiar” to “somewhat familiar” with departmental preparedness to prevent and respond to safety crises/ emergencies. This finding is important. It indicates a need for the local setting to explore potential barriers, such as large clinical caseloads, that may prevent NPs from engaging in nonclinical activities, thereby affecting their perception of their own leadership capacity. This finding may also prompt the local organization to understand gaps in preparing and tapping NPs for management and leadership in safety crises/emergencies. In this study we have examined the relationship between NP background characteristics and crisis leadership efficacy. The review of the literature uncovered no prior research on crisis leadership efficacy of NPs. There are similarities, however, with findings obtained by Hadley et al.,11 who found that C-LEAD correlated positively with the level of understanding among public health and safety workers regarding their departmental emergency response protocols. No significant relationships were found for C-LEAD with other background variables, including whether participants were in a leadership position with formal authority for crisis management.
This study revealed that there is a significant relationship between NPs’ level of crisis leadership efficacy and their familiarity with departmental preparedness in preventing and responding to patient emergencies. As organizations struggle to prepare themselves for safety crises/emergencies and safeguard their patients, is important to develop higher levels of crisis leadership efficacy among clinical leaders. The C-LEAD scale can be used to identify the capabilities of a clinical leader (such as an NP) prior to a crisis situation and, ultimately, to develop crisis leadership prototypes for health care and interventions to increase the efficacy of expert clinicians, including NPs, in managing crises. On the national level, there are implications for educational preparation of NPs and other advanced practice nurses. For example, it will be important to include a focus on leadership within safety crises/ emergencies within the leadership components of the doctor of nursing practice degree programs, all of which have leadership content. This research study has both implications and applications within the context of the integrated health system. The literature review indicated that there have been no other studies that have addressed the crisis leadership efficacy of NPs. Although the implications of this study at this stage may be relevant only to the local setting, we have provided an important starting point. Leaders in other health systems may wish to reproduce this study to determine the capabilities of their clinical leaders in managing patient safety‒related crises. We have found that most NPs in the local system perceived themselves as capable of managing a patient safety‒related crisis, even if not in a role of formal authority in managing such an event. This information is valuable to the organization because familiarity with departmental emergency protocols is an attribute organizations can control.
Limitations
Recommendations for Future Research
The study was limited to NPs working in acute care settings within a single integrated health system in the Northeast. The study design limits generalizing the results to other acute care hospital systems. Another study
The current accelerated redesign of traditional care delivery models and the increasing demand for patient safety support the need for continued research in the area of clinical leadership and crisis
www.npjournal.org
Implications for Nursing
The Journal for Nurse Practitioners - JNP
5
management of NPs. Based on our findings, future research is proposed to analyze whether crisis leadership training and NP specialization and preparedness affect the self-efficacy levels of NPs in managing patient safety‒related crises. Future research is also recommended to strengthen the generalizability of the findings of this study. Areas of interest for future research include examining crisis leadership efficacy of NPs across the country and the relationship between crisis leadership efficacy and patient outcomes. An exploration of the crisis leadership efficacy of multidisciplinary clinical leaders is also warranted. Therefore, it may be valuable to replicate this study within diverse health systems and in mixed geographical areas of the US to support and generalize the findings. Also, qualitative research may be an important next step to generate the depth of data needed to fully explore the reasons why NPs adopt certain crisis leadership styles.
A clinical leader, the person directing the immediate management of any patient safety‒related event, could possibly be the most vital stakeholder in ensuring that a life, or many lives, can be saved in the midst of a crisis. Efforts in fostering patient safety through the establishment of clinical guidelines, practice protocols, patient safety goals, and multidisciplinary crisis resource management often result in decreasing patient harm. It is important for organizations to understand the crisis leadership efficacy of clinical leaders, such as NPs, and cultivate their expertise and attributes necessary for efficacious crisis management. The results of our study serve as a stepping stone and may be utilized by NPs, nurse executives, physician collaborators, managers, and administrators to position NPs in a role with greater impact on patient care and patient safety. References
CONCLUSION
The public demand for patient safety and the increasing mandate for quality health care dictate the need for strong clinical leadership. The expanding role of advanced NPs provides institutions the opportunity to achieve insight into the aspects of their practice that support their qualification as clinical leaders. Higgins et al.17 found 4 interceding elements that impact the capability of advanced practitioners in fulfilling their leadership role. These include opportunities for professional development of the role, prospects to act as leaders, support and context for sustaining leadership, and personal traits of the practitioners. As health care moves from tiered leadership to situational leadership, and as team-based care models flourish, it is important for organizations to consider factors that enhance the self-efficacy of their clinical leaders and implement actions to nurture a highly self-efficacious multidisciplinary team to deliver optimal care and foster patient safety. Further exploration of the topic of crisis leadership efficacy is important to health care organizations and patient safety agencies. Many organizations have focused on the strategic components of crisis management rather than understanding the core crisis management leadership abilities of clinicians and clinical leaders. 6
The Journal for Nurse Practitioners - JNP
1. Agency for Healthcare Research and Quality. Team strategies & tools to enhance performance & patient safety. 2006. http://www.ahrq.gov/qual/ teamstepps/. Accessed February 15, 2015. 2. Institute of Medicine. To err is human: building a safer health system. https:// www.iom.edu/w/media/Files/Report%20Files/1999/To-Err-is-Human/To% 20Err%20is%20Human%201999%20%20report%20brief.pdf/. Accessed April 14, 2015. 3. Agency for Healthcare Research and Quality. Patient safety primers. 2015. http://psnet.ahrq.gov/primerHome.aspx/. Accessed May 15, 2015. 4. Mitroff II. Crisis Leadership: Planning for the Unthinkable. Hoboken, NJ: John Wiley & Sons; 2004. 5. Tichy NM, Bennis WG. Making judgment calls. Harvard Bus Rev. 2007; 85(10):94. 6. Boin A, Stern E, Sundelius B. The Politics of Crisis Management: Understanding Public Leadership When it Matters Most. Cambridge, UK: Cambridge University Press; 2005. 7. Coombs WT. Ongoing Crisis Communication. Thousand Oaks, Calif: Sage; 2014. 8. Klann G. Crisis Leadership. Greensboro, NC: Center for Creative Leadership; 2003. 9. Useem M, Cook JR, Sutton L. Developing leaders for decision making under stress: wildland firefighters in the South Canyon Fire and its aftermath. Acad Manag Learn Educ. 2005;4(4):461-485. 10. Wooten LP, James EH. Linking crisis management and leadership competencies: the role of human resource development. Adv Devel Hum Res. 2008;10(3):352-379. 11. Hadley CN, Pittinsky TL, Sommer SA, Zhu W. Measuring the efficacy of leaders to assess information and make decisions in a crisis: the C-LEAD scale. Leadership Q. 2011;22(4):633-648. 12. Coombs WT. Code Red in the Boardroom: Crisis Management as Organizational DNA. Westport, Conn: Greenwood Publishing; 2006. 13. Sweeney K. Crisis decision theory: decisions in the face of negative events. Psychol Bull. 2008;134(1):61. 14. Schoenberg A. Do crisis plans matter? A new perspective on leading during a crisis. Publ Rel Q. 2005;50(1):2-6. 15. Peltz R, Ashkenazi I, Schwartz D, et al. Disaster healthcare system management and crisis intervention leadership in Thailand—lessons learned from the 2004 Tsunami disaster. Prehospital Disaster Med. 2006;21(5): 299-302. 16. Shih FJ, Turale S, Lin YS, et al. Surviving a life-threatening crisis: Taiwan’s nurse leaders’ reflections and difficulties fighting the SARS epidemic. J Clin Nurs. 2009;18(24):3391-3400. 17. Higgins A, Begley C, Lalor J, Coyne I, Murphy K, Elliott N. Factors influencing advanced practitioners’ ability to enact leadership: a case study within Irish healthcare. J Nurs Manag. 2013.
Volume
-,
Issue
-, -/-
2015
18. Bandura A. Self-efficacy. 1994. Wiley Online Library. http://onlinelibrary.wiley .com/doi/10.1002/9780470479216.corpsy0836/full. 19. Chan K-Y, Drasgow F. Toward a theory of individual differences and leadership: understanding the motivation to lead. J Appl Psychol. 2001;86(3):481. 20. Amit K, Lisak A, Popper M, Gal R. Motivation to lead: Research on the motives for undertaking leadership roles in the Israel Defense Forces (IDF). Military Psychol. 2007;19(3):137.
Priscilla Samuel, DNP, FNP, is a nurse practitioner in the North Shore-LIJ Health System in Great Neck, NY. Mary T. Quinn Griffin, PhD, RN, FAAN, is a professor in the Frances Payne Bolton School of Nursing at Case Western Reserve University in Cleveland, OH. Maureen White, MBA, RN,
www.npjournal.org
NEA-BC, FAAN, is a senior vice president and chief nurse executive in the North Shore-LIJ Health System. Joyce J. Fitzpatrick, PhD, RN, FAAN, is a professor of nursing in the Frances Payne Bolton School of Nursing at Case Western Reserve University. She can be reached at jjfitzpatrick@ hotmail.com. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest. 1555-4155/15/$ see front matter © 2015 Elsevier, Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2015.06.010
The Journal for Nurse Practitioners - JNP
7