- Email: [email protected]
Using a 360° Feedback Evaluation to Enhance Interprofessional Collaboration
Using a 360° Feedback Evaluation to Enhance Interprofessional Collaboration Deborah Sikes, DNP, RN, CNE, Emily Jestes, DNP, RN, CNL, NE-BC, Colleen LeClair-Smith, DNP, RN, NEA-BC, and Rowena R.Yates, DNP, RN, NE-BC, CCRN
T Care
he enactment of the Patient Protection and Affordable
Act
(ACA)
created
limitless
opportunities for change and leadership in the U.S. healthcare system.1 Nurse leaders are responsible and accountable for improving patient safety, increasing patient satisfaction,
and
decreasing
cost
while
simultaneously creating a supportive, healthy work environment for their nursing staff. With the ever-changing healthcare landscape, nurse leaders must be able to create a common vision among teams and facilitate safe and improved patient outcomes across the continuum of care. Leadership is a crucial factor in nurse and patient outcomes and ultimately in the success of healthcare organizations.2 Furthermore, transformational leadership competencies of nurse leaders are essential for managing change processes effectively and delivering highquality care within healthcare organizations.3 An effective and efficient way to assess and develop transformational leadership competencies is to use 360° feedback. Transformational leaders look for pathways to foster and enhance communication within their teams and the organization. Although providing feedback is important, it is also necessary for leaders to receive feedback from their teams regarding their performance as leaders. By receiving feedback, especially 360° feedback, leaders can better address the needs of their subordinates. Transformational leaders focus on the “greater good” of the organization by using interprofessional feedback because it allows a pathway for higher team performance.
360° FEEDBACK The purpose and theory of leadership development using 360° feedback has been well documented during the past 25 years.4 Although clinical and nursing leadership experiences play vital roles in professional development, research suggests that the empirical evidence for this assumption is far from
64
Nurse Leader
definitive.5 Some assume that strong clinical experience will translate into being a strong nurse leader; however, the skills and competencies of clinical nurses are not the same as leadership competencies. Having a well-rounded assessment of leadership strengths, as well as areas for development, not only helps leaders know where to focus, but also helps direct
August 2015
Table 1. LPI Nursing Leadership Studies
Authors
Year Published
Study Focus
Instrument Used
Findings
Kelly et al.12
2014
To examine the relationship of transformational leadership practices, nurse characteristics, and formal leadership training of frontline nurse leaders in a large health system: 512 frontline nurse leaders in 23 hospitals
LPI SelfAssessment
Formal training influences only 1 component of transformational leadership behaviors, helping train leaders to model the way for their employees. Increasing a nurse leader’s level of formal education has a significant effect on improving overall transformational leadership practices and behaviors that inspire a shared vision and challenge the process.
Ross et al.13
2014
The transformational leadership practices of nurse leaders in professional nursing associations: 448 nurse leaders in professional nursing associations
LPI
Nurse leaders of professional nursing associations emulate practices of transformational leadership.
Kallas14
2014
Profile of an excellent nurse manager
LPI SelfAssessment
The LPI can be used to identify, recruit, and develop RNs in the nurse manager role as excellent leaders of effective healthcare teams.
Fardellone and Click15
2013
73 RNs (convenience sample)
LPI SelfAssessment
RNs with more experience show fewer leadership behaviors. Scores demonstrated a need for leadership training at all levels of practice. The highest average responses were for Enabling Others to Act and Modeling the Way.
Krugman et al.16
2013
To examine longitudinal outcomes of a leadership program for permanent and relief charge nurses from 1996 to 2012 divided into 3 phases
LPI
Charge nurse leadership reported significant gains despite institutional changes and educational interventions. Charge nurse leadership development cannot take place without purposeful mentoring and coaching by nurse managers and directors, led and modeled by the CNO.
Clavelle et al.17
2012
Transformational leadership practices of Magnet CNOs: 225 CNOs completed the survey
LPI SelfAssessment
Enabling Others to Act and Modeling the Way are the top transformational leadership practices exhibited by Magnet CNOs. As CNOs gain experience and education, they exhibit more transformational leadership characteristics.
Pedaline et al.18
2012
Formal mentoring program development for 10 frontline nurse managers in acute care
LPI SelfAssessment and 8 to 10 observers
Comparison of the LPI pre- and postassessments revealed an increase in the average score of the nurse manager’s selfassessment in all 5 leadership practices. Managers identified increased awareness, focus, and clarity as insights into their leadership skills as a result of the 360° feedback.
www.nurseleader.com
Nurse Leader
65
Table 1. LPI Nursing Leadership Studies (cont.)
Authors
Year Published
Study Focus
Instrument Used
Findings
Martin et al.3
2012
Development of leadership competencies of nurse leaders in Switzerland: Convenience sample of 14 ward leaders using the LPI assessment over 3 time periods
LPI-Self Assessment
Nurse leaders following the clinical leadership program for the development of leadership competencies of nurse leaders demonstrated significant improvement in 2 subscales of the LPI, Inspiring a Shared Vision and Challenging the Process.
Abraham and Man19
2011
15 registered nurses with BSNs and 5 years of nursing experience: A voluntary convenience sample
LPI and Nursing Activity Scale used for pre- and post-program assessments
The Nursing Leadership Perspectives Program enhanced leadership skills and promoted professionalism as evidenced by changes in assessment tool scores.
Wang et al.20
2011
The relationship between the transformational leadership of nurse managers and job satisfaction among clinical registered nurses: 238 nurses with >1 year of work experience
LPI and Nurse Job Satisfaction Scale
Transformational leadership of nurse managers could have an effect on the job satisfaction of clinical registered nurses.
each nurse leader’s individual plan for leadership growth. Leadership development involves interactions between people and the social and organizational environments in which they practice. Leadership development also emphasizes the enactment of leadership built on a foundation of mutual trust and respect.6 Although many leadership tools are available for professional development, utilization of feedback is important for the transformational leader. Use of 360° feedback can assist leaders in understanding the impact of their individual behavior on others. The leader gathers and receives information regarding leadership behaviors from multiple sources, such as subordinates, peers, and supervisors, in addition to self-evaluation.4
HISTORY OF 360° FEEDBACK The term feedback is associated with other common terminology, such as multisource feedback, multirater feedback, multisource assessment, full-circle appraisal, and 360° feedback. The history of feedback began with World War II, when the German military began gathering information from multiple sources to evaluate performance.7 Since that time, the concept of 360° feedback has gained momentum, and it has become much easier to implement with easy access to online assessments. Utilization of feedback, especially 360° feedback, can be employed as a process for leadership development by
66
Nurse Leader
means of fostering self-awareness and competency. This type of feedback is a resource used across industries, including business, government, nonprofit, military, healthcare, and education. Regardless of terminology, individual leaders who develop action plans or map specific pathways for professional development frequently use results obtained from 360° feedback, which offers a plethora of benefits for the developing leader. A 360° feedback is a valid assessment of leadership behavior and performance, offers opportunities for candid discussions about a leader’s performance and progress, and allows a leader to envision broader goals and objectives with employees and interprofessional teams. This type of feedback serves as a framework to encourage and support learning, skill development, and future goal setting. It provides an opportunity to improve leader performance and team performance, and it ultimately holds potential to influence and strengthen organizational culture.8 To create a strong organizational culture, the voice of each individual must be facilitated and supported. Nurses who participate in 360° evaluations report heightened capacities to effectively communicate their voices and visions.9 When they are encouraged to provide feedback, team cohesion and trust increase.10 Methodologies used to obtain feedback differ. Some are anonymous, whereas others are open and transparent. In addition to the variety of tools available for use, the
August 2015
Table 2. Definitions of Leadership Practices Subscales Compared to Transformational Leadership Characteristics
Transformational Leadership21
LPI Subscale
Scale Definition
Modeling the Way
Clarifying values by finding your voice; affirming the shared values of the group; setting an example by aligning actions with shared values
Inspiring a Shared Vision
Envisioning the future by imagining exciting and ennobling possibilities; enlisting others in a common vision by appealing to shared aspirations
Empowering others
Challenge the Process
Searching for opportunities by seizing the initiative and by looking outward for innovative ways to improve; generating small wins and learning from experience
Promoting teamwork
Enable Others to Act
Fostering collaboration by building trusting and facilitating relationships; strengthening others by increasing self-determination and developing competence
Charismatic leader
Inspiring teams
number of respondents required to provide feedback varies as well. Regardless of the methodologies used, employees report that 360° feedback more accurately reflects their performance than feedback received from a single individual, such as one’s immediate superior. To transform interprofessional teams, nurses need to build on the current state of practice. Although several 360° assessment tools exist, one of the most widely used in nursing is the Leadership Practices Inventory (LPI) developed by Kouzes and Posner.11
USE OF THE LPI IN NURSING LEADERSHIP Ten nursing studies were published between 2011 and 2014 regarding the use of the LPI in nursing leadership, strengthening the use of the LPI assessment as a leadership development tool. The literature was reviewed to describe the current state of practice. Search strategy terms used to explore the concept of 360° feedback in nursing included “registered nurse,” “360-degree feedback,” and “LPI assessment” using EBSCOhost and PubMed search engines. Summaries of nursing studies utilizing the LPI instruments are identified in Table 1.12-20
TRANSFORMATIONAL LEADERSHIP AND LPI The LPI closely aligns with transformational leadership, a leadership style that is found to be highly successful in healthcare settings.11 Transformational leadership styles in turn closely align with the 5 practices of exemplary leaderwww.nurseleader.com
ship described by Kouzes and Posner,11 a model commonly used in nursing as well as other disciplines (Table 2).21 Practices or domains identified in the LPI include Modeling the Way, Inspiring a Shared Vision, Challenging the Process, Enabling Others to Act, and Encouraging the Heart.11 The LPI is a 360° feedback assessment tool designed, using strong empirical evidence, to support the framework and validity of the assessment instrument as an accurate method to assess leadership skills.22 The 30-item LPI instrument is formatted with a 5-point scale divided into 5 domains of 6 questions per category.23 A distinct aspect of the LPI is the individual leader’s opportunity to self-select peers and colleagues to review his or her leadership strengths and skills. Use of the LPI to develop transformational leaders lends itself readily to selection of leaders throughout the organization and includes feedback from different professions’ perspectives.
IMPLICATIONS OF 360° FEEDBACK FOR NURSING Since the publication of the Institute of Medicine’s landmark report, To Err Is Human: Building a Safer Health System,24 which discussed the United States’ flawed and fragmented care delivery, healthcare has been in a constant state of change. Embracing this change is essential for organizations to survive in the current healthcare environment.25 Yet the need for effective personal relationships with “human to human sensitivity, acknowledgment, and respect for the patient care experience” remains constant.26 Nurses are positioned to take on leadership roles through their abilities to
Nurse Leader
67
Table 3. Strategies for Initiating or Expanding 360° Feedback
Implementing 360° Feedback
Leveraging 360° Feedback
Provide data to demonstrate value and outcomes
Define specific goals and objectives35
Determine organizational readiness for change36
Decide how and when information will be shared
Gain administrative support Assess commitment to participate Identify and phase in with key leaders38,39
Include interprofessional team members with result sharing Develop action plans37 Provide resource guides and supportive tools to assist leaders with action planning
Encourage and embrace interprofessional coworkers’ feedback
Embrace team differences and capitalize on everyone’s strengths for synergy
Define time frame for assessment completion
Plan ongoing leadership development40
effect change and improve care; the Institute of Medicine has recognized the importance of nursing leadership and charged nurses with understanding and assuming responsibilities as full partners and leaders in the care of patients. Improved care delivery requires an evolution of nursing practice.24 Simply stated, nurses at all levels must learn from others to ensure they are effective wherever they practice.27 Effective nursing leaders focus on building engaged teams that strive for excellence in practice and care.28 How do nurse leaders know what is working well with their teams? One strategy is to use a 360° feedback process that engages members of other professions in the feedback process and models what is needed for all leaders within an organization. With the convoluted state of healthcare, nurse leaders need greater perspectives to improve care; 360° feedback offers nurse leaders the ability to engage the insight and perspective of interprofessional teams. It encourages nurse leaders to identify their goals and determine how to improve leadership behaviors to ensure excellent nursing care.29
IMPLICATIONS FOR INTERPROFESSIONAL COLLEAGUES Although interprofessional, shared leadership has been discussed since the early 1980s, it has yet to be widely adopted into healthcare organizations.30–32 If true interprofessional collaboration is to be realized within healthcare organizations, nurse leaders must advocate for the use of 360° feedback throughout their organizations to build interprofessional teams and collaboration. Nursing cannot afford to focus its attention on improving nursing leadership alone but must look to the larger picture of producing dynamic, highly functioning interprofessional teams. Effective interprofessional teams have a positive impact on patient experience, quality outcomes, and costs. Not only does 360° feedback help individual leaders develop, it also helps their organizations. By implementing
68
Nurse Leader
360° feedback throughout the organization, individual leadership growth and performance can be measured, as can the performance of the organization.33,34 If nurse leaders participate in 360° feedback and their interprofessional colleagues do not, by default, a weak link has been created in the leadership of the healthcare organization. Nurse leaders have the opportunity to lead and influence organizations in modeling interprofessional evaluation feedback.
360° FEEDBACK USING INTERPROFESSIONAL COLLABORATION Some organizations already use a 360° approach to enhance interprofessional collaboration; others are considering such an approach. Table 3 identifies some common strategies that are useful in initiating or expanding use of 360° feedback.35-40 Effective communication is the key to any organizational change. Nurse leaders communicate the value of interprofessional collaboration and implementation of effective working strategies through evidence of improved leadership competencies. With all of the issues facing healthcare, the time is right to develop effective leaders.41 Using a 360° assessment provides the opportunity for honest conversations designed to enhance teams and their effectiveness.
IMPLICATIONS FOR THE FUTURE In this era of fast-paced, continuous implementation of change, focus on outcomes, and climate of “immediate results,” leaders do not have the luxury of doing things the way they have always been done. Nursing and healthcare have been slow to adopt evidence-based leadership practices such as 360° feedback in organizations. For leaders to be highly effective, teams must be highly effective. As a tool, 360° feedback is excellent at quickly assessing the leadership of members in interprofessional team. Interprofessional leadership occurs as a result of strategically targeting leadership and mentoring activities to develop
August 2015
individuals while getting the work of the organization accomplished. Kouzes and Posner11 challenge leaders to take teams to places they have never gone before. Leaders need to model the way by making 360° feedback a standard of nursing leadership practice and encourage their interprofessional colleagues to do the same. By incorporating 360° feedback into practice, leadership competency and confidence can be developed in each member of the team. This, in turn, leads to a stronger team positioned to produce better results and lead healthcare into the future. NL Note: We would like to thank Dr. Patricia Yoder-Wise for her support, encouragement, and expertise in the preparation of this article. References 1. U.S. Department of Health and Human Services. Read the law: The Affordable Care Act. Updated June 28, 2012. Available at: http://www.hhs.gov/healthcare/rights/law/. Accessed July 7, 2014. 2. Ulrich B, Lavandero R. Early S. Leadership competence: perceptions of direct care nurses. Nurse Leader. 2014;12:47-50. 3. Martin JS, McCormack B, Fitzsimons D, Spirig R. Evaluation of a clinical leadership programme for nurse leaders. J Nurse Manag. 2012;20:72-78. 4. Day DV, Fleenor JW, Atwater LE, Sturm RE, McKee RA. Advances in leader and leadership development: a review of 25 years of research and theory. Leadersh Q. 2014;25:63-82. 5. Day DV. The difficulties of learning from experience and the need for deliberate practice. Ind Organ Psychol. 2010;3:41-44. 6. Day DV. Leadership development: a review in context. Leadersh Q. 2000;11:581-613. 7. Fleenor JW, Prince JM. Using 360-Degree Feedback in Organizations: An Annotated Bibliography. Greensboro, NC: Center for Creative Leadership; 1997:1-88. 8. National Business Research Institute. 360 degree feedback. August 2010. Available at: http://www.nbrii.com/employee-survey-white-papers/360-degreefeedback/. Accessed July 9, 2014. 9. Berlin G, Grote K. Creating and sustaining change in nursing care delivery. May 2013. Available at: http://healthcare.mckinsey.com/creating-andsustaining-change-nursing-care-delivery. Accessed July 15, 2014. 10. Rolfe P. Transformational leadership theory: what every nurse needs to know. Nurse Leader. 2011;9(2):54-7. 11. Kouzes J, Posner B. The Leadership Challenge: How to Make Extraordinary Things Happen in Organizations. 5th ed. San Francisco, CA: Wiley & Sons; 2012. 12. Kelly LA, Wicker TL, Gerkin RD. The relationship of training and education to leadership practices in frontline nurse leaders. J Nurs Adm. 2014;44:158-163. 13. Ross EJ, Fitzpatrick JJ, Click ER, Krouse HJ, Clavelle JT. Transformational leadership practices of nurse leaders in professional nursing associations J Nurs Adm. 2014;44:201-206. 14. Kallas KD. Profile of an excellent nurse manager: identifying and developing health care team leaders. Nurs Adm Q. 2014;38:261-268. 15. Fardellone C, Click ER. Self-perceived leadership behaviors of clinical ladder nurses. Nurse Leader. 2013;11(6):51-53. 16. Krugman M, Heggem L, Kinney LJ, Frueh M. Longitudinal charge nurse leadership development and evaluation. J Nurs Adm. 2013;43:438-446. 17. Clavelle JT, Drenkard K, Tullai-McGuinness S, Fitzpatrick JJ. Transformational leadership practices of chief nursing officers in Magnet(R) organizations J Nurs Adm. 2012;42:195-201. 18. Pedaline SH, Wolf G, Dudjak L, Lorenz H, McLaughlin M, Ren D. Preparing exceptional leaders. Nurs Manage. 2012;43(9):38-44. 19. Abraham PJ, Man BC. Developing nurse leaders: a program enhancing staff nurse leadership skills and professionalism. Nurs Adm Q. 2011;35:306312. 20. Wang X, Chontawan R, Nantsupawat R. Transformational leadership: effect on the job satisfaction of registered nurses in a hospital in China. J Adv Nurs. 2012;68:444-451. 21. Smith M. Are you a transformational leader? Nurs Manage. 2011;42(9):4450. 22. John Wiley & Sons. Assessments: Leadership practices inventory (LPI) assessments. Updated 2014. Available at: http://www.leadershipchallenge. com/leaders-section-assessments.aspx. Accessed July 15, 2014.
www.nurseleader.com
23. Huber DL, Maas M, McCloskey J, Scherb CA, Goode CJ, Watson C. Evaluating nursing administration instruments. J Nurs Adm. 2000:30:251272. 24. Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: Institute of Medicine of the National Academies; 1999. 25. Mockett L, Horsfall J, O'Callaghan W. Education leadership in the clinical health care setting: a framework for nursing education development Nurse Educ Pract. 2006;6:404-410. 26. Malloch K. Innovation leadership: new perspectives for new work. Nurs Clin North Am. 2010;45(1):1-9. 27. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. October 5, 2010. Available at: http://www.iom.edu/Reports/2010/the-future-of-nursing-leading-changeadvancing-health.aspx. Accessed July 15, 2014. 28. Yoder-Wise PS, Kowalski K. Beyond Leading and Managing: Nursing Administration for the Future. St. Louis, MO: Mosby; 2006. 29. American Organization of Nurse Executives. The AONE nurse executive competencies. Updated 2011. Available at: http://www.aone.org/resources/ leadership%20tools/nursecomp.shtml. Accessed July 10, 2014. 30. Hoying C, Allen SR. Enhancing shared governance for interdisciplinary practice. Nurs Adm Q. 2011;35:252-259. 31. Brewton C, Eppling J, Hobley M. Our VOICE: an interdisciplinary approach to shared governance. Hosp Top. 2012;90(2):39-46. 32. Jukkala AJ, White ML. The continued need for interprofessional collaboration and research. Appl Nurs Res. 2014;27:95-96. 33. Bracken DW, Church AH. The "new" performance management paradigm: capitalizing on the unrealized potential of 360 degree feedback. People Strategy. 2013;36(2):34-40. 34. Hafford-Letchfield T, Bourn D. ‘How am I doing?’ Advancing management skills through the use of a multi-source feedback tool to enhance work-based learning on a post-qualifying post-graduate leadership and management programme. J Soc Work Educ. 2011;30:497-511. 35. Institute for Healthcare Improvement. Changes for Improvement. 2014. Available at: http://www.ihi.org/resources/Pages?Changes/default.aspx. Accessed June 27, 2014. 36. Shea CM, Jacobs SR, Esserman DA, Bruce K, Weiner BJ. Organizational readiness for implementing change: a psychometric assessment of a new measure. Implement Sci. 2014;9(1):1-15. 37. Hewitt-Taylor J. Planning successful change incorporating processes and people. Nurs Stand. 2013;27(38):35-40. 38. Omoike O, Stratton KM, Brooks BA, Ohlson S, Storfjell JL. Advancing nursing leadership: a model for program implementation and measurement. Nurs Adm Q. 2011;35:323-332. 39. Stanleigh M. Leading change. J Qual Particip. 2013;36(2):39-40. 40. Vukotich G. 360o feedback: ready, fire, aim—issues with improper implementation. Perform Improv. 2014;53(1):30-34. 41. Yoder-Wise PS. The future of leadership. J Nurs Adm. 2014;44:318-320.
Deborah Sikes, DNP, RN, CNE is Veteran to BSN Program Director at the Texas Tech University Health Sciences Center School of Nursing in Lubbock, Texas. She can be reached at [email protected]. Emily Jestes, DNP, RN, CNL, NEBC is Clinical Nurse Leader at Texas Health Presbyterian Hospital Plano in Plano, Texas. Colleen LeClair-Smith, DNP, RN, NEABC, is Director, Magnet, Recruitment and Nursing Resource Pool at University Medical Center in Lubbock, Texas. Rowena R.Yates, DNP, RN, NE-BC, CCRN is Vice President, Education/Research/Magnet at Medical Center in Lewisville, Texas. 1541-4612/2014/ $ See front matter Copyright 2015 by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.mnl.2014.10.002
Nurse Leader
69
T Care
he enactment of the Patient Protection and Affordable
Act
(ACA)
created
limitless
opportunities for change and leadership in the U.S. healthcare system.1 Nurse leaders are responsible and accountable for improving patient safety, increasing patient satisfaction,
and
decreasing
cost
while
simultaneously creating a supportive, healthy work environment for their nursing staff. With the ever-changing healthcare landscape, nurse leaders must be able to create a common vision among teams and facilitate safe and improved patient outcomes across the continuum of care. Leadership is a crucial factor in nurse and patient outcomes and ultimately in the success of healthcare organizations.2 Furthermore, transformational leadership competencies of nurse leaders are essential for managing change processes effectively and delivering highquality care within healthcare organizations.3 An effective and efficient way to assess and develop transformational leadership competencies is to use 360° feedback. Transformational leaders look for pathways to foster and enhance communication within their teams and the organization. Although providing feedback is important, it is also necessary for leaders to receive feedback from their teams regarding their performance as leaders. By receiving feedback, especially 360° feedback, leaders can better address the needs of their subordinates. Transformational leaders focus on the “greater good” of the organization by using interprofessional feedback because it allows a pathway for higher team performance.
360° FEEDBACK The purpose and theory of leadership development using 360° feedback has been well documented during the past 25 years.4 Although clinical and nursing leadership experiences play vital roles in professional development, research suggests that the empirical evidence for this assumption is far from
64
Nurse Leader
definitive.5 Some assume that strong clinical experience will translate into being a strong nurse leader; however, the skills and competencies of clinical nurses are not the same as leadership competencies. Having a well-rounded assessment of leadership strengths, as well as areas for development, not only helps leaders know where to focus, but also helps direct
August 2015
Table 1. LPI Nursing Leadership Studies
Authors
Year Published
Study Focus
Instrument Used
Findings
Kelly et al.12
2014
To examine the relationship of transformational leadership practices, nurse characteristics, and formal leadership training of frontline nurse leaders in a large health system: 512 frontline nurse leaders in 23 hospitals
LPI SelfAssessment
Formal training influences only 1 component of transformational leadership behaviors, helping train leaders to model the way for their employees. Increasing a nurse leader’s level of formal education has a significant effect on improving overall transformational leadership practices and behaviors that inspire a shared vision and challenge the process.
Ross et al.13
2014
The transformational leadership practices of nurse leaders in professional nursing associations: 448 nurse leaders in professional nursing associations
LPI
Nurse leaders of professional nursing associations emulate practices of transformational leadership.
Kallas14
2014
Profile of an excellent nurse manager
LPI SelfAssessment
The LPI can be used to identify, recruit, and develop RNs in the nurse manager role as excellent leaders of effective healthcare teams.
Fardellone and Click15
2013
73 RNs (convenience sample)
LPI SelfAssessment
RNs with more experience show fewer leadership behaviors. Scores demonstrated a need for leadership training at all levels of practice. The highest average responses were for Enabling Others to Act and Modeling the Way.
Krugman et al.16
2013
To examine longitudinal outcomes of a leadership program for permanent and relief charge nurses from 1996 to 2012 divided into 3 phases
LPI
Charge nurse leadership reported significant gains despite institutional changes and educational interventions. Charge nurse leadership development cannot take place without purposeful mentoring and coaching by nurse managers and directors, led and modeled by the CNO.
Clavelle et al.17
2012
Transformational leadership practices of Magnet CNOs: 225 CNOs completed the survey
LPI SelfAssessment
Enabling Others to Act and Modeling the Way are the top transformational leadership practices exhibited by Magnet CNOs. As CNOs gain experience and education, they exhibit more transformational leadership characteristics.
Pedaline et al.18
2012
Formal mentoring program development for 10 frontline nurse managers in acute care
LPI SelfAssessment and 8 to 10 observers
Comparison of the LPI pre- and postassessments revealed an increase in the average score of the nurse manager’s selfassessment in all 5 leadership practices. Managers identified increased awareness, focus, and clarity as insights into their leadership skills as a result of the 360° feedback.
www.nurseleader.com
Nurse Leader
65
Table 1. LPI Nursing Leadership Studies (cont.)
Authors
Year Published
Study Focus
Instrument Used
Findings
Martin et al.3
2012
Development of leadership competencies of nurse leaders in Switzerland: Convenience sample of 14 ward leaders using the LPI assessment over 3 time periods
LPI-Self Assessment
Nurse leaders following the clinical leadership program for the development of leadership competencies of nurse leaders demonstrated significant improvement in 2 subscales of the LPI, Inspiring a Shared Vision and Challenging the Process.
Abraham and Man19
2011
15 registered nurses with BSNs and 5 years of nursing experience: A voluntary convenience sample
LPI and Nursing Activity Scale used for pre- and post-program assessments
The Nursing Leadership Perspectives Program enhanced leadership skills and promoted professionalism as evidenced by changes in assessment tool scores.
Wang et al.20
2011
The relationship between the transformational leadership of nurse managers and job satisfaction among clinical registered nurses: 238 nurses with >1 year of work experience
LPI and Nurse Job Satisfaction Scale
Transformational leadership of nurse managers could have an effect on the job satisfaction of clinical registered nurses.
each nurse leader’s individual plan for leadership growth. Leadership development involves interactions between people and the social and organizational environments in which they practice. Leadership development also emphasizes the enactment of leadership built on a foundation of mutual trust and respect.6 Although many leadership tools are available for professional development, utilization of feedback is important for the transformational leader. Use of 360° feedback can assist leaders in understanding the impact of their individual behavior on others. The leader gathers and receives information regarding leadership behaviors from multiple sources, such as subordinates, peers, and supervisors, in addition to self-evaluation.4
HISTORY OF 360° FEEDBACK The term feedback is associated with other common terminology, such as multisource feedback, multirater feedback, multisource assessment, full-circle appraisal, and 360° feedback. The history of feedback began with World War II, when the German military began gathering information from multiple sources to evaluate performance.7 Since that time, the concept of 360° feedback has gained momentum, and it has become much easier to implement with easy access to online assessments. Utilization of feedback, especially 360° feedback, can be employed as a process for leadership development by
66
Nurse Leader
means of fostering self-awareness and competency. This type of feedback is a resource used across industries, including business, government, nonprofit, military, healthcare, and education. Regardless of terminology, individual leaders who develop action plans or map specific pathways for professional development frequently use results obtained from 360° feedback, which offers a plethora of benefits for the developing leader. A 360° feedback is a valid assessment of leadership behavior and performance, offers opportunities for candid discussions about a leader’s performance and progress, and allows a leader to envision broader goals and objectives with employees and interprofessional teams. This type of feedback serves as a framework to encourage and support learning, skill development, and future goal setting. It provides an opportunity to improve leader performance and team performance, and it ultimately holds potential to influence and strengthen organizational culture.8 To create a strong organizational culture, the voice of each individual must be facilitated and supported. Nurses who participate in 360° evaluations report heightened capacities to effectively communicate their voices and visions.9 When they are encouraged to provide feedback, team cohesion and trust increase.10 Methodologies used to obtain feedback differ. Some are anonymous, whereas others are open and transparent. In addition to the variety of tools available for use, the
August 2015
Table 2. Definitions of Leadership Practices Subscales Compared to Transformational Leadership Characteristics
Transformational Leadership21
LPI Subscale
Scale Definition
Modeling the Way
Clarifying values by finding your voice; affirming the shared values of the group; setting an example by aligning actions with shared values
Inspiring a Shared Vision
Envisioning the future by imagining exciting and ennobling possibilities; enlisting others in a common vision by appealing to shared aspirations
Empowering others
Challenge the Process
Searching for opportunities by seizing the initiative and by looking outward for innovative ways to improve; generating small wins and learning from experience
Promoting teamwork
Enable Others to Act
Fostering collaboration by building trusting and facilitating relationships; strengthening others by increasing self-determination and developing competence
Charismatic leader
Inspiring teams
number of respondents required to provide feedback varies as well. Regardless of the methodologies used, employees report that 360° feedback more accurately reflects their performance than feedback received from a single individual, such as one’s immediate superior. To transform interprofessional teams, nurses need to build on the current state of practice. Although several 360° assessment tools exist, one of the most widely used in nursing is the Leadership Practices Inventory (LPI) developed by Kouzes and Posner.11
USE OF THE LPI IN NURSING LEADERSHIP Ten nursing studies were published between 2011 and 2014 regarding the use of the LPI in nursing leadership, strengthening the use of the LPI assessment as a leadership development tool. The literature was reviewed to describe the current state of practice. Search strategy terms used to explore the concept of 360° feedback in nursing included “registered nurse,” “360-degree feedback,” and “LPI assessment” using EBSCOhost and PubMed search engines. Summaries of nursing studies utilizing the LPI instruments are identified in Table 1.12-20
TRANSFORMATIONAL LEADERSHIP AND LPI The LPI closely aligns with transformational leadership, a leadership style that is found to be highly successful in healthcare settings.11 Transformational leadership styles in turn closely align with the 5 practices of exemplary leaderwww.nurseleader.com
ship described by Kouzes and Posner,11 a model commonly used in nursing as well as other disciplines (Table 2).21 Practices or domains identified in the LPI include Modeling the Way, Inspiring a Shared Vision, Challenging the Process, Enabling Others to Act, and Encouraging the Heart.11 The LPI is a 360° feedback assessment tool designed, using strong empirical evidence, to support the framework and validity of the assessment instrument as an accurate method to assess leadership skills.22 The 30-item LPI instrument is formatted with a 5-point scale divided into 5 domains of 6 questions per category.23 A distinct aspect of the LPI is the individual leader’s opportunity to self-select peers and colleagues to review his or her leadership strengths and skills. Use of the LPI to develop transformational leaders lends itself readily to selection of leaders throughout the organization and includes feedback from different professions’ perspectives.
IMPLICATIONS OF 360° FEEDBACK FOR NURSING Since the publication of the Institute of Medicine’s landmark report, To Err Is Human: Building a Safer Health System,24 which discussed the United States’ flawed and fragmented care delivery, healthcare has been in a constant state of change. Embracing this change is essential for organizations to survive in the current healthcare environment.25 Yet the need for effective personal relationships with “human to human sensitivity, acknowledgment, and respect for the patient care experience” remains constant.26 Nurses are positioned to take on leadership roles through their abilities to
Nurse Leader
67
Table 3. Strategies for Initiating or Expanding 360° Feedback
Implementing 360° Feedback
Leveraging 360° Feedback
Provide data to demonstrate value and outcomes
Define specific goals and objectives35
Determine organizational readiness for change36
Decide how and when information will be shared
Gain administrative support Assess commitment to participate Identify and phase in with key leaders38,39
Include interprofessional team members with result sharing Develop action plans37 Provide resource guides and supportive tools to assist leaders with action planning
Encourage and embrace interprofessional coworkers’ feedback
Embrace team differences and capitalize on everyone’s strengths for synergy
Define time frame for assessment completion
Plan ongoing leadership development40
effect change and improve care; the Institute of Medicine has recognized the importance of nursing leadership and charged nurses with understanding and assuming responsibilities as full partners and leaders in the care of patients. Improved care delivery requires an evolution of nursing practice.24 Simply stated, nurses at all levels must learn from others to ensure they are effective wherever they practice.27 Effective nursing leaders focus on building engaged teams that strive for excellence in practice and care.28 How do nurse leaders know what is working well with their teams? One strategy is to use a 360° feedback process that engages members of other professions in the feedback process and models what is needed for all leaders within an organization. With the convoluted state of healthcare, nurse leaders need greater perspectives to improve care; 360° feedback offers nurse leaders the ability to engage the insight and perspective of interprofessional teams. It encourages nurse leaders to identify their goals and determine how to improve leadership behaviors to ensure excellent nursing care.29
IMPLICATIONS FOR INTERPROFESSIONAL COLLEAGUES Although interprofessional, shared leadership has been discussed since the early 1980s, it has yet to be widely adopted into healthcare organizations.30–32 If true interprofessional collaboration is to be realized within healthcare organizations, nurse leaders must advocate for the use of 360° feedback throughout their organizations to build interprofessional teams and collaboration. Nursing cannot afford to focus its attention on improving nursing leadership alone but must look to the larger picture of producing dynamic, highly functioning interprofessional teams. Effective interprofessional teams have a positive impact on patient experience, quality outcomes, and costs. Not only does 360° feedback help individual leaders develop, it also helps their organizations. By implementing
68
Nurse Leader
360° feedback throughout the organization, individual leadership growth and performance can be measured, as can the performance of the organization.33,34 If nurse leaders participate in 360° feedback and their interprofessional colleagues do not, by default, a weak link has been created in the leadership of the healthcare organization. Nurse leaders have the opportunity to lead and influence organizations in modeling interprofessional evaluation feedback.
360° FEEDBACK USING INTERPROFESSIONAL COLLABORATION Some organizations already use a 360° approach to enhance interprofessional collaboration; others are considering such an approach. Table 3 identifies some common strategies that are useful in initiating or expanding use of 360° feedback.35-40 Effective communication is the key to any organizational change. Nurse leaders communicate the value of interprofessional collaboration and implementation of effective working strategies through evidence of improved leadership competencies. With all of the issues facing healthcare, the time is right to develop effective leaders.41 Using a 360° assessment provides the opportunity for honest conversations designed to enhance teams and their effectiveness.
IMPLICATIONS FOR THE FUTURE In this era of fast-paced, continuous implementation of change, focus on outcomes, and climate of “immediate results,” leaders do not have the luxury of doing things the way they have always been done. Nursing and healthcare have been slow to adopt evidence-based leadership practices such as 360° feedback in organizations. For leaders to be highly effective, teams must be highly effective. As a tool, 360° feedback is excellent at quickly assessing the leadership of members in interprofessional team. Interprofessional leadership occurs as a result of strategically targeting leadership and mentoring activities to develop
August 2015
individuals while getting the work of the organization accomplished. Kouzes and Posner11 challenge leaders to take teams to places they have never gone before. Leaders need to model the way by making 360° feedback a standard of nursing leadership practice and encourage their interprofessional colleagues to do the same. By incorporating 360° feedback into practice, leadership competency and confidence can be developed in each member of the team. This, in turn, leads to a stronger team positioned to produce better results and lead healthcare into the future. NL Note: We would like to thank Dr. Patricia Yoder-Wise for her support, encouragement, and expertise in the preparation of this article. References 1. U.S. Department of Health and Human Services. Read the law: The Affordable Care Act. Updated June 28, 2012. Available at: http://www.hhs.gov/healthcare/rights/law/. Accessed July 7, 2014. 2. Ulrich B, Lavandero R. Early S. Leadership competence: perceptions of direct care nurses. Nurse Leader. 2014;12:47-50. 3. Martin JS, McCormack B, Fitzsimons D, Spirig R. Evaluation of a clinical leadership programme for nurse leaders. J Nurse Manag. 2012;20:72-78. 4. Day DV, Fleenor JW, Atwater LE, Sturm RE, McKee RA. Advances in leader and leadership development: a review of 25 years of research and theory. Leadersh Q. 2014;25:63-82. 5. Day DV. The difficulties of learning from experience and the need for deliberate practice. Ind Organ Psychol. 2010;3:41-44. 6. Day DV. Leadership development: a review in context. Leadersh Q. 2000;11:581-613. 7. Fleenor JW, Prince JM. Using 360-Degree Feedback in Organizations: An Annotated Bibliography. Greensboro, NC: Center for Creative Leadership; 1997:1-88. 8. National Business Research Institute. 360 degree feedback. August 2010. Available at: http://www.nbrii.com/employee-survey-white-papers/360-degreefeedback/. Accessed July 9, 2014. 9. Berlin G, Grote K. Creating and sustaining change in nursing care delivery. May 2013. Available at: http://healthcare.mckinsey.com/creating-andsustaining-change-nursing-care-delivery. Accessed July 15, 2014. 10. Rolfe P. Transformational leadership theory: what every nurse needs to know. Nurse Leader. 2011;9(2):54-7. 11. Kouzes J, Posner B. The Leadership Challenge: How to Make Extraordinary Things Happen in Organizations. 5th ed. San Francisco, CA: Wiley & Sons; 2012. 12. Kelly LA, Wicker TL, Gerkin RD. The relationship of training and education to leadership practices in frontline nurse leaders. J Nurs Adm. 2014;44:158-163. 13. Ross EJ, Fitzpatrick JJ, Click ER, Krouse HJ, Clavelle JT. Transformational leadership practices of nurse leaders in professional nursing associations J Nurs Adm. 2014;44:201-206. 14. Kallas KD. Profile of an excellent nurse manager: identifying and developing health care team leaders. Nurs Adm Q. 2014;38:261-268. 15. Fardellone C, Click ER. Self-perceived leadership behaviors of clinical ladder nurses. Nurse Leader. 2013;11(6):51-53. 16. Krugman M, Heggem L, Kinney LJ, Frueh M. Longitudinal charge nurse leadership development and evaluation. J Nurs Adm. 2013;43:438-446. 17. Clavelle JT, Drenkard K, Tullai-McGuinness S, Fitzpatrick JJ. Transformational leadership practices of chief nursing officers in Magnet(R) organizations J Nurs Adm. 2012;42:195-201. 18. Pedaline SH, Wolf G, Dudjak L, Lorenz H, McLaughlin M, Ren D. Preparing exceptional leaders. Nurs Manage. 2012;43(9):38-44. 19. Abraham PJ, Man BC. Developing nurse leaders: a program enhancing staff nurse leadership skills and professionalism. Nurs Adm Q. 2011;35:306312. 20. Wang X, Chontawan R, Nantsupawat R. Transformational leadership: effect on the job satisfaction of registered nurses in a hospital in China. J Adv Nurs. 2012;68:444-451. 21. Smith M. Are you a transformational leader? Nurs Manage. 2011;42(9):4450. 22. John Wiley & Sons. Assessments: Leadership practices inventory (LPI) assessments. Updated 2014. Available at: http://www.leadershipchallenge. com/leaders-section-assessments.aspx. Accessed July 15, 2014.
www.nurseleader.com
23. Huber DL, Maas M, McCloskey J, Scherb CA, Goode CJ, Watson C. Evaluating nursing administration instruments. J Nurs Adm. 2000:30:251272. 24. Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: Institute of Medicine of the National Academies; 1999. 25. Mockett L, Horsfall J, O'Callaghan W. Education leadership in the clinical health care setting: a framework for nursing education development Nurse Educ Pract. 2006;6:404-410. 26. Malloch K. Innovation leadership: new perspectives for new work. Nurs Clin North Am. 2010;45(1):1-9. 27. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. October 5, 2010. Available at: http://www.iom.edu/Reports/2010/the-future-of-nursing-leading-changeadvancing-health.aspx. Accessed July 15, 2014. 28. Yoder-Wise PS, Kowalski K. Beyond Leading and Managing: Nursing Administration for the Future. St. Louis, MO: Mosby; 2006. 29. American Organization of Nurse Executives. The AONE nurse executive competencies. Updated 2011. Available at: http://www.aone.org/resources/ leadership%20tools/nursecomp.shtml. Accessed July 10, 2014. 30. Hoying C, Allen SR. Enhancing shared governance for interdisciplinary practice. Nurs Adm Q. 2011;35:252-259. 31. Brewton C, Eppling J, Hobley M. Our VOICE: an interdisciplinary approach to shared governance. Hosp Top. 2012;90(2):39-46. 32. Jukkala AJ, White ML. The continued need for interprofessional collaboration and research. Appl Nurs Res. 2014;27:95-96. 33. Bracken DW, Church AH. The "new" performance management paradigm: capitalizing on the unrealized potential of 360 degree feedback. People Strategy. 2013;36(2):34-40. 34. Hafford-Letchfield T, Bourn D. ‘How am I doing?’ Advancing management skills through the use of a multi-source feedback tool to enhance work-based learning on a post-qualifying post-graduate leadership and management programme. J Soc Work Educ. 2011;30:497-511. 35. Institute for Healthcare Improvement. Changes for Improvement. 2014. Available at: http://www.ihi.org/resources/Pages?Changes/default.aspx. Accessed June 27, 2014. 36. Shea CM, Jacobs SR, Esserman DA, Bruce K, Weiner BJ. Organizational readiness for implementing change: a psychometric assessment of a new measure. Implement Sci. 2014;9(1):1-15. 37. Hewitt-Taylor J. Planning successful change incorporating processes and people. Nurs Stand. 2013;27(38):35-40. 38. Omoike O, Stratton KM, Brooks BA, Ohlson S, Storfjell JL. Advancing nursing leadership: a model for program implementation and measurement. Nurs Adm Q. 2011;35:323-332. 39. Stanleigh M. Leading change. J Qual Particip. 2013;36(2):39-40. 40. Vukotich G. 360o feedback: ready, fire, aim—issues with improper implementation. Perform Improv. 2014;53(1):30-34. 41. Yoder-Wise PS. The future of leadership. J Nurs Adm. 2014;44:318-320.
Deborah Sikes, DNP, RN, CNE is Veteran to BSN Program Director at the Texas Tech University Health Sciences Center School of Nursing in Lubbock, Texas. She can be reached at [email protected]. Emily Jestes, DNP, RN, CNL, NEBC is Clinical Nurse Leader at Texas Health Presbyterian Hospital Plano in Plano, Texas. Colleen LeClair-Smith, DNP, RN, NEABC, is Director, Magnet, Recruitment and Nursing Resource Pool at University Medical Center in Lubbock, Texas. Rowena R.Yates, DNP, RN, NE-BC, CCRN is Vice President, Education/Research/Magnet at Medical Center in Lewisville, Texas. 1541-4612/2014/ $ See front matter Copyright 2015 by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.mnl.2014.10.002
Nurse Leader
69