DEVELOPMENT AND VALIDATION OF A LEADERSHIP TRAINING PROGRAM FOR NURSES

Objectives: To identify strategies that facilitate the development of leadership, correlating them with characterization of variables, and to create and validate a leadership training program for nurses. Method: developed in two phases. First: a cross-sectional study, performed in a general hospital in São Paulo, Brazil. The 70 nurses in the sample had at least three months of work experience in the institution. An instrument was used to collect data with characterization variables (gender, age, postgraduate, work shift and length of working career and contact with the theme of leadership) and collection of suggested strategies to develop more prominent leadership in the literature. Data were collected (February-April 2016) and analyzed descriptively. The Mann-Whitney and Kruskal Wallis tests were used to verify the correlations (p<0.05). Second phase: validation study of the program using the Delphi technique, from March to June 2017. Following the construction of the program, and considering the results obtained in the first phase, judges were selected with the following criteria: to be a nurse, researcher in leadership and nursing administration, with article publications in the last five years and teaching experience. Results: the strategies indicated in the first phase were: performance of experienced


INTRODUCTION
The discussion on leadership competence has become frequent in the nursing training and development context.Administration, management and leadership were included among the general skills and abilities proposed for the course, which was promoted by the National Curricular Guidelines (NCG) for the Undergraduate Nursing Course, through the National Education Council Resolution (NEC) and the Higher Education Chamber (HEC) nº3/2001. 1It is noted that new NCG are being proposed, which should soon be put into practice.
This legal requirement has caused a demand for reflection on how professors should teach leadership to nurses in undergraduate and lato sensu and stricto sensu postgraduate courses, as well as by nursing managers and directors in the health services.
From this perspective, a bibliometric study 2 was performed that showed the scientific production on this theme in the literature.These studies were classified in five groups of themes: 1) training and development programs, 2) leadership teaching strategies, 3) academic preparation for leadership, 4) reflections on leadership teaching, and 5) other themes.
In the training and development programs, the following strategies were used: 1) practical activities, combined with the theoretical teaching of leadership and the performance of experienced leaders as facilitators of the teaching-learning process; 2) case studies and group work; 3) partnership between universities and health services; 4) residency and continuing education programs for new graduates, with emphasis on clinical decision-making and leadership in the workforce; 5) immersion periods in the routine of nurse leaders; 6) development of progressive and individualized plans; 7) master's degree for the development of nurse leaders; 8) distance learning; 9) creating portfolios, and 10) international partnerships.Many studies on leadership are descriptive in character and focus on the teaching and development strategies used, as well as the satisfaction of users with the taught content.However, few studies have evaluated the impact of training and development programs on the performance of nurse leaders. 2 All the strategies identified 2 are related to the leadership coaching model, which allows the leaders to reach their greatest potential, utilizing their strengths, abilities and talents.This is achieved by means of the coach leader who works on key aspects such as the perception of self, the other and the team, as well as their drive to generate results. 3iven the scarce national scientific production on this subject, it is important to carry out further research in order to identify teaching strategies and leadership development that may provide greater benefits to nurses.
Thus, in order to identify the strategies available in the literature that are the most conducive to the teaching and development of nurse leadership, we intend to diagnose those which nurses from a teaching hospital consider facilitating to their development as leaders.In addition, we plan to design a program to develop the leadership of these nurses.Thus, we will be able to contribute to the development of the current nursing managers and to the training and education of new leaders in the national scenario.
Therefore, the objectives of this study were: 1) to identify the strategies that facilitate the development of leadership that could facilitate the mastery of this competency by nurses in a teaching hospital the most, 2) to correlate them with the variables of personal characterization, and 3) to construct and validate a program for training in leadership for nurses.

METHOD
This study was developed in two phases:

Phase 1
A cross-sectional study, carried out in a large general teaching hospital located in southern São Paulo city, Brazil.
The sample was established for convenience, and was composed of 70 nurses (28.5% of the total number of nurses in the institution) which were chosen at random.These participants had worked in the institution for at least three months.This inclusion criterion was adopted to ensure that they were not included in the study while working in their trial work period.
The nurses were informed regarding the purpose of the study, and then received the informed consent form and the data collection instrument in an envelope.The sample participants were instructed to fill out the instrument outside the work environment.A date was then scheduled for the collection of the completed forms.
The data collection instrument was constructed by the researchers and consisted of two parts.The first part contained information regarding personal characterization: sex, age, work experience since graduation, university, length of time working in the institution, work shift, contact with the theme of leadership, as well as completed postgraduate courses.5][6] Both lists were scored by the respondents.The second followed an analogue scale (0-10), according to the importance given by the participants to each strategy.A blank space also included for participants to leave personal suggestions.
This instrument was evaluated by professors of a Nursing School of a Federal University, located in southern São Paulo city, Brazil.Minor adjustments were made according to the observations.After approval of the project by the Research Ethics Committee, data were collected between February and April 2016, and then analyzed using descriptive statistics.The Mann-Whitney and Kruskal Wallis tests were used to verify possible correlations between teaching strategies, including leadership development, and the personal characterization data (p<0.05).

Phase 2
A validation study, which adopted the Delphi 7 technique, was performed from March to June 2017, with the following steps: 1) development of a program by researchers and a permanent education nurse in the hospital under study, containing the items: identification (I), content (II), objectives (III), program content (IV), teaching and learning strategiesb (V) resources (VI) evaluation (VII) bibliography (VIII) schedule of activities (IX).For this, the results obtained in Phase 1 were used.2) selection of judges, considering the following criteria: be a nurse, researcher on the topic of nursing leadership and administration, with article publications in periodicals indexed in the last five years and teaching experience; and 3) applying two rounds using the Delphi technique.
The judges evaluated each item of the program on a Likert scale (Fully agree, agree, disagree and do not disagree nor agree and strongly disagree).There was a space to record the suggestions.The Content Validity Index (CVI) was adopted to identify agreement between them.Firstly, for each judge, the relative frequency of their answers was calculated with the following formula: total responses for each Likert scale item / total of program items.Secondly, the total items for totally agree / total number of answers given by all judges was considered as general CVI of the training program.The acceptable values adopted in this study were 0.80 to 0.90 .8

Phase 1
The characteristics of the 70 nurse participants are presented in Table 1.*More than one response was possible for this variable.

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It must be noted that the sample is primarily composed of young people, post-graduates who have only recently began to work in the institution.
The strategies with the most scores were: "Establishment of partnerships between university and the hospital"; "Work of experienced leaders as facilitators in the teaching learning process" and "Accomplishment of practical activities allied with theoretical teaching on leadership" (Figure 1).When correlating the characterization variables with the leadership development strategies, it is highlighted that "Experienced leaders acting as facilitators in the teaching and learning process" received a significantly higher score for men (p = 0.033), and younger nurses had higher scores for the "Establishment of partnerships between university and the hospital" (p = 0.019).No correlation was observed in the other items.

Phase 2
Thus, the constructed program content took the following items into account: A brief history of leadership theories and leadership concept from the Coaching Leadership model, 3 which consists of a professional with more experience who conducts the leader training process; the personal / professional characteristics / skills that the nurse needs to develop in order to become a leader; competences associated with leadership: teamwork, communication, conflict resolution, decisionmaking, negotiation and lifelong learning.

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The teaching and learning strategies identified by the respondents were as follows: establishment of partnerships between university and the hospital: the professors of a Nursing School of a Federal University that is linked with the hospital in the field of study will guide improvement projects during training; performance of experienced leaders as facilitators in the teaching-learning process: nurses who have leadership characteristics and longer periods of experience in the hospital will accompany the nurses participants in the proposed training program, assisting them in leadership development; performance of practical activities allied to the theoretical teaching of leadership: this training intends to create improvement projects, in view of the challenges experienced in the university hospital.
Seven judges were initially selected to perform the Delphi technique; four (A1, A2, A3 and A4) of these were included in the study.
In the first round, a CVI of 0.42 was observed.The relative frequency of responses for each judge, as shown in figure 1, indicates that items I, II, IV, V, VI, VII, VIII and IX should be reviewed (Table 2).In the second round, a CVI of 0.81 was obtained.The degrees of concordance between the judges was "agree" or "strongly agree" for every item in the program showing that there is a good agreement between them (Table 3).

DISCUSSION
The majority of the nurses who participated in this study were between 30 and 34 years of age, completed a postgraduate degree course and worked for up to five years in the hospital where the study was conducted.These findings are similar to the results of the Nursing Profile in Brazil study, 9 which identified nurses aged 31-35 years (22.4%), with up to five years of work experience (29.6%) with post-graduate degrees (80.8%) in the State of São Paulo (Brazil).
These professionals, especially the younger ones, highlighted the establishment of partnerships between university and hospitals as a strategy which favors the development of leadership in nurses.Given the importance of this competency, as well as the incipient initiatives to achieve their learning, such partnerships can help prepare nurses to assume leadership roles, thus helping to improve their performance in the labor market. 102] To this end, respondents, especially males, understood that the role of experienced leaders as facilitators of the teaching-learning process is an effective aid.Likewise, practical activities associated with theoretical teaching of leadership were highlighted by most of the subjects as an effective strategy.
Studies have shown that students, when led in their practical experiences by nurses who acted as facilitators, were able to identify the leadership characteristics of these professionals and to understand the role of the leader.This aids the students' perception of how to develop their own leadership.In addition, they were able to establish relationships between theoretical content and practical experience, in an approach that gave a special meaning to learning.] The program content proposed in the present study included a brief history of theories of leadership and the contemplation of these strategies.It was considered convenient to offer the nurses who would participate in the training an opportunity to reflect on the trajectory of the exercise and this competence as well as the creation and use of the theoretical references that based it over time.
Coaching leadership was chosen as the basis for developing the program, confirming the strategies highlighted by the participants in the present study.This is a framework whose essence is the development of competencies to achieve goals, starting from an adjustment between the style of leadership and the level of readiness of the leaders to perform tasks and establish relationships, 3 being a model for the exercise of leadership in the hospital context.The main skills of the leader coach are to encourage self-knowledge of the leaders by considering their leadership style and interpersonal skills and attitudes, listening to them, maintaining their interest, and meeting their professional needs. 3he personal and professional skills that nurses need to develop in order to become a leader were also considered as well as the skills associated with leadership, which are essential to guide work and facilitate the achievement of goals.The choice and application of theses competences was based on the concepts presented below.
Teamwork: is fundamental to ensure that the achievement of objectives is a collective construction process (not an idea restricted to a specific group), benefitting people management and becomes a priority for the leader. 15ommunication: is essential to coordinate the team.Clarity, objectivity, conciseness, feedback and assertiveness enable the leader to work with the team.
Conflict resolution: when conflict-generating situations are resolved in nursing teams, they contribute to the professional and personal development of those involved, generating greater satisfaction, impacting the quality of care and facilitating group leadership. 17ecision making: constantly permeates the work of the nurse. 18Understanding the basic principles that govern this practice, being guided by ethics and current legislation are essential to leadership.
Negotiation: knowledge of the techniques used for effective negotiation 19 allows the leader to use appropriate tools to manage the available resources and lead the team to the desired results.
Permanent education: allows the strengthening of the group, because it favors significant learning and increases the possibility of implementing the changes 20 agreed between the leader and those being led.
This study was conducted in a hospital with its own organizational characteristics and a local context, which may limit the generalization of the results obtained.2] Initiatives such as the proposal presented in the present study are part of the path to be taken in that direction.
The consensus among the judges was acquired in the second round of the Delphi technique.The judges participated actively in this process, responding to the requests within the requested deadline.The suggestions were extremely relevant and contributed to the quality of the proposed program.

Figure 1 -
Figure 1 -Box Plot of the leadership strategies development by nurses.São Paulo, Brazil 2016.

Table 2 -
Answer frequencies of each judge in relation to each item of the program for complete training in the first round of the Delphi technique.São Paulo, Brazil, 2017

Table 3 -
Answer frequencies for each judge in relation to each item of the complete training program in the second round of the Delphi technique.São Paulo, 2017