DEVELOPMENT AND VALIDATION OF A LEADERSHIP TRAINING PROGRAM FOR NURSES

DESARROLLO Y VALIDACIÓN DE UN PROGRAMA DE CAPACITACIÓN EN LIDERAZGO PARA ENFERMEROS

ABSTRACT

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 leaders as facilitators in the teaching-learning process (the highest scores were given by men; p=0.033) and establishment of partnerships between university and hospital (the largest choice was made by young nurses, p=0.019). In the second phase, a content validity index of 0.81 was reached, considered satisfactory.

Conclusion:

the program can be applied, and future studies will evaluate its effectiveness.

DESCRIPTORS:
Leadership; Nursing; Continuing education; Hospitals, teaching; Nursing staff

RESUMEN

Objetivos:

identificar las estrategias que facilitan el desarrollo del liderazgo, correlacionándolas con las variables de caracterización, y construir y validar un programa de capacitación en liderazgo a enfermeros.

Método:

desarrollado en dos etapas. Primera: estudio transversal, realizado en un hospital general en San Pablo, Brasil. Los 70 enfermeros de la muestra tenían al menos tres meses de vínculo institucional. Para la recolección de datos, se utilizó un instrumento con variables de caracterización (sexo, edad, posgrado, turno y horas de trabajo, y contacto con el tema liderazgo) y recolección de estrategias sugeridas para desarrollar liderazgos más destacados en la literatura. Se recolectaron los datos entre febrero y abril de 2016, y los mismos se analizaron de forma descriptiva. Se utilizó los tests de Mann-Whitney y Kruskal Wallis para comprobar las correlaciones (p<0,05). Segunda etapa: estudio de validación del programa, utilizando la técnica Delphi, entri marzo y junio de 2017. Luego de la construcción del programa, y considerando los resultados obtenidos en la primera etapa, se seleccionaron jueces con los siguientes criterios: ser enfermero(a), investigador(a) de liderazgo y administración en enfermería, que hayan publicado en los últimos cinco años y que tengan experiencia como docentes.

Resultados:

las estrategias indicadas en la primera etapa fueron: actuación de líderes especialistas como facilitadores en el proceso de enseñanza-aprendizaje (las mejores notas las obtuvieron los hombres; p=0,033) y establecimiento de colaboraciones entre universidad y hospital (la elección más numerosa fue por enfermeros jóvenes; p=0,019). En la segunda etapa, se alcanzó un índice de validez de contenido de 0,81, considerándose como satisfactorio.

Conclusión:

el programa se puede aplicar y los futuros estudios se encargarán de evaluar su efectividad.

DESCRIPTORES:
Liderazgo; Enfermería; Educación continuada; Hospitales de enseñanza; Personal de enfermería.

RESUMO

Objetivos:

identificar as estratégias que facilitam o desenvolvimento da liderança, correlacionando-as com variáveis de caracterização, e construir e validar um programa para treinamento em liderança para enfermeiros.

Método:

desenvolvido em duas fases. Primeira: estudo transversal, realizado em um hospital geral em São Paulo, Brasil. Os 70 enfermeiros da amostra tinham pelo menos três meses de vínculo institucional. Foi usado um instrumento para coleta de dados com variáveis de caracterização (sexo, idade, pós-graduação, turno e tempo de trabalho e contato com o tema liderança) e coleta das estratégias sugeridas para desenvolver liderança mais destacadas na literatura. Os dados foram coletados (fevereiro-abril de 2016) e analisados descritivamente. Utilizou-se os testes de Mann-Whitney e Kruskal Wallis para verificar as correlações (p<0,05). Segunda fase: estudo de validação do programa usando a técnica Delphi entre março-junho de de 2012. Após a construção do programa, e considerando os resultados obtidos na primeira fase, foram selecionados juízes com os seguintes critérios: ser enfermeiro (a), pesquisador (a) de liderança e administração em enfermagem, com publicações nos últimos cinco anos e experiência de ensino.

Resultados:

as estratégias indicadas na primeira fase foram: atuação de líderes experientes como facilitadores no processo ensino-aprendizagem (as notas maiores foram dadas por homens; p=0,033) e estabelecimento de parcerias entre universidade e hospital (a maior escolha foi feita por enfermeiros jovens; p=0,019). Na segunda fase, foi atingido um índice de validade de conteúdo de 0,81, considerado satisfatório.

Conclusão:

o programa pode ser aplicado, e estudos futuros avaliarão sua efetividade.

DESCRITORES:
Liderança; Enfermagem; Educação continuada; Hospitais de ensino; Recursos humanos de enfermagem

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) nº3/2001.1 It 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 study2 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 identified2 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.3

Given 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. The second part contained a list with teaching strategies and another with leadership development strategies found in the literature.4^-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 Delphi7 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

RESULTS

Phase 1

The characteristics of the 70 nurse participants are presented in Table 1.

Table 1 -
Variables of personal characterization of the nurses. São Paulo, Brazil 2016. (n=70)

Variables	Total n (%)
Sex
Male	16 (22.9)
Female	54 (77.1)
Age(years)
20-24	11 (15.7)
25-29	19 (27.1)
30-34	20 (28.6)
35-39	10 (14.3)
40-44	8 (11.4)
45-49	2 (2.9)
Time since graduation (years)
1 - 5 years	6 (8.6)
6 - 10 years	15 (21.4)
11 - 15 years	20 (28.6)
16 - 20 years	29 (41.4)
Other degree
Non-university student	68 (97.1)
Biomedicine	1 (1.4)
Philosophy	1 (1.4)
Place of training
University	51 (72.9)
College	19 (27.1)
Work experience (years)
≤ 1	11 (15.7)
1-5	36 (51.4)
6-10	12 (17.1)
11-15	5 (7.1)
15-20	6 (8.6)
Work shift
Morning (6 h)	31 (44.3)
Evening(6 h)	27 (38.6)
Night (12 h)	8 (11.4)
Day (8 h)	4 (5.7)
Post-graduation
No	15 (21.4)
Yes	55 (78.6)
Contact with the theme of leadership*
During undergraduate course	66 (94.3)
Lectures	23 (32.9)
In-service training	18 (25.7)
In post-graduation course	6 (8.6)
In specialization course	10 (14.3)
Without previous contact with the theme	1 (1.4)

• ^*More than one response was possible for this variable.

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).

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

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, decision-making, negotiation and lifelong learning.

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).

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

Judges	Answers	Absolute frequencies (n)	Relative frequencies (%)
A1	Strongly agree	5	55.56
	Agree	4	44.44
	Do not agree nor disagree	0	0.00
	Disagree	0	0.00
	Strongly disagree	0	0.00
A2	Strongly agree	3	33.34
	Agree	3	33.33
	Do not agree nor disagree	1	11.11
	Disagree	2	22.22
	Strongly disagree	0	0.00
A3	Strongly agree	3	33.33
	Agree	6	66.67
	Do not agree nor disagree	0	0.00
	Disagree	0	0.00
	Strongly disagree	0	0.00
A4	Strongly agree	4	44.44
	Agree	5	55.56
	Do not agree nor disagree	0	0.00
	Disagree	0	0.00
	Strongly disagree	0	0.00

• A1: first judge; A2: second judge; A3: third judge; A4: fourth judge.

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).

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

Judges	Answers	Absolute frequencies (n)	Relative frequencies (%)
A1	Strongly agree	9	100
	Agree	0	0.00
	Do not agree nor disagree	0	0.00
	Disagree	0	0.00
	Strongly disagree	0	0.00
A2	Strongly agree	4	44.40
	Agree	5	55.60
	Do not agree nor disagree	0	0.00
	Disagree	0	0.00
	Strongly disagree	0	0.00
A3	Strongly agree	8	88.90
	Agree	1	11.10
	Do not agree nor disagree	0	0.00
	Disagree	0	0.00
	Totally disagree	0	0.00
A4	Strongly agree	8	88.90
	Agree	1	11.10
	Do not agree nor disagree	0	0.00
	Disagree	0	0.00
	Strongly disagree	0	0.00

• A1: first judge; A2: second judge; A3: third judge; A4: fourth judge.

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.10

The need to promote job satisfaction and to reduce the turnover of nurses in the hospitals where they work, as well as the shortage of these professionals in some countries (e.g. the US), are important justifications for the creation and implementation of leadership development programs both nationally and internationally.11^-12 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 use of this strategy benefitted the students' personal and professional growth, since it allowed the development and improvement of several characteristics and abilities, such as self-determination, self-esteem, self-evaluation, self-confidence, knowledge, maturity, professionalism, responsibility, job satisfaction, problem-solving, autonomy and leadership.13^-14

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.3

The 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.15

Communication: 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.17

Decision making: constantly permeates the work of the nurse.18 Understanding 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 negotiation19 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 changes20 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. However, it is understood that training is one of the foundations for developing leadership and only competent management of the teaching-learning process can be the necessary basis for the nurse's satisfactory performance as a leader.21^-22 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.

CONCLUSION

The performance of experienced leaders as facilitators of the teaching-learning process and the establishment of partnerships between university and the hospital were the strategies that facilitate the learning of the leadership competence according to the nurses who participated in this study. In this sense, the creation of Professional Master's Degrees with this theme propitiates the feasibility of these strategies, since it can train experienced leaders to work in favor of the development of other nurses and favors the integration between hospital and university.

The creation of training based on participants' expectations was a differential of this research, since it showed the planning of a program directed at the real needs of these professionals. However, it is recommended that future studies evaluate its effectiveness, and produce evidence that can be used in team management. This initiative can also support the creation and implementation of other programs in diverse contexts, thus enhancing the training and education of leaders in the area of nursing.

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NOTES

• FUNDING INFORMATION
  This study was financed to the Scientific Initiation Program of CNPq for funding this study (Institutional Program of scientific initiation fellowships -IPIBIC/PIBIC-Af and PIBIT under UNIFESP 2015/2016).
• ETHICS COMMITTEE IN RESEARCH
  Approved by the Ethics Committee in Research with Human Beings of the Escola Paulista de Enfermagem, Univseridade Federal de São Paulo, Parecer n. 1.387.911. Certificate of Presentation for Ethical Appreciation: 51035815.6.0000.5505.

Publication Dates

• Publication in this collection
  20 May 2019
• Date of issue
  2019

History

• Received
  26 Feb 2018
• Accepted
  30 May 2018