I have had an interest lately in styles of leadership and effect of leadership on outcomes, particularly clinical outcomes. This first came up as a reference to leadership rounding in a performance improvement group I belong to. As an incidental finding, those units where leadership rounding was done had better performance in infection prevention.
At the time of this analysis, there were only 2 units doing what they called leadership rounding. This has since changed to include most of the units involved in the process but what is referred to as “leadership rounding” varies amongst the individual units. The early adopters modeled their leadership rounding after the Studer Group® model. The Studer Group® advocates various types of rounding, including patient/family rounding to increase satisfaction levels, hourly patient rounding for safety and staff rounding as a method for retention.1, 2 We were more interested in staff rounding as a method to ensure changes are implemented and to remove barriers to implementation of the change(s). The more I have considered the effect of leadership on successful improvement, it is obvious that successful leadership rounding is a manifestation of a larger style of leadership support and involvement.
In a study of 29 mental health teams, Versteeg, Laurant, Franx, Jacobs, Wensing found that teams with strong leadership showed better outcomes in implementation of the bundles for various diagnoses.3 In addition, support from the management of the organization, even when they were not part of the QI team, related positively to better outcomes. Strating & Neibaur found that organizational support is crucial to optimize the impact of a team’s improvement efforts.4 This is conceptualized as making time, finances, means and instruments available and having a manger who shows interest, coaches and encourages professionals in their achievements.
Transformational leadership is a term used often in the pursuit of Magnet® status. Kouzes & Posner are often credited for this leadership model but the term was introduced by Burns many years ago, in 1978.5-7 Transformational leaders might be termed as inspirational. The concept is one of motivation by example and constantly challenging followers to reach their highest potential. Part of the focus is also to develop leadership in their followers. This highlights an old concept of the difference between a manager and a leader. When talking about leaders, there are formal and informal leaders. Formal leaders are those in a position of leadership i.e. management or administration. Their support and motivation is critical and is what helps to develop positive leadership in those in informal leadership positions. Managers can’t be everywhere all the time so the informal leaders provide motivation and support for improvement in their absence. Tomlinson talks about distributed or shared leadership, highlighting the importance of both the formal and informal leadership.8 Other authors talk about transforming care at the bedside meaning staff who do the work are most likely to know what improvements need to be made .9-11 Therefore, the purpose of leadership rounding for improving patient outcomes involves gathering ideas for change, collecting information about recent changes, ensuring that staff are aware of changes that have been implemented i.e. policy changes, that supplies and equipment are available to perform the new processes, and that the new processes are working as intended.
Just to clarify this, here is an example of one of my own experiences in this arena. A decision had been made to bar code and scan breast milk to ensure proper matches to mother/baby and prevent feeding the wrong milk to the wrong baby. Several systems capable of doing this were evaluated and one was decided upon and purchased. Staff were aware that this change was going to be made and education was provided on how to use the equipment, although not 100% of the staff were inserviced due to vacations and sick leave. Unfortunately, there were technical delays which resulted in a gap between inservicing and go-live of the system. Once the system went live, charge nurses were provided with further inservicing to support staff in the absence of the “expert” and the expert was present at the beginning of each shift until all staff who might need to use the system had been given a quick “just in time” inservice and had proper access to the system. The change to use of a bar code system took more than technical know-how, though. It also involved a culture change. Many staff believed that the old system of double-checking containers visually was just as effective and there was really no need for this new system that they saw as more work and inconvenience. This was where the informal leaders were important. Change theory shows us that not all people will change at once as long as the old method is still available. Therefore, staff members were identified as the informal leaders, through a process of observing who was getting really good at use of the bar code scanner and processing of the milk as well as the presence of a positive attitude toward the change. In addition, simply having a leader who expressed genuine interest in simplifying the system as much as appropriate and ironing out difficulties along the way helped motivate more staff to work through some of the more minor issues in implementation. This involved lots of rounding, not only at the beginning of the shift but periodically around feeding times to make sure things were going as expected, supplies were available and any issues were handled quickly and efficiently.
Surely, there are any number of examples readers have of changes that were implemented both successfully and unsuccessfully. The obvious difference, in many cases is the leadership in the process. I have been on the receiving end of some changes that get implemented with no explanation of why or how this change came about but is just being implemented “because.” While these types of changes are a much greater struggle to implement, they also lead to poor morale amongst a work force who wants to understand the why and how of caring for our small, fragile patients. Regardless of what the leadership style is called, it involves the leader being a part of the process, involving those doing the work but also understanding what the work involves. The leader also needs to be a part of the process once it is implemented to ensure it works as expected and be willing to make changes along the way to make sure the outcome is the intended outcome.
1. Baker SJ. Rounding for outcomes: an evidence-based tool to improve nurse retention, patient safety, and quality of care. Journal of Emergency Nursing. 2010;36(2):162-164.
2. Meade CM, Bursell AL, Ketelsen L. Effects of nursing rounds: on patients’ call light use, satisfaction and safety. American Journal of Nursing. 2006;106(9):58-70.
3. Versteeg MH, Laurant MG, Franx GC, Jacobs AJ, Wensing MJ Factors associated with the impact of quality improvement collaboratives in mental healthcare: an exploratory study. Implementation Science. 2012;9:7-1.
4. Strating, Nieboer. Explaining variation in perceived team effectiveness: results from eleven quality improvement collaboratives. Journal of Clinical Nursing. 2012; doi: 10.1111/j.1365-2702.2012.04120
5. Kouzes JM, Posner BZ. 1987. The Leadership Challenge: How to Get Extraordinary Things Done in Organizations. Josey-Bass, San Francisco, CA.
6. Kouzes JM, Posner BZ. 2000. Leadership practices inventory: Psychometric properties. San Francisco, CA: Wiley.
7. Burns JM. 1978. Leadership. New York: Harper & Row Publishers.
8. Tomlinson J. Exploration of transformational and distributed leadership. Nursing Management. 19(4):30-35.
9. Dearmon V, Roussel L, Buckner EB, Mulekar M, Pomrenke B, Salas S, Mosley A, Brown S, Brown A. Transforming care at the bedside (TCAB): Enhancing direct care and value-added care. Journal of Nursing Management. 2013;21:668-678.
10. Adams JM, Denham D, Neuneister RI. Applying the model of interrelationship of leadership, environments and outcomes for nurse executives: A community hospital’s exemplary in developing staff nurse engagement through documentation improvement initiatives. Nursing Administration Quarterly. 2010;34:201-207.
11. Meredith E, Cohen E, Raia L. Transformational leadership: Application of magnet’s new empiric outcomes. Nursing Clinics of North America. 2010;45:49-64.
Looking for additional reading on this topic?
View Sandy Beauman’s related blog entry, Professionalism In Nursing.