Enhancing Nursing Leadership in Long-Term Care

Literature Review

Enhancing Nursing Leadership in Long-Term Care A Review of the Literature Theresa A. Harvath, PhD, RN, CNS; Kristen Swafford, MS, RN, CNS; Kathryn Smith, MS, RN, PMHNP; Lois L. Miller, PhD, RN; Miriam Volpin, BS, RN; Kathryn Sexson, MS, RN, FNP; Diana White, PhD; and Heather A. Young, PhD, GNP, FAAN

ABSTRACT

The quality of care provided to nursing home residents has been the subject of broad criticism for years. Mounting evidence suggests that the quality of nursing home care can be improved by strengthening the roles of nurses in these facilities. This article reviews the literature on programs designed to enhance nursing leadership in long-term care, examines outcomes associated with leadership in long-term care, and outlines recommendations for programs to enhance nursing leadership in nursing home settings. The findings suggest that nursing leadership training programs for nurses working in nursing homes are urgently needed to improve quality in the nation’s nursing homes and stabilize the workforce. To maximize their effectiveness, these leadership training programs should be part of a continuum of leadership development that begins in nursing education programs and persists throughout a nurse’s career trajectory.

The quality of care provided to nursing home residents has been the subject of broad criticism for years. Despite both public and private sector initiatives to create substantial and lasting improvements, opinions of nursing home care remain low (Mattimore et al., 1997; Winzelberg, 2003). Quality problems stem, in part, from the fact that the needs of older adults in nursing homes have grown increasingly complex during the past 20 years. Many residents are now

extremely frail, have multiple complex health problems, and require specialized care. Mounting evidence suggests that the quality of nursing home care can be improved by strengthening the roles of nurses in these facilities (Harrington et al., 2000; Horn, Buerhaus, Bergstrom, & Smout, 2005; Rantz, 2003; Reinhard & Stone, 2001; Shaughnessy, Kramer, Hittle, & Steiner, 1995; Tellis-Nayak, 2007). However, while it is well rec-

Dr. Harvath is Associate Professor, and Director, Advanced Practice Gerontological Nursing, Ms. Swafford is a doctoral candidate, Ms. Smith is a doctoral student, Dr. Miller is Professor, Ms. Volpin and Ms. Sexson are doctoral students and John A. Hartford Predoctoral Scholars, and Dr. Young is Grace Phelps Distinguished Professor, Director, John A. Hartford Center for Geriatric Nursing Excellence, and Director, Rural Health Research Development, School of Nursing, Oregon Health & Science University, Portland, Oregon. Dr. White is a Senior Research Associate, Portland State University, Portland, Oregon. This work was supported by two grants to the American Academy of Nursing—a Planning Grant for the Hartford Centers of Geriatric Nursing Excellence Nursing Home Collaborative funded by The Atlantic Philanthropies, and by the Building Academic Geriatric Nursing Capacity Coordinating Center funded by the John A. Hartford Foundation, Inc. The authors acknowledge the support of the Oregon Health & Science University John A. Hartford Center of Geriatric Nursing Excellence and the American Academy of Nursing. They also acknowledge Elizabeth Tornquist for her editing assistance. Address correspondence to Theresa A. Harvath, PhD, RN, CNS, Associate Professor, and Director, Advanced Practice Gerontological Nursing, School of Nursing, Oregon Health & Science University, 3455 SW U.S. Veterans Road, SN-6S, Portland, OR 97239-2941; e-mail: [email protected].

Research in Gerontological Nursing • Vol. 1, No. 3, 2008

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ognized that nurses are integral to improving the quality of care (American Health Care Association, 2001; Reinhard & Reinhard, 2006), most RNs in these settings have had inadequate preparation in gerontological nursing content (Aroian, Patsdaughter, & Wyszynski, 2000; Brannon, Smyer, & Cohn, 1992; Reinhard & Reinhard, 2006; Swagerty, Lee, Smith, & Taunton, 2005; Tellis-Nayak, 2005; VaughanWrobel & Tygart, 1993), and the bulk of nursing home care is provided by paraprofessionals with very limited education. Nurses are often responsible for supervising the care provided by these paraprofessionals, but few nursing programs prepare graduates to delegate or supervise. In addition, the majority of directors of nursing in nursing homes have themselves graduated from diploma or associate degree programs (Aroian et al., 2000; Vaughan-Wrobel & Tygart, 1993), which typically lack the content on leadership, management, and organization needed to execute that role (Tellis-Nayak, 2005; Vaughan-Wrobel & Tygart, 1993). The high turnover rate among directors of nursing in nursing homes also makes it difficult for them to acquire these skills once they are in the role (Tellis-Nayak, 2005). The need to develop nursing leadership skills in nursing homes has been documented repeatedly (Aroian et al., 2000; Brannon et al., 1992; Reinhard & Reinhard, 2006; Swagerty et al., 2005; Tellis-Nayak, 2005; Vaughan-Wrobel & Tygart, 1993). Interestingly, however, few authors have explicitly said what they mean by leadership. Looking more broadly at definitions of leadership within nursing, Sellgren, Ekvall, and Tomson (2006) noted that the early focus of research was on the leadership styles exhibited by individuals in positions of authority. The assumption here is that individuals who occupy those positions possess leadership. Leadership in nursing has also sometimes been associated with certain personality characteristics or traits, including thoughtfulness, responsiveness, commitment, creativity, resilience, vision, scholarship, courage, and innovation (McBride, Fagin, Franklin, Huba, & Quach, 2006). Recently, however, it has been recognized that “becoming a leader is not just a matter of becoming skilled or knowledgeable, but using one’s skills and knowledge in order to make a difference” (McBride et al., 2006, p. 226). Thus, while it is important for nursing leaders to be visionary, creative, and courageous, they also need to develop the skills necessary to motivate individuals and organizations to change. In addition, some authors assert that nurses in leadership positions need to have sound business acumen to direct organizational resources toward desired change (Jennings, Scalzi, Rodgers, & Keane, 2007; Upenieks, 2002). Thus, leadership may be conceptualized as a set of skills

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and attributes associated with the ability to effect change at all levels within an organization (Beverly et al., 2006; Houser & Player, 2004; Kitson, 2004; McBride et al., 2006). This article reviews the literature on programs designed to enhance nursing leadership in long-term care, examines outcomes associated with leadership in long-term care, and outlines recommendations for programs to enhance nursing leadership in nursing home settings.

Method This review is limited to research on nursing leadership in nursing homes. To be included in the review, studies had to be conducted in nursing homes or other long-term care facilities (e.g., assisted living, adult foster care) and had to describe leadership enhancement programs, assess leadership needs of nursing home nurses, or examine the relationships between leadership and outcomes for nursing home staff, residents, or environments. Studies of nursing supervision of nursing assistants or other nursing home personnel, as well as programs focusing exclusively on enhancement of nursing assistants, were excluded from the review, as such work is reviewed in a separate article (Collier & Harrington, 2008). We had originally planned to include only published reports of research evaluating leadership enhancement programs in nursing homes; however, because of a lack of published work, we expanded our criteria to include unpublished reports as well. The initial search used the following terms: nursing homes, nursing administration, leadership, nurse administrators, leader, empowerment, motivation, mentorship, nursing leaders, nursing practice, nurses, and long-term care. A full list of terms searched in each database can be found online at http://www.geronurseresearch.com. Those terms were used to search MEDLINE, CINAHL, Evidence-Based Medicine Reviews, and PsycINFO. The search was limited to “research” and to citations from 1990-2007. A total of 383 articles were reviewed for relevance by title and, if available, by abstract. Of those, 136 were retrieved and received a full-text review; however, none were relevant for inclusion in this report. Medical Subject Headings terms from articles that were closely related to our topic were used for further database searches. A CINAHL search using those terms yielded 33 articles that were reviewed for relevance by title and, if available, by abstract. Of those, 3 received a full-text review. A Medline search yielded 184 articles, 21 of which received a full-text review. A further search in PsycINFO including the above terms, with the addition of management, health care administration, and management training, resulted in 42 articles, 7 of which received a full-

GeroNurseResearch.com

Enhancing Nursing Leadership in Long-Term Care

text review. We also followed up on programs cited in the Scanning the Field report by Reinhard and Reinhard (2006) and requested any unpublished reports of program evaluation that were available.

Results Despite the general consensus that leadership skills are important for nursing home nurses, we found very little evidence to support this claim. In addition, we found only weak evidence that particular programs enhanced leadership. In total, 642 citations were reviewed for relevance by title and abstract, with 167 of those receiving a full-text review. Of these, four met our criteria for inclusion in the final review. In addition, we found eight studies that linked leadership among nursing home nurses to a variety of outcomes—(One study [West, Lyon, McBain, & Gass, 2004] included other health care institutions as well as a nursing home.)—and three studies that explored the educational needs of nursing leaders in nursing homes. A comprehensive description of all of the studies reviewed can be found online at http://www.geronurseresearch.com. Leadership Enhancement Programs No well-designed randomized controlled trials of leadership enhancement programs were found. All four studies used a pretest-posttest design. In addition, Merritt (2003) used a nonrandomized control group. The evaluation for each of these programs was conducted by individuals involved in offering the leadership training; none were evaluated by an outside evaluator. These programs are summarized below, and the outcomes are listed in Table 1. LEAP. LEAP (Learn, Empower, Achieve, and Produce) was developed by the Mather LifeWays Institute on Aging (n.d.), and its Web site indicates that the program has been offered in many nursing homes across the country. LEAP has two separate modules, one aimed at nurse managers and staff nurses, and one aimed at certified nursing assistants (CNAs). Person-centered care principles are a major theme of the training, which also includes content on mentoring, conflict resolution, and problem solving. An evaluation of LEAP (Hollinger-Smith & Ortigara, 2004) found that a greater proportion of nursing staff rated the following items as excellent or above average at 6 months and 12 months following the training when compared with the ratings at baseline: l Their degree of work empowerment (x2 = 64.13, p < 0.001). l Leadership effectiveness (x2 = 39.22, p < 0.001). l Organizational climate (x2 = 64.13, p < 0.001).


Job satisfaction (x2 = 53.85, p < 0.001). l Work effectiveness (x2 = 67.34, p < 0.001). In addition, the program has received a number of awards. Conflict Management Training. A dissertation study conducted by Merritt (2003) evaluated a seminar on conflict management designed to enhance nursing leadership skills. This 4-hour program had four key objectives: expanding self-awareness, developing awareness of others, assessing conflict situations, and applying new conflict management skills. Participants in the experimental group showed significant changes in their dominant conflict management style 4 weeks after the intervention (x2 = 39.85, p < 0.001, df = 6), with increases in their competing styles (t = –3.70, p < 0.01, df = 65) and decreases in their avoiding (t = 3.89, p < 0.01, df = 65) and accommodating styles (t = 2.51, p < 0.05, df = 65). Scores for collaborating and compromising styles increased but were not statistically significant. Participants in the control group experienced reductions in the collaborating management style and increases in the competitive and avoiding styles. However, it is important to note that the groups differed substantially in their dominant styles at baseline, which may have contributed to the differences at posttest. Clinical Leadership Skill Training. Researchers at the University of Pennsylvania School of Nursing (SullivanMarx & Snyder Phillips, 2005) evaluated a leadership training program designed to increase the clinical leadership skills of nurses in long-term care (both home care and nursing home care). This program contained five modules related to team building, presence and communication, power and negotiation, change theory and process, and management. Two additional modules focused on principles of adult education and cultural competence, and six modules focused on geriatric nursing best practices. Using a pretest-posttest design, the researchers reported that groups who received the training improved slightly in their knowledge of change theory (correct responses at pretest = 73.3%; correct responses at posttest = 81%). Feedback from participants suggested that the leadership training module should be lengthened to all day and should include conflict management. The Pacific Northwest Nursing Leadership Institute. In an effort to reduce the turnover of nurse managers in long-term care, Washington State established the Pacific Northwest Nursing Leadership Institute (PNNLI) (Wilson, 2005), a consortium of nurse leaders formed to support the development of nursing leaders. The PNNLI consisted of a l

189

190

X

X

X

X

X

X

SullivanMarx & Snyder Phillips (2005) (IV)

X

Wilson (2005) (IV)

No significant relationship between leadership and time management effectiveness found. Note. Levels of evidence indicate rankings established to stratify evidence by quality.

a

Reduced costs of care

Improved quality of care

Improved work effectiveness

Increased retention/reduced turnover

Job satisfaction

Enhanced organizational/work climate

Improved leadership skills

Dimension

Merritt (2003) (III)

HollingerSmith & Ortigara (2004) (IV)

Leadership Enhancement

X

X

Anderson et al. (2003) (VI)

Hartley & Kramer (1991)a (VI)

X

X

X

X

Pearson et al. (1992) (VI)

Study (Level of Evidence)

Table 1

X

X

X

X

X

X

ScottCawiezell Swagerty et al. Stone et al. et al. (2005) (VI) (2002) (IV) (2005) (VI)

Outcomes Research

Outcomes Associated with Nursing Leadership in Nursing Homes

X

X

TellisNayak (2007) (VI)

X

X

X

West et al. (2004) (VI)

Harvath et al.



2-day retreat-style workshop and seven 1-day seminars on leadership that included modules on fiscal management, employee performance, communication, coaching, teamwork, process improvement skills, and personal effectiveness (Wilson, 2005). Participants included nurse managers with a wide range of experience in management. The program resulted in a significant increase in participants’ intent to stay in their current position (t = 4.58, p < 0.001) but no change in job satisfaction (t value not reported). Interestingly, there was a significant attrition of participants in the program, which was attributed to job stress. It is not clear whether their inclusion in the final study would have altered the intent-to-stay figures. Outcomes Associated with Leadership in Nursing Homes Nursing leadership has been associated with a wide variety of positive outcomes in long-term care (Table 1). Most studies have found improvements in the quality of care provided as a result of leadership training (Anderson, Issel, & McDaniel, 2003; Pearson, Hocking, Mott, & Riggs, 1992; Scott-Cawiezell et al., 2005; Stone et al., 2002; Swagerty et al., 2005; Tellis-Nayak, 2007; West et al., 2004). In addition, some studies showed an increase in staff retention (Stone et al., 2002; Wilson, 2005) and job satisfaction (HollingerSmith & Ortigara, 2004; Pearson et al., 1992; Tellis-Nayak, 2007), whereas others showed improvements in the organizational and work climate (Hollinger-Smith & Ortigara, 2004; Pearson et al., 1992, Stone et al., 2002) or reductions in the cost of care (Stone et al., 2002). Moreover, the evaluation of the Wellspring Model (Stone et al., 2002) found that in some facilities, a lack of leadership skills among geriatric nurse practitioners was a barrier to success. However, the evidence of the improvements cited is modest at best. The studies were either descriptive or involved single-group pretest-posttest designs. Also, in most studies, the evaluation was conducted by individuals associated with the training program, not by independent evaluators. Educational Needs of Nursing Leaders in Nursing Homes Several studies have assessed the educational needs of nursing leaders in nursing homes (Krichbaum, Johnson, & Ryden, 1992; Luggen, 1997; Vaughan-Wrobel & Tygart, 1993). These studies highlight the importance of content traditionally thought of as leadership (e.g., motivating others, creative problem solving, conflict resolution), as well as content related to important organizational and management skills. Two studies (Krichbaum et al., 1992; Luggen,


1997) also pointed to a need for enhanced clinical skills of nurses at all levels. In particular, they noted an interest in a better understanding of how to translate current research into practice and how to implement best practices. Dimensions of Leadership Enhancement Programs Our review of the literature suggests that comprehensive leadership training programs should include content in four distinct dimensions (Table 2): l Interpersonal skills (e.g., communication skills, inspiration and motivation, conflict resolution). l Clinical skills (e.g., use of best practices, research translation, person-centered care). l Organizational skills (e.g., strategic planning and visioning, change theory). l Management skills (e.g., regulatory compliance, financial and budgetary planning, employee supervision and mentoring). Interpersonal Skills. In the studies to date, skills that fall into the interpersonal dimension have been referred to most frequently. Authors evaluating several programs have described a leadership philosophy that values employees and seeks to empower them (Stone et al., 2002). This leadership philosophy is often referred to as “making an investment” in frontline staff and recognizing the important role they play in the quality of care provided to residents. Interpersonal skills that follow from this philosophy include creating a receptive environment by using listening skills and soliciting feedback from employees (Stone et al., 2002), clearly expressing standards and role expectations (Scott-Cawiezell et al., 2005), enhancing information flow by eliminating communication barriers (Anderson et al., 2003), and contributing to processes that help make staff voices heard (Scott-Cawiezell et al., 2005; Swagerty et al., 2005; Tellis-Nayak, 2007). The Wellspring Model encourages nurse leaders to communicate with the intent to nurture and guide employees rather than using a task-oriented, “telling” approach (Stone et al., 2002). Identifying small successes in improving clinical outcomes and verbally expressing those to individual employees are ways to achieve this guiding and nurturing approach (Stone et al., 2002). Clinical Skills. We found that the clinical skills dimension received least attention in all of the articles reviewed, perhaps because expertise in clinical skills was presumed to be present in nurse leaders. In one of the few articles touching on this area, Hollinger-Smith and Ortigara (2004) suggested this gerontological nursing expertise can serve as a source of identity and pride for long-term care nurses.

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Table 2

Core Content for Nursing Leadership Enhancement Programs Study (Level of Evidence) Leadership Enhancement Programs Educational Needs Assessments

Dimension

HollingerSmith & Ortigara (2004) (IV)

Merritt (2003) (III)

SullivanMarx & Snyder Phillips (2005) (IV)

Wilson (2005) (IV)

X

X

Krichbaum et al. (1992) (VI)

Luggen (1997) (VI)

VaughanWrobel & Tygart (1993) (VI)

X

X

Interpersonal skills Communication

X

Inspiration/motivation Conflict resolution

X

Relationship building

X

X

X

Self-awareness

X

X

X

X

X

Clinical skills Use of best practices

X

X

Research translation

X

Gerontological nursing Person-centered care

X

X

X

Organizational skills Strategic planning/vision

X

Policy development

X X

Negotiation

X

Team building

X

X

Change theory

X

X

X

X X

Management skills Recruitment/retention Human resources policies and procedures

X

Regulatory compliance Financial/budgetary planning Employee supervision/ mentoring

X X

Quality improvement

X

X

X

X

X

X

X

X

X

X

X X

X

X X

Note. Levels of evidence indicate rankings established to stratify evidence by quality.

For example, some facilities identify their charge nurses as “gerontological clinical experts.” Clinical skills have also been promoted as a way for all levels of nursing leadership to help frontline staff in times of stress or to train nursing assistants in how to handle challenging resident behaviors (Tellis-Nayak, 2007). Additionally, West et al. (2004) sug-

192

gested that nurses in managerial positions require excellent clinical skills to serve as the primary resource to other staff, residents, and families. Organizational Skills. Several authors have identified organizational skills that fall into the dimensions of strategic planning and vision or are part of a philosophy that



guides goals and priorities. For example, Scott-Cawiezell et al. (2005) noted that a successful nursing home leadership approach is one that emphasizes an internal commitment to standards of care rather than one focusing externally on regulation and competition. In a nursing home with exemplary leadership, this philosophy is openly discussed and demonstrated through the life of the facility, and it is understood by all staff as the driving force for decision making. In addition, Stone et al. (2002) pointed to the importance of leaders who have the skills to see the organizational-level implications of decisions and policies such that congruence between desired practice and current policies is a priority. The skills of negotiation are seen as critical for nurse leaders in long-term care and include the ability and confidence to “lobby” the facility administration for the needs of staff and residents (Stone et al., 2002). This requires being persistent and collaborative in one’s approach to win over skeptics (Stone et al., 2002) through the appropriate use of power (Sullivan-Marx & Snyder Phillips, 2005). An empowerment philosophy (Hollinger-Smith & Ortigara, 2004) that embraces participatory decision making structure (Anderson et al., 2003) points to the importance of skills in team building. Skills in this area include nurse leaders’ participation in direct-care activities as a means of relieving CNA burden in times of stress and serving as a clinical role model for practice change (Hollinger-Smith & Ortigara, 2004; Swagerty et al., 2005; Tellis-Nayak, 2007). The Wellspring Model encourages nurse leaders to contribute to the creation of a collaborative forum in which decisions are made that serve the interests of both staff and management (Stone et al., 2002). Four studies identified a need for nurse leaders to have skills as a change agent. These skills include awareness of and strategies to address potential saboteurs (Stone et al., 2002), understanding organizational change theory and process (Sullivan-Marx & Snyder Phillips, 2005), recognizing one’s role as a bridge between frontline staff and administrative staff in the dissemination and implementation of practice changes (Swagerty et al., 2005), and taking advantage of one’s position to question unsatisfactory current practices (West et al., 2004). These studies also identified a need for nurses in managerial positions to recognize their role as clinical decision makers but to advocate the use of a collaborative style in gathering information for a final decision. West et al. (2004) suggested that nurse leaders who fulfill this role well can reduce the frustration and burden that result when no one is making decisions, otherwise the decision making process is lengthy and convoluted.


Management Skills. Management skills have also been identified as important for nurse leaders, although they have been less well described. Priority skills in this dimension include the creation of policies and procedures that foster a safe workplace for staff and ensure that frontline staff have sufficient tools and supplies to do their job well (Tellis-Nayak, 2007). Several studies have highlighted the need for nurse leaders to reduce the use of surveillance and rules to regulate staff performance, and instead use a person-centered approach that offers constructive feedback, fair evaluations, and a mentoring relationship to assist CNAs in enhancing current skills or gaining new ones (Anderson et al., 2003; Hollinger-Smith & Ortigara, 2004; Stone et al., 2002). To enhance current skills and contribute to the development of new skills in direct-care staff, nurse leaders need to be able to assess the knowledge of staff so education can be targeted and individualized (Stone et al., 2002). Two studies have also identified the skills of recognizing, appreciating, and supporting frontline staff as key to successful supervision (Hollinger-Smith & Ortigara, 2004; Scott-Cawiezell et al., 2005). Interestingly, the rationale for including elements from these four dimensions in leadership training is based on rather weak evidence. None of the programs included elements from all four dimensions. In addition, there has often been a lack of clarity in the definitions of the elements and in how the content should be taught. For example, the majority of articles have stressed the importance of improving communication skills, yet very few described the aspects of communication that should be addressed. Focusing on Nurses at Different Levels in the Nursing Home Whereas some of the articles we reviewed focused on nurses at particular levels in the organization (e.g., Hollinger-Smith & Ortigara, 2004; Krichbaum et al., 1992), others were more general and did not differentiate content on the basis of job title or position (e.g., Luggen, 1997; Scott-Cawiezell et al., 2005). Several authors noted that although all nurses could benefit from content in each of these areas, it might be useful to distinguish the competencies required of nurses in particular settings or positions. For example, many authors agree that sound clinical skills are foundational for any nurse leader. However, the level of clinical proficiency needed to enact one’s role is likely to vary depending on the role. Nurses engaged with older adults at the bedside need to be well versed in best practices for frail older adults. In contrast, nurses in more administrative or managerial roles need only to understand

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Table 3

Targeted Content for Nursing Leadership Enhancement Programs Staff Nurse

Resident Care Manager

Director of Nursing

Nursing Executive

Communication

X

X

X

X

Inspiration/motivation

X

X

X

X

Conflict resolution

X

X

X

X

Relationship building

X

X

X

X

Critical thinking/problem solving

X

X

X

X

Self-awareness

X

X

X

X

Use of best practices

X

X

X

Research translation

X

X

X

X

Gerontological nursing

X

X

X

X

Person-centered care

X

X

X

Dimension Interpersonal skills

Clinical skills

Organizational skills Strategic planning/vision

X

X

Policy development

X

X

Negotiation

X

X

X

X

Delegation

X

X

X

X

Team building

X

X

X

X

Change theory

X

X

X

X

Recruitment/retention

X

X

Human resources policies and procedures

X

X

Regulatory compliance

X

X

Financial/budgetary planning

X

X

Management skills

Employee supervision/mentoring

X

X

X

X

Quality improvement

X

X

X

X

enough about the clinical needs of nursing home residents to ensure appropriate resources (human and otherwise) are directed at those needs. Most authors also agree that all nurses need enough organizational skills to be confident advocates of change. However, nurses in positions of authority need additional business skills to understand the relationships between the costs of care and the complex reimbursement formulas of Medicare and Medicaid and private health and long-term care insurance and to allocate resources appropriately (Rusch, 2004).

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Kinds of Leadership Training Programs All of the leadership enhancement programs reviewed have involved single-day or multi-day workshops or continuing education offerings (Hollinger-Smith & Ortigara, 2004; Merritt, 2003; Sullivan-Marx & Snyder Phillips, 2005; Wilson, 2005). However, several programs noted the importance of ongoing support and mentorship to help nurses gain real-life experience enacting various aspects of the leadership role. Although we could find no studies indicating the most effective way to deliver leadership en-



hancement content in long-term care, it seems reasonable to conclude that programs that include both education and ongoing mentorship and support are likely to be more effective than are single-course offerings. Costs Related to Leadership Enhancement Programs The costs involved in developing and delivering leadership enhancement programs in nursing homes were not reported for any of the programs evaluated. In fact, only one of the studies we reviewed even addressed the issue of cost (Stone et al., 2002): The evaluation of the Wellspring Model reported that facilities had to invest “considerable organizational resources” to implement and support the model (p. 22). However, some of these expenses may have been recouped with reductions in average cost per resident day, as compared with other nursing homes. In addition, programs that reported increased staff retention may have experienced reductions in the costs associated with hiring new staff. However, these data were not systematically gathered or reported; thus, the overall financial impact of these programs cannot be estimated on the basis of current data.

Discussion and Recommendations This literature review suggests that although enhancing the leadership skills of nurses in nursing homes may lead to improvements in the quality of care that residents receive, the evidence for this is relatively weak. Not enough strong evaluative data exists to endorse the adoption of any particular leadership enhancement program, although some seem promising (e.g., LEAP). Therefore, we recommend that initiatives designed to improve the quality of nursing home care include provision for leadership enhancement. More specifically, we recommend that: l Any leadership enhancement program include content on interpersonal skills, clinical skills, organizational skills, and management skills (level of evidence = V), as these content areas are frequently identified in needs assessments (Table 3). l Specific leadership competencies be developed for nurses at each level in the nursing home organization (level of evidence = VII). These specific leadership competencies can guide the development of leadership enhancement programs and facilitate their evaluation. They will also create a set of expectations or incentives for nurses in nursing homes. l Leadership enhancement focus on nurses at all levels in the organization but be tailored to the needs of those in different positions (e.g., staff nurses, resident care man-


agers, directors of nursing) (level of evidence = V). Although nurses in positions of authority (e.g., directors of nursing) are likely to benefit from leadership enhancement, some evidence suggests that the quality of care and the work environment in nursing homes may improve more by increasing the leadership skills of bedside nurses who are in close daily contact with direct-care workers and residents. l Leadership enhancement programs include an educational component as well as ongoing mentorship to support the development of leadership skills over time (level of evidence = VII). Although mentorship was not the focus of any of the studies reviewed in this article, several authors suggested that single-day workshops were likely insufficient to fully develop leadership skills and ensure their enactment. l Plans for systematically evaluating the effectiveness and outcomes, including costs, accompany any leadership enhancement program offered, due to a lack of strong evidence of the effectiveness of leadership enhancement programs (level of evidence = VII).

Conclusion This review suggests that the evidence on the effectiveness of leadership enhancement programs in nursing homes is relatively weak. However, leadership training programs that have been developed in other health care settings (e.g., hospitals) and by other disciplines could be applicable to nursing home settings. Although such programs will need to be adapted to address the unique features of the nursing home environment, it may be more cost effective to use them than to develop and test new leadership enhancement programs. Leadership training programs for nurses working in nursing homes are urgently needed to improve quality in our nation’s nursing homes and stabilize the workforce. To maximize effectiveness, these leadership training programs should be part of a continuum of leadership development that begins in nursing education programs and persists throughout a nurse’s career trajectory. Because a significant number of nurses in leadership roles in nursing homes have not received any leadership training, basic preparation is required. Ongoing opportunities for mentoring are also needed to ensure the translation and sustainability of skills and competencies gained in training and education programs. By strengthening the leadership skills of nursing home nurses, it may be possible to produce and sustain improvements in quality of care that are essential to promote the quality of life of frail older adults in nursing homes.

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