Health care systems worldwide are undergoing transformation alongside the development of scientific therapies and insurance system reform. Amid these changes, any member of a health care team can assume a leadership role; nurses with leadership competence can facilitate the growth of other professionals (Institute of Medicine, 2011). Nurses who use appropriate leadership skills improve hospital, colleague, and patient outcomes (Aiken et al., 2014; Boamah et al., 2018). Adequate development of leadership behaviors and skills can enhance nurses' commitment, reduce turnover, and result in greater professionalism (Fallatah et al., 2017).
Leadership capability is considered a core competency of nursing college graduates (American Association of Colleges of Nursing [AACN], 2013; American Nurses Association, 2014). Ideally, prospective courses for cultivating leadership competency should start early in the undergraduate program (Knight & Hamilton, 2019) as leadership competence development cannot be acquired in a single course. Competence-based curricula should cross all areas of nursing and be reinforced each semester by all faculty (Bokonjic et al., 2019). Although undergraduate nursing students are assumed to be our future nurse leaders, typical nursing curricula, including most undergraduate nursing programs, deliver leadership issues or nursing administration only in the final semester. The failure to embed leadership objectives in a nursing curriculum will miss opportunities to influence and cultivate nursing leaders in the following generation.
Bloom classified learning into cognitive, affective, and psychomotor domains (Bloom et al., 1956). Anderson and Krathwohl (2001) revised the cognitive process domain of Bloom's taxonomy to include remember, understand, apply, analyze, evaluate, and create. To provide undergraduate nursing students with a preliminary grasp of leadership competence, this study, conducted in Taiwan, primarily addressed the cognitive domain of the taxonomy. A cognitive learning model to improve leadership competencies of nursing students was adopted by Pepin et al. (2011), who considered that leadership competencies should be fostered in stages whereby students must first recognize the importance of leadership in nursing so that they can appropriately practice clinical care behaviors that are leader competent. Cultivating leadership competency is important, not only in the clinical domain but also in the domains of education and research (Jones-Schenk, 2018).
BACKGROUND
Leadership can be defined as the process of leading people to achieve a shared vision (Curtis et al., 2011; Huber, 2013). Opinions differ about the qualities and competencies leaders should have. Chuang (2011) identified that beyond developing integrity, sense of responsibility, self-confidence, passion, insightfulness, innovation, ambition, and knowledge, nurses should possess leadership competence. To gradually master a variety of leadership skills entails effort and training.
The American Organization for Nursing Leadership (AONL, 2018) divides nursing leadership into three aspects: creating the leader in yourself, leading people, and managing the business. Our research team added a fourth dimension, vision building, to ensure broad application of the framework and distinguish its core elements for baccalaureate nursing leadership competence. We developed our framework to encompass the following: 1) personal characteristics, individual characteristics or lasting behaviors, typically positive thinking, thoughtfulness, and willingness to meet challenges (Demeh & Rosengren, 2015); 2) leading people, the competencies and methods used to manage and influence others in group activities, typically empathy, innovativeness, and communication/negotiation (Broome, 2015; Chappell & Richards, 2015); 3) resource management, using multiple strategies, organizations, plans, and controlling measures to allocate organizational resources and achieve objectives (Curtis et al., 2011); and 4) vision building, competency at incorporating future objectives, mandates, and core values of an organization into ultimate objectives. Leaders with vision-building capabilities are able to identify the needs of their organization and its members, perform evaluations from multiple perspectives, engage in sensible and detailed thinking before making a decision, and make correct decisions (Blazun et al., 2015).
Traditional baccalaureate nursing curricula have no requirement to incorporate the core elements of nursing leadership. Rather, more than 90 percent of nursing educators utilize specific strategies for educating students (Kalb et al., 2012). Methods generated from qualitative analysis typically include incorporating leadership content in classroom teaching, cultivating leadership knowledge and techniques during clinical internships, and conducting self-reflection from a leadership perspective (Kalb et al., 2012). According to a systematic review by Lyons et al. (2018), 10 of 11 studies reviewed showed that leadership training programs enhanced leadership competence. Nurse educators need to integrate theory into practice through a combination of practical courses and educational strategies (Fawaz et al., 2018). Leadership education should be implemented to aid nursing students to apply their nursing knowledge while exerting an influence on clinical tasks in learning to care for and manage patients (Curtis et al., 2011). We propose that to cultivate leadership competence and improve the traditional baccalaureate curriculum, it is important to apply competence-based leadership objectives across the entire nursing curriculum.
METHOD
This study encompassed the development of a comprehensive educational framework to improve nursing students' knowledge and attitudes toward nursing leadership; the embedding of objectives related to leadership competency into the undergraduate nursing curriculum of one university; and the evaluation of the effectiveness of embedding competencies into the curriculum. The study was conducted in three phases from August 2015 through July 2017. In Phase 1, nationwide clinical and academic experts were invited to identify the learning objectives related to leadership competencies using the Delphi method. In Phase 2, the identified learning objectives and modified teaching objectives were embedded into the curriculum of the university. Discussions about the process were held with each member of the nursing faculty. Phase 3 began with the next academic year, when the newly embedded leadership courses were taught. Participating students evaluated themselves at the beginning and at the end of that academic year.
Phase 1: Developing Learning Objectives
PARTICIPANTS
A national panel of Taiwanese clinical and academic experts was recruited. All members of the 12-member panel (five nurse managers and seven academic experts) held master's or doctoral nursing degrees. They had a mean nursing experience of 24.4 years (SD = 3.4). The panel participated in two Delphi rounds to determine the learning objectives of leadership competence for undergraduate nursing students.
PROCEDURE
The learning objectives, developed by the research team based on a literature review, were further developed for three levels (Level 1, freshmen and sophomore; Level 2, junior; Level 3, senior). Each level contained the three dimensions of leadership competence identified by the AONL (2018) and altered by the research team: personal characteristics, leading people, resource management, and vision building. The Delphi approach was conducted in four steps: 1) select experts, 2) mail teaching objectives to expert panel members, 3) revise teaching objectives according to the experts' opinions, and 4) mail feedback and revised questionnaires to the panel. Steps were repeated until consensus was achieved.
DATA ANALYSIS
The experts rated each objective from 1 to 5 (1 = not appropriate for undergraduate students, 5 = very important). The threshold for consensus was set at 75 percent of the experts rating the item as 4 or 5 on the 5-point scale and a quartile deviation (QD) for each item (Faherty, 1979). Descriptive analysis was conducted using SPSS 20 (IBM, USA). The QD (QD = [Q3-Q1]/2) of items was used to examine dispersion; a QD of <.6 reflected high-level agreement among the experts for a particular item. After two Delphi rounds, consensus was achieved. All 12 experts had identified the overall learning objective (demonstrate leadership competence in patient care and teamwork) and three levels of overall learning objectives, with four subobjectives at each level (see Table 1).
Phase 2: Embedding Objectives Into Courses
The objectives of leadership competencies were then embedded into all required undergraduate professional courses to correspond with appropriate teaching objectives (see Supplemental Content 1 for details, available at http://links.lww.com/NEP/A282). Only objectives related to leadership competence were revised for nursing courses. Faculty members were informed of the study details; individual and group discussions were held with each faculty member concerning the learning objectives and modified teaching objectives in each course. A list of teaching strategies for leadership development was also suggested, including class lecture, peer group activities, and learning by observing teachers' behaviors.
Phase 3: Implementation and Evaluation
DESIGN AND SAMPLE
A pretest/posttest design method was implemented to evaluate the objectives in the nursing curriculum. All freshman, sophomore, junior, and senior students from the university-based nursing program in Taiwan were invited to participate in the intervention (N = 139). Procedures were first reviewed and approved by the university's institutional review board (B-ER-104-121). Comprehensive information was provided by the investigator to students prior to their giving signed consent. Students were told the study was voluntary, and they could withdraw at any time. For students younger than 20, their guardian's consent was required; both student and guardian signed the consent form. Of 139 nursing students asked if they were willing to participate in the intervention, 19 refused, for a participation rate of 86 percent.
INSTRUMENT AND DATA ANALYSIS
The Nursing Leadership Competence Assessment Scale for Undergraduate Nursing Students (NLCAS/UNS) was developed by the research team to evaluate leadership competence among the participating students. The NLCAS/UNS was based on the modified teaching objectives that had been embedded into the courses. The 14 items are scored using a 7-point Likert scale; 7 indicates the highest competence. Cronbach's alpha for the overall scale was .96; alphas for the three subscales, recognizing, experiencing, and applying, were .88, .89, and .92, respectively. Descriptive statistics of the NLCAS/UNS questionnaire data were analyzed using SPSS (V. 20.0). Paired-sample t-tests were performed to determine the differences in course effectiveness. Statistical significance was set at p < .05.
RESULTS
Phase 1
Each of the three levels of learning objectives was reviewed by the Delphi panelists; consensus was achieved after two survey rounds. In Round 1, half of the objectives had failed to reach a QD of >.6. After objectives were revised to reflect the expert comments, the expert panel was sent the revised learning objectives. Learning objectives were found to meet the QD < .6 cut score in Round 2 (see Table 1).
Since the learning objectives were developed initially based on a literature review, some Delphi experts recommended amending the wording; for example, they were concerned that the term nurse models could refer either to students or their nursing models; all instances of "nurse models" in the objectives were changed to "nursing leaders." In consideration of nursing students being at the baccalaureate level, the Delphi experts suggested, "The relatively wide target of nursing practices should be narrowed" and "It is best not to exceed the scope of the first three levels of the Bloom taxonomy." Accordingly, the overall learning objective for leadership competence among nursing students was identified as "Demonstrating leadership competence in patient care and teamwork." Consensus was reached for the three levels of recognizing, experiencing, and applying. The Level 1 overall objective became "recognizing achievements among leaders," the level 2 overall objective became "experiencing personal characteristics, leading people, resource management, and vision building among nursing leaders," and the Level 3 overall objective was "applying leadership competence in patient care and teamwork."
Phase 2
The four-year undergraduate nursing requires students earn a total of 128 credits, with professional required courses comprising 85 credits, elective courses comprising 15 credits, and general knowledge courses comprising 28 credits. The learning objectives and modified teaching objectives for leadership competence were embedded into the 12 required professional courses. Level 1 (freshman and sophomore) objectives focused on understanding the four dimensions of the framework (personal characteristics, leading people, resource management, and the process of vision building) in four courses: two sessions of Introduction to Nursing, Fundamentals of Nursing, and Human Development. Level 2 (junior) objectives targeted experience of the four dimensions in four courses: Maternity Nursing, Adult Health Nursing, Pediatric Nursing, and Bioethics and Nursing. Level 3 (senior) objectives emphasized application in four courses: Nursing Administration, Mental Health Psychiatric Nursing, Community Health Nursing, and Seminar in Professional Issues.
The 12 faculty members responsible for teaching the modified courses were given instructions regarding introduction of the core elements of nursing leadership education. To achieve faculty consensus regarding the innovative objectives, meetings were held to discuss lecture content before, during, and at the end of the semester. The principal investigator (PI), supported by the department administrator, played a critical role to facilitate implementation of the learning objectives. Before each course began, the PI asked faculty to discuss the content of lectures that needed adjustment.
A range of teaching strategies was adopted to incorporate the objectives into each course. They included individual and group projects, discussions about clinical experiences, critical thinking, and self-reflection. To encourage students to apply the leadership knowledge and skills they were learning to real-world scenarios, a situational learning approach to observe theory in practice was also used. Throughout the semester, the PI conferred with faculty about any difficulties they might be having with meeting the objectives. For example, when teaching about bioethics and nursing, faculty members could first help students recognize their own personal characteristics and then experience relevant personal leadership characteristics they would need in specific ethical events.
Phase 3
Embedding the objectives for leadership competence into the 12 courses was evaluated using the NLCAS/UNS. The students were stratified by year. The pretest was given at the beginning of the academic year (September 2016); the posttest was given at the end of the academic year (July 2017). A total of 120 students participated in the 12 courses, 94 female (78.3 percent) and 26 male (21.7 percent) nursing students. Level 1 had 59 students (32 freshmen, 27 sophomores), Level 2 had 29 students, and Level 3 had 32 students. Student perceptions of their leadership competence improved significantly from pretest to posttest in 9 of the 14 items, p = .001 to .030 (see Supplemental Content 2 for pretest and posttest scores, available at http://links.lww.com/NEP/A283).
DISCUSSION
The study was conducted to evaluate the embedded objectives of leadership competency introduced in an undergraduate nursing program. During Phase 1 of the Delphi process, some experts maintained that nursing students would not apply leadership education until they were involved in clinical work; they declared that emphasizing leadership education in undergraduate study is unnecessary. However, the AACN (2013) indicated that fostering leadership characteristics is key to university education and an important component of student development. Numerous nurse managers reported that, when they first undertook management tasks, they lacked support and felt stressed (Tyczkowski et al., 2015). Therefore, we believe cultivating leadership and management competencies in an undergraduate program is essential. The teaching strategies in this study have been shown to be effective in nursing leadership education (Giordano, 2019; Goktepe et al., 2018; Kaddoura et al., 2016; Knight & Hamilton, 2019).
The NLCAS/UNS was administered both before and after the intervention. A comparison of pretest and posttest scores demonstrated that leadership competence improved significantly on nine items after the intervention. However, the scores on five items (4, 8, 11, 13, 14) did not improve significantly. Lack of improvement on these items (p = .581, .693, .564) may be the result of a ceiling effect, which can make change undetectable. A possible explanation for the ceiling effect of Item 4 (understanding importance of professional competence and interpersonal relationships in nursing care) at Level 1 (pretest M = 4.96) may be due to students already having these characteristics. Especially, because students had accumulated three years of nursing education, the pretest scores of Item 11 (ability to apply leadership competence in nursing practices), Item 13 (ability to allocate resources for community development affairs), and Item 14 (ability to build one's own career visions for the nursing profession) had already been higher at Level 3 (pretest M = 4.69-5.50; posttest M = 4.97-5.63).
Item 8 (p = .279), communication and coordination ability, and Item 13 (p = .265), ability to allocate resources for community development affairs, were both related to advanced practical experiences. Some Delphi experts identified that leadership and management were applicable to experienced personnel and limited to theory in undergraduate nursing education, noting that when nursing students first practice in clinical environments, they may not be able to exert leadership or use related concepts. As complex skills require additional practice and integration, a one-year course may be inadequate to achieve obvious change. This study aimed to promote students' leadership competence during their university education with the hope that they will use it appropriately when they can. As lack of practical experience impedes students from executing leadership tasks, future additions may include more effective practical training at Level 3.
The AACN (2013) set the following goals as graduation criteria of university nursing students: provide patients with comprehensive care, assume the role of patient spokesperson, and deavor to ensure patient safety and offer adequate patient care. These goals do not require students to lead the development of the nursing profession. Therefore, this study focused on developing leadership competencies related to patient care and teamwork among undergraduate students. Nursing students' appropriate novice behaviors to take on leadership roles relative to the nursing profession may occur in daily activities as students support patients and the health care team. In addition, nursing students may consider a specific public issue such as the coronavirus pandemic and begin familiarity with health policy affecting practice. Furthermore, students may choose to join a professional association. In this study, the nursing students determined their own goals in the profession, established their own visions, and were encouraged to further develop those visions when proceeding to higher education levels.
The findings of this study were limited by its being a one-year course intervention and assessment. Leadership competencies can be cultivated by enabling students to accumulate relevant leadership skills from various courses throughout their four years of study. Future studies can administer pretests and posttests to a group of students not only at the beginning and end of each academic year but also from their freshman to senior years, thus following their progression and enabling comparison between each grade, which may produce different outcomes. The evaluation of this study was limited by lack of objective evidence. Further study is needed to add objective measures, not just self-report, in order to facilitate more effective outcomes.
CONCLUSION
Nursing students at graduation are expected to demonstrate leadership competence in patient care and teamwork. This study used teaching as an intervention, with the main purpose of developing objectives for various learning levels. The innovative objectives were embedded into the undergraduate nursing curriculum of the participating university. The results reveal that nursing students' leadership competencies improved throughout the modified curriculum. These results can serve as a reference for other universities seeking to promote nursing leadership education. Future advanced curricula that incorporate nursing leadership education should be developed at the master's level. Once this and similar curricula are established, nursing managers can expect newly graduated nurses to be more prepared and ready to take on a leadership role.
Based on the results and implications from this study, we have three recommendations for implementation and research. First, because the scope of nursing leadership is broad and diverse, nurse leaders in different roles and positions can be invited to teach students about a wide range of leadership knowledge. Second, it is necessary to determine faculty perceptions about nursing leadership in order to ensure the quality of their teaching of nursing leadership. Third, longitudinal follow-up for the achievement of graduates is needed as a reference for nursing leadership education.
REFERENCES