Leadership Profiles of Senior Nurse Executives
As hospitals reorganize to meet the demand for accessible, cost-effective quality healthcare, nursing's active participation as part of the top management team is vital. The purpose of this study was to describe the leadership profiles of four senior nurse executives and determine their congruence with the theoretical perspectives of the stratified systems theory. A multiple case study methodology was employed to develop individual and group leadership profiles through related experiences obtained during an interview, the organization's expectations based on their job descriptions, and a survey of their self-perceptions of how they spent most of their time. The findings indicated that the executives' leadership behavior was consistent with the theory in that they reported more frequent leadership behaviors at the strategic domain, less activity at the organizational domain, and infrequent activity at the production domain. Individual profiles were uniformly consistent with the group profile.
Healthcare today is undergoing rapid change (Gilmartin, 1996; Henderson, 1995; Hillebrand, 1994). Hospitals are restructuring in response to economic pressures and managed care initiatives (Advisory Board, 1996). Issues of cost, quality, access, effectiveness, fragmentation of care delivery, and health status outcomes are driving forces in the restructuring of the national health care delivery system (Gilmartin, 1996). The emerging model of health care focuses on disease prevention, health promotion, and primary care. Seamless networks of service providers oriented toward community health needs and chronic disease management are the evolving structure in lieu of stand-alone hospital (Alexander, 1997; Coile, 1996; Gilmartin, 1996; Hillebrand, 1994; Shugrue, 1997). Because of the extensive hospital restructuring, mergers, and closures that are occurring at an unprecedented rate, Alexander (1997) contends that a revolution is occurring, and the role of the nurse executive must be analyzed in depth because of their increasing responsibilities in organizations today (Redmond, 1995).
Nurse executives have been recognized as best prepared by education and administrative expertise to develop and operate the new systems created under restructuring initiatives (Redmond, 1995). Often they are the only people on the executive team with the necessary "integrator skills" to be successful (Cilliers, 1989; Crowell, 1996; Jaco, Price, & Davidson, 1994). Coile (1996) describes the 21st century health care management team as focused on the core business of patient care management in a capitated (managing the risk of enrolled population based on a per member per month fee versus the old fee-for-service structure) environment. He predicts that 50% of the executive team will be clinically experienced physicians and nurses. The purpose of this study, therefore, was to describe the leadership profiles of senior nurse executives representing each of the four categories of acute healthcare hospitals.
Senior nurse executives have been analyzed and profiled in many ways. They are characteristically described in the literature in terms of academic preparation, gender, marital status, age, ethnicity, years in current position and total years of nursing administration experience. Education was seen as a key element in the career development of senior nurse executives (Ytterberg, 1993). They are now expected to have a master's degree in nursing or a related field as their highest degree (Adams, 1990; Alexander, 1997; Harrison & Roth, 1987; Jaco et al., 1994; Sorrentino, 1992). Nursing is a female-dominated profession which is reflected in the gender makeup of senior nurse executives (Rozier, 1996). Ultimately the influence of women as leaders, service providers, and consumers will continue to be a major force in the healthcare industry and be part of the success of their healthcare organizations in the future (Borman, 1993). The majority of male and female nursing executives are married (Rozier, 1996) and their average age is 46 years old (Ytterberg, 1993). Ethnicity was poorly documented in the literature and when found (Redmond, 1995) revealed 70 % of the nurse executives were European-American and 3 % were African-American. On the average, senior nurse executives reported being in their current positions for five years (Barton, 1994; Redmond, 1995; Rozier, 1996) which may be related to the restructuring and turbulent environment of today's current healthcare industry.
Based on the understanding of the requisite experiences in career preparation and development of senior nurse executives, Redman (1995) developed four major taxonomies characteristic of a developing nurse. Simms (1991) added to the profile by depicting a model for important developmental themes encompassing an executive's entire career. They found that senior nurse executives develop their own unique leadership style, ascribe a philosophy of life-long learning, exhibit a high self-esteem with a personal definition of success, and a high regard for the needs of others. They were found to be visionary executives, not threatened by competition, and active in their professional organizations (Redmond, 1995; Simms, 1991; Vestal, 1995). Senior nurse executives have also been profiled by leadership styles (Dunbam-Taylor, 1995; Dunbam-Taylor & Klafebn, 1995; Dunham & Fisher, 1990; Redmond, 1995; Simms, 1991; Vestal, 1995), effectiveness (Adams, 1988; Adams, 1990; Dunbam-Taylor, 1995; Dunbam-Taylor & Klafebn, 1995; Dunham & Fisher, 1990; Henderson, 1995; Redmond, 1995; Simms, 1991; Vestal, 1995) and competencies (Connelly, 1997; Sorrentino, 1992). Lundrigan (1992), developed a grounded theory of chief nurse executive leadership in a rural setting and found that nurse executives built connections to nursing in a changing world by connecting with people, sustaining nursing operations, and relating to the hospital's chief executive officer. In summary, many aspects of senior nurse executive leadership have been studied, however there was a significant gap in the literature that described, analyzed, and profiled senior nurse executives' leadership behaviors and looked at their differences across a hierarchical healthcare organization. The purpose of this study, therefore, was to determine the frequency of occurrence of leadership behaviors categorized according to three hierarchical functional domains in order to profile senior nurse executive leadership.
According to the stratified systems theory, there are critical tasks that must be performed by leaders if an organization is going to function effectively. As the leader moves higher in the organization, these critical tasks become increasingly complex and qualitatively different (Jacobs & Levis, 1992; Jaques, 1986; Jaques, 1990; Johnston, 1991; Lundrigan, 1992; Phillips & Hunt, 1992). Jacobs and Jaques (1990, p. 282) have defined leadership as a process by which meaningful direction is given to collective effort thereby causing an action of willing effort to achieve purpose. In this study, a senior nurse executive is the registered nurse occupying the highest executive position in an acute care hospital. He or she is ultimately responsible for nursing activities throughout the organization and, in the organizational chart, these executives are responsible to the hospital administrator or chief executive officer as part of the executive-level, decision-making management team.
The stratified systems theory describes three hierarchical functional domains at which each senior nurse executive's behavior was examined: strategic, organizational, and production. The highest functional domain is the strategic domain and consists of activities that set the direction for their system within a larger organizational entity. The leader's work consists of planning for the future, positioning the organization for success, marketing to the external environment, creating and disestablishing strategic units, and at the same time, being adept with and concerned about broad political, economic, sociocultural, and technological development (Zaccaro, 1996). Synthesis and integration are large components of executive work because of the large amount of uncertainty. Executive influence is more likely to take the form of creation options that are assessed through consensus-building process.
The middle functional domain is the organizational domain. At this level, leaders are concerned with administrative management within the organizational structure (Jacobs & Levis, 1992). The scope and complexity of performance requirements at this level are less than at the strategic domain. It requires the leader to provide a comprehensive frame of reference that begins to pattern elements of the external environment for the organization as a whole (Zaccaro, 1996). Successful performance within this domain requires a complex cognitive map to deal with problems at a systems level and have some degree of prior knowledge. The leader's work at this level is to develop and implement intervention strategies and influence outcomes, their actions are guided by organizational policies and procedures. Unlike the strategic domain, focus is primarily internal to the system and behaviors are directed towards interfacing and networking with adjacent systems within the organization that impact on the leader's system and coordinating and integrating the activities of multiple subsystems.
The lowest functional domain is the production domain. At this level leaders' work is concerned with direct creation of goods and services (Jacobs & Levis, 1992). Leadership is characterized by direct and small group interaction (Zaccaro, 1996). In this domain the leaders' work is procedurally specified and tasks are fairly concrete. Successful performance requires cognitively simple, linear, unidimensional thought processes to accomplish the designated work. The critical issue at this level is balancing performance with personnel development needs and requirements (Zaccaro, 1996).
The leadership behaviors were categorized according to the three functional domains in order to obtain leadership profiles. These leader behaviors were developed by Yukl (1997) and consisted of a comprehensive classification of effective leader and manager behavior. The four general categories within this taxonomy are decision making, information giving-seeking, influencing people, and building relationships. Information giving-seeking information consists of informing, clarifying, and monitoring behaviors. Making decisions consists of planning, problem solving, consulting, and delegating. Influencingpeople consists of rewarding, recognizing, and motivating and inspiring behavior. Building relationships consists of networking, team building and conflict management, developing and mentoring, and supporting behaviors.
Based on the above conceptual framework, the following research questions were developed:
- What are the leadership behaviors of senior nurse executives located in four different acute care hospitals?
- What is the leadership profile for these executives?
- To what degree does the stratified systems theory conceptual framework assist in understanding and interpreting senior nurse executive behavior and profile?
The methodology for this research study was based on Yin's case study method (Yin, 1994). The theory to be developed was Jaques' stratified system's theory (Jaques, 1976; Jaques, 1985), the selected cases were senior nurse executives, and the data collection was accomplished through interviews, job descriptions, and self-surveys. The four case studies comprised the non-governmental not-for-profit senior nurse executive, the non-governmental for-profit senior nurse executive, the government federal senior nurse executive, and the government state senior nurse executive. Interviews, job descriptions, and self-surveys were transcribed and reviewed. Each case, as well as between cases were compared, and finally, all were compared to the theory to develop implications. Several tactics (Table 1) to establish the quality of this case study research were used (Yin, 1994).
Note: Construct validity, reliability, and external validity are quantitative research terms used by Yin (1994) to apply quality and rigor to qualitative case study research. Credibility, dependability and applicability are substitution terms proposed by Ross (1996) and Lincoln and Guba (1985) because they are deemed more appropriate to qualitative research.
The cases for this study were selected from one of the four American Hospital Association classifications of acute healthcare hospital (1997a). The study, therefore, had a senior nurse executive from each one of the following categories: For Profit (FP), Not For Profit (NFP), Governmental-Federal (GF), and Governmental-State (GS). In order to ensure a high degree of organizational complexity, these senior nurse executives had to hold a position in the acute healthcare hospital that had a minimum capacity of 100 beds, and each senior nurse executive had to be responsible for at least 100 personnel. Lastly, each executive held a position in a hierarchical structure in which the senior nurse executive was part of the top management team. These criteria were chosen to deliberately select nurse executives operating in fast-paced, complex, and changing environments in which they have a large employee responsibility. The large hospital size and turbulent environment increases the complexity of the leadership processes required to deal with this environment theoretically requiring them to exhibit higher level strategic leadership processes. No health care setting has provided a more visible and crucial nurse executive role than the acute care hospital (Vestal, 1995), therefore, acute care hospitals and not chronic care facilities were selected.
Given the above criteria, a member of a regional board of directors for the American Organization of Nurse Executives was contacted to assist in identifying potential participants. As a key informant, this nurse executive had an extensive knowledge of the senior nurse executives in this region. A case study protocol was then developed and followed to standardized the data collection process and ensure the quality of this case study design. It consisted of a standardized process for contacting each executive, giving them information, securing their informed consent, and ensuring their anonymity.
Taped interviews were conducted in the private office of each senior nurse executive and lasted 1-11/2 hours. Each interview consisted of six open-ended questions with predetermined sequence and wording structured to expose all senior nurse executives to a nearly identical experience. The interview format, however, was flexible enough to help each senior nurse executive express their perceptions of their leadership experiences in their own terms. A pilot test of the interview questions was conducted prior to data collection. Each interview was subsequently transcribed verbatim by the researcher and sent to the participants for review to ensure accuracy and anonymity. Their job descriptions were obtained along with a self-perception survey in which they were asked to estimate the percentage of time they spent at the strategic, organizational, or production level. Data management was assisted through the use of NUD*IST (Non-numerical Unstructured Data Indexing, Searching, and Theorizing) software (1997b). Two index coding trees were constructed using the domains of the stratified systems theory(1997a) and the taxonomy of effective leadership behaviors (Yukl, 1997). All interviews and job descriptions were coded using these index trees (See Figure1 on the next page).
Figure 1. Two NUD*IST coding indexes used to develop the leadership profiles of senior nurse executives. Document coding was accomplished by storing references to text units according to these classification categories. The text unit used was a sentence determined during transcription by the researcher.
The inter-rater reliability on the coding process was .83. Leadership profiles were developed for each executive and the executives as a group by looking at the frequency of leadership behaviours occurring in each domain. These reported behaviours in the interview were, in turn, compared with their position's specific requirements in their job description and each executive's self-perception as reported in the survey.
The characteristics of the selected nurse executive sample included two nurse executives in their 40s and two in their 50s. Three executives were European-American and one was African-American. All executives were female. Three were married and one was widowed. Of the four executives, all had master's degrees outside their discipline. As a group, these nurse executives were very experienced (Figure 2).
Figure 2. (See top of next column) Nursing experience of the senior nurse executives interviewed in this study. Abbreviations in the legend are as follows: GS is the senior nurse executive from the government federal category of acute health care hospital; NFP is the senior nurse executive from then ot-for-profit hospital; FP is the senior nurse executive from the for-profit hospital; and GF is the senior nurse executive from the government-feseral hospital.
The Group Leadership Profiles
As a group, the most frequent leadership behaviours of senior nurse executives in four different acute care hospitals were in the strategic domain. Twenty-nine percent occurred in the organizational domain and 4% occurred in the production domain. This pattern was substantiated for the executives as a group as well as for each individual executive (Figure 3).
Figure 3. Frequencies of self-reported activities by senior nurse executives as a group categorized by stratified systems domains. The percentages do not add up to one hundred since not all interviewees' responses fit the categories and therefore not coded.
The predominant self-reported leadership behavious was decision making followed by building relationships, information giving/seeking, and influencing people. These executives self-reported decision making in conjunction with building relationships for about 40% of their time (Figure 4 on next page).
Figure 4. Frequencies of self-reported activities by senior nurse executives as a group categorized by leadership behaviors. The percentages do not add up to one hundred since not all interviewees' responses fit the categories and therefore not coded.
The frequencies of leadership behaviors at each domain constitute the group leadership profile. There was a consistent frequency pattern across the strategic and organizational domains, but it was not seen at the production level. Decision-making was the primary activity in the strategic and organizational domains followed in lesser frequency by building relationships, then information giving/seeking. At the production domain, information giving/seeking was the primary activity followed by building relationships and influencing people with decision-making the least reported (Figure 5).
Figure 5. Leadership profile of the senior nurse executives as a group. Leadership profiles are the frequencies of leader behaviors reported by stratified system domain categories. The percentages do not add up to one hundred since not all interviewees' responses fit the categories and therefore not coded.
When the individual profiles were examined, the patterns were reflective of the group as a whole (Figure 4) with the following exceptions. The, Government Federal senior nurse executive reported building relationships instead of decision making as her predominant leadership behavior at the strategic domain. At the organizational domain, two of the four executives exhibited this stair-step pattern.
The Government Federal and Government State senior nurse executives, did not have decision making as their predominant leadership behavior. The Government State senior nurse executive reported information giving/seeking as her predominant leader behavior followed by building relationships and decision making at comparable frequencies. Whereas, the Government Federal executive reported her second most frequently occurring leadership behavior as information giving/seeking instead of building relationships. At the production level, the stair-step pattern was not visible. Each senior nurse executive had a uniquely different pattern of leadership behavior.
The profile which follows on the next page (Figure 6) represents what these senior nurse executives reported as their leadership behavior or what they say they do as executives, but what are the expectations of the organization? In order to answer this question, each one's job description was coded using the same methodology with the results depicted in Figure 7. Clearly the organization expected less strategic work and more organizational domain work that these executives were self-reporting.
Figure 6. (Top of next page) Leadership profile of the individual senior nurse executives. Leadership profiles consist of the frequencies of leader behaviors reported by stratified system domain categories. The percentages do not add up to one hundred since not all interviewees' responses fit the categories and therefore not coded.
Figure 7. (See Below) Comparison of senior nurse executive frequency of stratified systems theory domain activities between their interview and their job descriptions.
In general, the senior nurse executives performed higher at the strategic level than what the organizations expected. In contrast, they performed lower at the organizational level than what the organization expected. At the production level there was a good match between reported performance and organizational expectations.
The third comparison point was what did the executives perceive their primary leadership activities to be When comparing each senior nurse executive's individual self-perceptions with their self-reported behaviors, there was a mismatch at the strategic and organizational domain, but there was a good match at the production domain. The For Profit senior nurse executive's self-perception was comparable at all domains. The Government Federal and Government State executives perceived themselves as spending more time at the strategic domain than they reported in their interviews, whereas the Not For Profit executive perceived herself as spending less time at the strategic domain than she reported in her interview. Senior nurse executives were then ranked according to the frequencies of self-reported leadership behaviors in the strategic domain (Figure 8, See below).
Figure 8. Senior nurse executives ranked by the frequency of their stratified systems theory domains with each other.
The executive with the highest frequency of leadership behaviors in the strategic domain was the Not For Profit executive. Her corresponding leadershipbehaviors at the organizational and production levels were ranked last. Since this executive held the highest position in the top management team of one of the two largest acute healthcare organizations concomitant with personnel responsibility, she should, according to the stratified systems theory, and did exhibit the highest frequency of leader behaviors in the strategic domain with lesser activity at the two lower levels. In terms of her leadership behaviors, she had the highest frequency of decision-making that she described as, " a broader planning." "You have to devote the time and have a rigorous process to evaluate some of these decisions." "It's assimilation of data and complex critical thinking, critical thinking is a big deal." "It's careful attention to what is our core service, and it's paying attention to what are community issues." "Its related to the connectedness, the compassion, the way you provide the services as well as the actual services provided that had got to be part of it." "You collect the people that best understand that and you make the best decision for what you know, but you have some discipline and rigor of your analysis and thinking." "You manage everything you can man sis and thinking." "You manage everything you can manage, then you stay fluid for what comes with the next change."
The Government State executive had the second highest frequency of leadership behaviors in all of the domains. This senior nurse executive had extensive nursing and administrative experience. She had been in her current position three times longer than any of the executives and had over 20 years in nursing administration. Her healthcare organization was one of the largest with a bed capacity of over four hundred. Consequently, the number of personnel for whom she was responsible exceeded one thousand. The leadership behaviors used by this executive were information giving/seeking, decision-making, and building relationship at comparable frequency. She gave and sought information at a greater frequency in the organizational and production level that at the strategic level. Since she was one of the most experienced administrators with the longest time in her current position, this pattern of information giving/seeking behavior may, again, be related to an experienced administrator with an extensive historical knowledge of the organization and the healthcare environment. Her information seeking was to determine issues on patient dissatisfaction to "see trends or patterns of incidences in things that are happening." Her primary focus was on people issues and "what's important to the patients." She did this primarily by listening to community groups, getting feedback through the risk management process, patient surveys, and patient feedback. Her primary reasons for seeking information was to "learn some things and use some money and deal with it [patient dissatisfaction issues] differently, to pinpoint in terms of where you want to go, to determine community and cultural differences, and to determine systems that don't work." "Just keep your ears open to kind ofget a sense." In terms of information giving behaviors, her primary reason was "as a mechanism to establish norms and internal accountability." "I just keep saying it over and over again."
The For Profit executive was ranked third in frequency of leadership behaviors in the strategic domain, first in the organizational domain, and third in the production domain. This executive was the youngest of the group, had been in her current position for less than two years, and her healthcare organization was the smallest.
The Government Federal executive ranked last in the strategic domain, third in the organizational domain, and first in the production domain. The reason for this style was found in the interview text of this executive. . "I transitioned to another level." "My staff is very skilled at policy development now so I do a lot of reviewing of policies rather than doing the policies." She preferred to be involved with her consumers of healthcare. She had extensive involvement in the beneficiaries using her healthcare organization, where as the other SNEs involvement centered on work performance improvement activities with employees. This executive gave information to the patient population eligible for care so they would be knowledgeable about their health benefits. She was directly involved in sending letters and being an advocate for the patients. "Lots of people ...will often call me and people will send folks to me." "I love to talk to [them]..you get to listen to their stories and it's just a remarkable kind of thing." Her style was similar to the medical model in that she was involved in clinical practice along with the administrative responsibilities of her position.
Implications and Recommendations
The stratified systems theory was used as the conceptual framework of this study, but it does not totally account for the differences in the leadership profiles of the four senior nurse executives. Therefore, there must be other things that are causing the differences in the profiles. One of the ways to study these differences may be to study the leadership profiles found in all three levels in the same hierarchical organization. Another approach would be to develop leadership profiles in organizations that are not involved in health care, for example, organizations involved in business or manufacturing. Developing leadership profiles in a wide range of hierarchical organizations and in different levels within one organization would give a comparative basis upon which invaluable patterns and themes of leadership might emerge.
Other areas of study would be to see how the CEO and their subordinates relate these leadership profiles to the perceived effectiveness of the executive. Is there a leadership profile that is more effective in the strategic domain, the organizational domain, or the production domain? If so, can these principles be incorporated into the performance evaluation of organizational leaders? Is there a profile pattern for executives across disciplines? Does each discipline have a requisite profile necessitated by their uniqueness? What do our training programs, on the job experiences, and continuing education teach? Do they teach to the leadership behaviors as indicated in the profiles?
The main implication of this study lies in the development of future leaders and managers. These leadership profiles can be incorporated in leadership education and training programs or any curriculum designed to prepare nursing leaders for executive level positions. Current leaders can use them to analyze their leadership patterns and also the profiles of their immediate supervisors. Communicating this new understanding could help to better prepare Senior Nurse Executives for the complexities of leadership in healthcare hierarchies. Perhaps by teaching leaders that there are qualitative differences in leadership behaviors as they move up the hierarchy, they can be better prepared for the transition to higher level positions in their organization's hierarchy. Sometimes, just an awareness of the behaviors in the different domains can lead to reflection and insights on leadership, which ultimately adds to the value of their organization. In this time of resource efficiency and constraint, discussions of the appropriateness of leadership behaviors for senior nurse executive would be an interesting dialogue.
Another implication is that the job descriptions of these leadership positions should match the frequency of reported leader behaviors in their respective domains. It could be that the job as experienced determines the level of work instead of the written job description. If these are not in congruence, is the job description inaccurate, or the leader not performing up to the organization's expectations? How are job descriptions written and do they accurately represent the needs of the organization and reflect the work required of the executive in that position? If their performance evaluation is based on the written job descriptions, then the expectations of the organization should be congruent with the leader's performance. If this is not the case, the tension created in a leader may ultimately lead to failure and loss of a valuable organizational resource. Therefore, careful attention should be given to the currency of the written job descriptions. They should accurately depict the organization's expectations of their leaders and subsequently rate their organizational value based on an accurate assessment of the organizational requirements. In summary, this study generated leadership profiles for senior nurse executives in acute care hierarchical healthcare organizations. In turn, these profiles were compared for cross case patterns and themes.
This study helped to fill a gap in the existing literature by assuming a phenomenological paradigm to better understand leader behaviors at qualitatively different domains. Even though all of the study's research questions were answered, it certainly generated thoughts and future challenges for researchers.
About the Author
Eileen A. Hemman, EdD, RN, Colonel, is Army Nurse Corps Director, Hospital Education Department at the Dwight David Eisenhower Army Medical Center, Ft. Gordon, Georgia.
AcknowledgmentThe views expressed in this article are those of the author and do not reflect the official policy or position of the Department of the Army, the Department of Defense or the U.S. goverment.
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