May, 2015 - SUPPORT Summary of a systematic review | print this article |

Do educational interventions for nurses help to improve leadership skills, behaviour and practice?

Leadership is a key factor in shaping improvements in complex healthcare organisations and therefore managers and health professionals need to improve their leadership skills continually. Nurses play an important role in improving healthcare quality and safety. Educational interventions to foster or improve their leadership skills are therefore of interest.

Key messages

It is uncertain whether educational interventions to promote leadership in nurses help to improve their leadership skills, practices and behaviour within their organisations
No studies were found that evaluated the impact of educational interventions to foster leadership in nurses on the quality and safety of health care in their organisations

Who is this summary for?

People making decisions concerning the training of leaders in nursing to improve quality and safety in health care organizations.

This summary includes:

Key findings from research based on a systematic review
Considerations about the relevance of this research for low income countries

Not included:

Recommendations
Additional evidence not included in the systematic review
Detailed descriptions of interventions or their implementation

This summary is based on the following systematic review:

Cummings G, et al. Factors Contributing to nursing leadership: a systematic review .

J Health Serv Res Policy. 2008

Oct;13(4):240-8

What is a systematic review?

A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.

SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.

Glossary of terms used in this report

Background references on this topic

Background

Leadership is defined as a process whereby an individual influences a group of people to achieve a common goal. Clear, strong leadership is important for quality and safety improvements in healthcare organisations. There is a need to engage clinicians, nurses and other healthcare workers in leadership tasks, to recognise the importance of their leadership roles, and to find ways to improve leadership skills.

Nurses play a key role in the complex demands of health care within organisations. Educational interventions to improve their leadership skills, behaviours and practices are therefore of interest.

How this summary was prepared

After searching widely for systematic reviews that can help inform decisions about health systems, we have selected ones that provide information that is relevant to low-income countries. The methods used to assess the reliability of the review and to make judgements about its relevance are described here

Knowing what’s not known is important

A reliable review might not find any studies from low-income countries or might not find any well-designed studies. Although that is disappointing, it is important to know what is not known as well as what is known.

A lack of evidence does not mean a lack of effects. It means the effects are uncertain. When there is a lack of evidence, consideration should be given to monitoring and evaluating the effects of intervention, if it is used.

About the systematic review underlying this summary

Type of	What the review authors searched for	What the review authors found
Review objectives: To examine the factors that contribute to nursing leadership and the effectivennes of educational interventions in developing leadership behaviours in nurses
Study designs & interventions	Any experimental study evaluating educational activities (e.g leadership development programmes). The authors also searched for non-intervention studies (these are not included in this summary).	9 pre- and post-intervention studies on educational activities to develop leadership skills, behaviours and practices.
Participants	Nurses working in healthcare organisations.	Nurses working in the same hospital (6), nurses from different settings attending a course and leadership (3).
Settings	Any setting	Hospitals (6), educational institutions on leadership (3), United States of America (USA)(5), United Kingdom (UK (2), Canada (1) and Australia (1).
Outcomes	Any outcome associated with nursing leadership	Leadership skills, competencies and behaviours, measured through several questionnaires (9), job satisfaction (1).
Date of most recent search: December 2006
Limitations: This is a well-conducted systematic review with only minor limitations. However it has not been update since 2006
Cummings G, Lee H, Macgregor T, Davery M, Wong C, Paul L, Stafford E. Factors contributing to nursing leadership: a systematic review. J Health Serv Res Policy 2008 Oct;13(4):240-8

Cummings G, et al. Factors Contributing to nursing leadership: a systematic review .

J Health Serv Res Policy. 2008

Oct;13(4):240-8

About the certainty of the  evidence (GRADE)

High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.

Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.

Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.

Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.

* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.

† Substantially different = a large enough difference that it might affect a decision.

See last page for more information.

Summary of findings

This review identified 24 studies, of which 9 were evaluations of the effects of educational interventions to improve leadership skills in nurses. Six were conducted in healthcare organisations (mostly hospitals) and three in educational institutions.

All the studies were conducted in high-income countries (USA, UK, Canada, and Australia). Educational interventions of this kind may influence outcomes in multiple domains and may lead to additional changes in the performance of nurses. However, this review focused specifically on impacts of such interventions on leadership skills, competences and behaviours.

It is uncertain whether educational interventions to increase leadership in nurses improve their leadership skills, practices and behaviours in their healthcare organisations. The certainty of this evidence is very low.
No studies were found that evaluated the impact of educational interventions to foster leadership in nurses on the quality and safety of healthcare in their organisations.

Educational interventions to increase leadership skills, behaviours and practices in nurses
People: Nurses Settings: Healthcare organisations Intervention: Educational interventions to increase leadership skills, behaviours and practices Comparison: No educational intervention
Outcomes	Impact	Certainty of the evidence (GRADE)
Leadership skills, behaviours and practices	All but one of the 9 studies recorded an increase in leadership behaviour or practices. Most studies used self-reporting instead of an objective measure of leadership behaviours and practices. Few studies measured such behaviours in the context of the healthcare organisation of the participants.
Quality and safety improvement	No studies were found that evaluated the impact of educational leadership interventions on quality and safety improvements in the healthcare organisations in which the participants worked.
GRADE: GRADE Working Group grades of evidence (see above and last page)

Relevance of the review for low-income countries

Findings	Interpretation*
APPLICABILITY
The review identified 9 studies evaluating educational interventions to increase leadership skills, behaviours and practices in nurses. It is uncertain whether leadership education improves the leadership skills, behaviours and practices of nurses. This is because the certainty of the evidence is very low. It is uncertain whether leadership education improves the leadership skills, behaviours and practices of nurses. This is because the certainty of the evidence is very low. No studies were found that evaluated the impact of leadership education in quality and safety improvement outcomes.	All studies were conducted in high-income countries. We are very uncertain if such interventions may have different effects in low-income country settings. The importance of leadership education in health care is usually recognised in high-income countries, even though the certainty of the available evidence is low. However, the relative importance of leadership education, especially within the public sector, is not as well established in many low-income countries.
EQUITY
This review did not address equity issues.	Healthcare organisations which have strong leaders often have more influence when seeking and obtaining resources. This may result in a widening gap in resource allocation between organisations if leadership skill levels vary. Equity considerations may vary when selecting leaders in different social settings, particularly if societies are hierarchical and have divisions based on gender, religion, ethnicity, education and socioeconomic status.
ECONOMIC CONSIDERATIONS
The review did not provide data about the cost or cost-effectiveness of interventions	It is important to consider other potential effects of interventions designed to increase leadership skills (trained leaders, for example, might expect better remuneration or ask for innovative solutions for the organisations they work in). The long-term organisational commitment of staff must be taken into account. Nurse leaders need time to engage other workers (e.g. doctors), recognise the contribution of other leaders, and bring about change. Training in leadership may result in greater career mobility. It is very important to understand the benefits and disadvantages of interventions designed to improve or raise leadership skills. This facilitates an understanding of the cost effectiveness of such interventions and enables a comparison with other interventions for improving the quality and safety of healthcare organisations.
MONITORING & EVALUATION
The majority of the included studies only evaluated leadership skills and used methodological approaches from non-health leadership literature. Self-reporting was used as the only measuring instrument in many studies. No studies were found that evaluated the impact of educational leadership on quality and safety improvements or other health care outcomes.	There is a lack of consensus about the best way to measure leadership skills, especially in the inherently complex world of health care. Methodologies attuned to the particular complexities of healthcare organisations are therefore needed. The measurement of leadership skills and their potential effects is complex and methodologies such as self-reporting may be insufficiently sensitive and specific. Other more objective methodological approaches may provide more accurate measurements of leadership skills, practices and behaviours. Interventions to improve leadership skills may be resource intensive and may have unexpected consequences. Monitoring and evaluation are therefore important.
		*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see:	www.supportsummaries.org/methods

Additional information

Related literature

Øvretveit J. Leading improvement. Journal of Health Organization and Management 2005; 19:413-30.

Wong CA, Cummings GG. The relationship between nursing leadership and patient outcomes: a systematic review. J Nurs Manag. 2007 Jul;15(5):508-21.

Cummings GG, MacGregor T, Davey M, Lee H, Wong CA, Lo E, Muise M, Stafford E. Leadership styles and outcome patterns for the nursing workforce and work environment: a systematic review. Int J Nurs Stud. 2010 Mar;47(3):363-85.

Kuoppala J, Lamminpää A, Liira J, Vainio H. Leadership, job well-being, and health effects - a systematic review and a meta-analysis. J Occup Environ Med. 2008 Aug;50(8):904-15.

This summary was prepared by

Gabriel Rada, Unit for Health Policy and Systems Research, School of Medicine, Pontificia Universidad Católica de Chile, Chile

Conflict of interest

None declared. For details, see: www.supportsummaries.org/coi

Acknowledgements

This summary has been peer reviewed by: Greta Cummings, Canada; David Yondo, Cameroon

This review should be cited as

Cummings G, et al. Factors contributing to nursing leadership: a systematic review.

J Health Serv Res Policy. 2008 Oct;13(4):240-8.

The summary should be cited as

Rada G. Do educational interventions for nurses help to improve leadership skills, behaviour and practice? A SUPPORT Summary of a systematic review. May 2015. www.supportsummaries.org

This summary was prepared with additional support from:

The Health Policy and Systems Research Unit (Unidad de Investigación en Políticas y Sistemas de Salud- UnIPSS) is a Chilean research collaboration for the generation, dissemination and synthesis of relevant knowledge about health policy and systems based at the School of Medicine of the P. Universidad Católica de Chile

About certainty of evidence (GRADE)

The “certainty of the evidence” is an assessment of how good an indication the research provides of the likely effect, i.e. the likelihood that the effect will be substantially different from what the research found. By “substantially different” we mean a large enough difference that it might affect a decision. These judgements are made using the GRADE system, and are provided for each outcome. The judgements are based on the study design (randomised trials versus observational studies), factors that reduce the certainty (risk of bias, inconsistency, indirectness, imprecision, and publication bias) and factors that increase the certainty (a large effect, a dose response relationship, and plausible confounding). For each outcome, the certainty of the evidence is rated as high, moderate, low or very low using the definitions on page 3.

For more information about GRADE

SUPPORT collaborators:

The Cochrane Effective Practice and Organisation of Care Group (EPOC) is part of the Cochrane Collaboration. The Norwegian EPOC satellite supports the production of Cochrane reviews relevant to health systems in low- and middle-income countries . www.epocoslo.cochrane.org

The Evidence-Informed Policy Network (EVIPNet) is an initiative to promote the use of health research in policymaking in low- and middle-income countries. www.evipnet.org

The Alliance for Health Policy and Systems Research (HPSR) is an international collaboration that promotes the generation and use of health policy and systems research in low- and middle-income countries. www.who.int/alliance-hpsr

Norad, the Norwegian Agency for Development Cooperation, supports the Norwegian EPOC satellite and the production of SUPPORT Summaries. www.norad.no

The Effective Health Care Research Consortium is an international partnership that prepares Cochrane reviews relevant to low-income countries. www.evidence4health.org

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