PROFESSIONAL DEVELOPMENT OF NURSING LEADERS: A CASE STUDY OF CANADIAN NURSES ASSOCIATION PRESIDENTS by Laura Jane Colley BScN, University of British Columbia, 1994 A THESIS SUBMITTED IN PARTIAL REQUIREMENT FOR THE FULFILLMENT OF THE DEGREE OF MASTER OF SCIENCE IN NURSING in FACULTY OF GRADUATE STUDIES We accept this as confirming to the required standard Dr. Maggie Theron, Supervisor Dr. Sonya Grypma, Supervisor Dr. Sonia Udod, 3rd Reader TRINITY WESTERN UNIVERSITY MARCH 2017 Nursing Leadership Development ii Abstract Nursing leadership is important in every domain of nursing. However, nursing leadership development is not well understood or documented. This study addresses this gap by turning to an overlooked source of leadership knowledge: presidents of the Canadian Nurses Association (CNA). The CNA has had exceptional leaders during its 108-year history. Many have influenced nursing practice, changed the perception of nursing, and improved healthcare. Yet, little is known about how they became such outstanding leaders. Using a qualitative design, this study aims to inspire and inform current and future nurses by exploring the experiences and leadership journeys of CNA presidents. Altogether, seven nurses who have held the title of president of the CNA were interviewed, either face to face or by Skype. These interviews focused on their personal experiences and perspectives about their leadership journey. Their definitions, philosophies, and motivations for pursuing this particular leadership role were also explored. Through interpretive description methodology the following six themes were identified: Relentless Incrementalism; Embracing Opportunities, , A Service Mindset, Taking the Long View, Enduring Heartbreak, and Taking a Seat at the Table. By providing a deeper understanding of the motivation and experiences of CNA presidents, the findings of this study not only provide insight into the practice wisdom of those who have gone before, they also provide a resource for the development of nursing leaders today. Nursing Leadership Development iii Acknowledgements Throughout my life I have been blessed by opportunities to learn and grow. These opportunities have been provided by my gracious Heavenly Father and Lord Jesus Christ who have placed me in this time and in this place for such a time as this. I am grateful for His presence, His care and His strength for this journey. I would like to acknowledge and thank my supervisory committee, Dr. Magdalena Theron and Dr. Sonya Grypma, who have provided me with support, encouragement, feedback and enthusiasm throughout this process. You were both readily available when I needed guidance and worked tirelessly to help me finish well. This project would not be complete without you. I would also like to acknowledge my friends and family who have sustained me throughout the Master’s program. Specifically, during this project, you have provided meals, encouragement, prayers, support and celebration. Your love and support will never be forgotten. Dedication To my amazing mother who has endured an ever changing world with courage and a thirst for knowledge. Her encouragement and steadfast presence in my life have allowed me to pursue opportunities I never thought possible. In recognition of who you are and all you have done, I dedicate this work to you. Nursing Leadership Development iv Table of Contents Abstract ii Acknowledgements and Dedication iii Chapter 1: Introduction and Background 1 Background 2 Definition 4 Purpose and Objectives 5 Research Design 5 Overview of Thesis 5 Chapter 2: Literature Review 7 Canadian Nurses Association 7 Leadership Theories 8 Transformational leadership 9 Servant leadership 11 Authentic leadership 13 Complexity theory 14 Leadership Versus Management 16 What Is Leadership? 18 All Nurses as Leaders 19 The Need for Nursing Leadership 20 Gap in the Literature 22 Summary 26 Nursing Leadership Development Chapter 3: Research Design, Method, and Procedures v 28 Research Design and Method 28 Interpretive Description 28 Sampling and Recruitment 30 Participants 31 Data Collection 32 Data Analysis and Interpretive Description 33 Ethical Considerations 34 Credibility and Qualitative Research 35 Auditability 35 Reflexivity 35 Credibility and Interpretive Description 36 Analytic logic 36 Interpretive authority 37 Disciplinary relevance 37 Contextual awareness 37 Summary Chapter 4: Findings 38 39 Relentless Incrementalism 40 Embracing Opportunities 44 Forged Opportunities 44 Obligatory Opportunities 47 Unexpected Opportunities 49 Nursing Leadership Development Opportunities Lost A Service Mindset vi 51 53 Service as Philosophy 53 Service as Embodiment 55 Taking the Long View 57 Receiving Mentorship 57 Extending Mentorship 59 Promoting Nursing 61 Promoting Nurses 63 Enduring Heartbreak 64 Taking a Seat at the Table 67 Summary 71 Chapter 5: Discussion 72 Relentless Incrementalism: Pursuing a Vision 72 Embracing Opportunities: Opportunities Are the Paths to Success 77 Taking the Long View 84 Mentorship 84 Promoting nurses and the nursing profession 87 The Heartbreak of Horizontal Violence 90 A Service Mindset: An Expression of Authenticity 92 A Seat at the Table: Inspired by the Past, Empowered for the Future 95 Summary 96 Chapter 6: Limitations, Implications, and Recommendations 97 Nursing Leadership Development vii Summary of the Study 97 Limitations 98 Implications for Nursing Research 99 Implications for Nursing Education 100 Implications for Nursing Practice 101 Summary 102 References 104 Appendix A: Literature Search 113 Appendix B: Letter of Invitation 115 Appendix C: Consent 117 Appendix D: Interview Questions 122 Nursing Leadership Development 1 Chapter 1: Introduction and Background Florence Nightingale once said, “Were there none who were discontented with what they have, the world would never reach for anything better” (“Florence Nightingale Quotes,” n.d.). Discontent likely motivated Nightingale to take on the task of leading 37 nurses to Turkey to care for soldiers during the Crimean war. Her strength as a leader led to the birth of modern nursing. Since that pivotal event in 1854, many nurses have become leaders throughout the world. These men and women have shaped the lives of nurses, patients, and healthcare systems around the globe, including in Canada. There is no doubt that leadership is essential to the success of any profession including nursing. Yet, what does it mean to be a leader? Copious amounts of literature have been produced over the decades about great leaders and why they were considered great. Yet there is very little about how those leaders became great and what motivated them to pursue leadership. What was their path? What did their journey look like? Why did they pursue that path? Herminia Ibarra (2015) stated in her book Act Like a Leader, Think Like a Leader, Researchers all too often identify high-performing leaders, innovative leaders, or authentic leaders and then set out to study who these leaders are or what they do. Inevitably, the researchers discover that effective leaders are highly self-aware, purposedriven, and authentic. But with little insight on how the leaders became that way, the research falls short of providing realistic guidance for our own personal journeys. (p. 3) Because we have discovered more about who leaders are while holding a positional role of leadership, we have room to explore the journey to leadership as a valuable resource for the professional development of current and future leaders. Nursing Leadership Development 2 Background In June 2015 I had the privilege to attend the Canadian Nurses Association (CNA) annual general meeting in Ottawa, Ontario, as a voting delegate for the Association of Registered Nurses of British Columbia. One portion of the meeting was dedicated to the memory of Verna Huffman Splane, who had died earlier in the year at age 100. Her accomplishments as a nursing leader were vast and inspiring. From her multiple roles within the World Health Organization, to her position as the first chief nursing officer of Canada, to her long career as a professor at the University of British Columbia, she was a high-level nursing leader who was positively influential. Throughout the memorial I found myself asking, “How does someone become a leader like this woman? Did she pursue specific opportunities? Is this type of transformational leadership intrinsic or can it be developed? What trajectory did she take to become a leader? Did she make specific decisions that led her down this path? Were there particular influences along the way?” Surveying the room, I noticed a number of inspiring nursing leaders, many of whom had served as presidents of the CNA. All of these women and men had a story about their journey to the helm of the national organization of nurses, which represents almost 400,000 registered nurses (RNs) nationally. They also had stories about their personal development as leaders, whether in title or in presence. Perhaps the former, current, and future (president-elect) presidents of the CNA would be able to answer some of the questions going through my mind regarding how to develop as a nursing leader, which could ultimately provide direction to current nursing concerns and impact patient health issues. As I began to delve into the topic of nursing leadership development, it became clear that this subject had not been well explored. Overall, the expansive theme of leadership is Nursing Leadership Development 3 unquestionably an area of interest. A preliminary search on an online bookstore, using leadership as a keyword, returned over 52,000 books. The abundance of available literature on the broad topic of leadership decreased to 1,028 results when the keyword search was refined to nursing leadership. Further, the journal database CINAHL Complete returned 38,000 articles when using the keyword leadership. This decreased to 13,500 articles when nursing leadership was used. Clearly, leadership is a topic of interest in a broad sense, as well as in a specific sense, in relation to nursing. Nursing leadership as a subset of the broad category has much literature dedicated to it with an emphasis on what nursing leaders are like but little specifically about the leadership development journeys of CNA presidents as they represent high-level leaders in the nursing profession. There is even less information about how nursing leadership skills are passed on from one CNA president to the next. Yet, nursing leadership is considered to be important in the success of nursing, nurses, and the healthcare system. The organization that stands out in regard to nursing leadership is the CNA. Leadership is important to the CNA, as seen in the position statement on nursing leadership released in 2009. This position statement defines nursing leadership and emphasizes that it is needed in every domain of nursing from the bedside to the boardroom. An emphasis is placed on leadership as a characteristic of an individual rather than the position or title that individual holds and stresses that leadership must be passed on from one leader to another: “Leadership does not just ‘happen’ nor is it sustained without intense, ongoing support. Leadership exists as a continuum that evolves and is strengthened from a combination of innate and learned skills that must be groomed” (CNA, 2009, p. 2). Nursing Leadership Development 4 The CNA published a clear statement about nursing leadership emphasizing its importance. Yet, the presidents of that association remain an untapped resource of knowledge and wisdom about nursing leadership development. What could be learned from the individuals who had served as president of this national organization? Could this information be valuable to nurses? The primary question explored in this study was the following: How can an exploration of the leadership journeys of CNA presidents provide insight into the practice wisdom of those who have gone before and serve as a resource for nursing leadership development across the domains of the profession? Related subquestions included the following: a. How do CNA presidents describe their own development and function as leaders? b. What is the philosophy of leadership of each CNA president? How has that developed over time? c. What advice would CNA presidents give to future nursing leaders? Definition Leadership, in a broad sense, is defined as “the office or position of a leader; the capacity to lead; the act or an instance of leading” (“Leadership,” n.d.). A leader is defined as “a person who directs a military force or unit; a person who has a commanding authority or influence” (“Leader,” n.d.). These definitions are just the beginning of how people describe leadership and leaders. Yet, for the purpose of this project I have drawn from Yoder-Wise (2015), Grossman and Valiga (2013), Bennis (2009), and Yukl (2012) to define leadership as follows: the process Nursing Leadership Development 5 by which a self-aware, credible and courageous person engages and influences others toward a collective vision and direction for the purpose of achieving measurable goals. Purpose and Objectives The purpose of this study was to provide insight into the nuances of leadership development in nursing through an exploration of the professional experiences, characteristics, and reflections of CNA presidents. This study also explored how being a high-level nursing leader provides a gateway for change. This exploration assisted to broaden the understanding of nursing leadership development and how nursing leadership facilitates change, which serves as a valuable resource for the development of nurses as leaders. Research Design Interpretive Description as a qualitative method was used to interview seven CNA presidents regarding their leadership development journeys. Overview of Thesis In Chapter 1 a foundation is laid about the purpose and significance of this study. In Chapter 2 a literature review provides an analysis of what is already known about the topic of nursing leadership. It includes information pertinent to the research questions and describes search and retrieval methods used to obtain that literature. It also discusses the concepts of leadership and the differences between leadership and management, noting the lack of literature regarding leadership development. In Chapter 3 the interpretive description research design, methods, and procedures are outlined including a detailing of the sampling procedures and ethical considerations. Scientific quality, validity, and reliability and limitations are also included. In Chapter 4 findings are presented as six themes. In Chapter 5 the findings are discussed as to how or whether they relate to current literature on leadership. The final chapter, Nursing Leadership Development Chapter 6, outlines limitations and implications, including recommendations for nursing research, nursing education, and nursing practice. 6 Nursing Leadership Development 7 Chapter 2: Literature Review There is an abundance of literature about nursing leadership. This chapter presents a review of that literature including an overview of the CNA and leadership theories and a discussion of leadership versus management. The question “What is leadership development?” is explored, along with the notion of “all nurses as leaders” and the need for nursing leadership. A literature search was completed using multiple combinations of the search terms nurs*, lead*, profess*, manage, educat*, develop*, and Canada. These search terms were used in CINAHL Complete, Medline, Biomedical Reference, ERIC, and Business Source Complete. Results were received in each database; however, 25 articles for this literature review were chosen from CINAHL Complete and Medline. Literature which focused on nursing leaders in formal leadership positions, as opposed to management, in a Canadian context was the primary focus of the literature review. However, some articles which discussed leadership qualities or development related to nursing management were included, as well as articles from the United States. Articles published within the last ten years were of primary interest, however some sources outside of this parameter were chosen based on significance related to a theory or a concept. Canadian Nurses Association The CNA is “the national professional voice of registered nurses in Canada, advancing the practice of nursing and the profession to improve health outcomes in a publicly funded, notfor-profit health system” (CNA, n.d.) The vision of the CNA is that RNs are “leaders and partners working to advance nursing and health” (CNA, n.d.). The CNA seeks to fulfill the vision and mission by unifying, strengthening, promoting, and advocating the role of the registered nurse for the sake of serving the public interest: “This organization pursues this Nursing Leadership Development 8 through influencing public policy from the RN perspective at federal and provincial levels which then influences healthcare at the local level” (CNA, n.d.). Because the CNA is an organization that promotes nurses as leaders for the purpose of influencing healthcare, a position statement on nursing leadership was released in 2009. This position statement delineated the value of nursing leadership, stating that it “plays a pivotal role in the immediate lives of nurses and it has an impact on the entire health system and the Canadians it serves” (CNA, 2009, p. 1). Therefore, Canada’s health system requires a steady supply of visionary and energetic nursing leaders across the domains of the discipline who are credible, courageous, visible and inspiring to others and who have the authority and resources to support modern, innovative and professional nursing practice. (CNA, 2009, p. 1) The eight-page document outlines the importance of nursing leadership today and in the future related to the continuously changing and challenging climate of Canadian healthcare. The release of this statement nationally highlighted how there is an expected need for nursing leadership as a characteristic and as an office. If Canadian healthcare is to continue to strive to provide equitable and accessible healthcare for all of its citizens, healthcare and healthcare organizations, like the CNA, must be led by individuals who embody credibility, courage, visibility, and inspiration. But how does one become a nursing leader? What can we learn about leadership development from those who have taken up visible national nursing roles? Leadership Theories Grossman and Valiga (2013) discussed the history of leadership theories in the opening chapter of their book The New Leadership Challenge. One of the first leadership theories was the “great man” theory, identified in the 1840s, which focused on being born into the right family Nursing Leadership Development 9 which would ensure an individual inherited the right characteristics. Other historical theories included trait theories and situational theories. Development of leadership theories continued throughout the 20th century and into the 21st century. Contemporary leadership theories consider the person, situation, qualities, and maturity of the individual—that is, leadership is something one develops, not something one is (or is not) born with (Grossman & Valiga, 2013). Transformational, servant, and authentic leadership, along with complexity theory, are important recent theories which illustrate the fluidity of leadership theories and strategies. These theories align with values that are often attributed to the nursing profession such as collaboration and shared responsibility. Transformational leadership. Yoder-Wise (2015) stated that transformational leadership is “based on an inspiring vision that changes the framework of the organization for employees. Employees are encouraged to transcend their own self-interest” (p. 40). This transcendence is achieved by the leader “articulating an inspirational vision; by encouraging novel, innovative thinking” (Yoder-Wise, 2015, p. 40). In a review of leadership styles, Cummings et al. (2010) stated, “transformational leadership motivates others to do more than they originally intended and often more than they thought possible” (p. 364) by being relationally focused and taking each individual follower into consideration. Further, transformational leadership attempts to engage employees emotionally by connecting with their values, which encourages innovation (Yoder-Wise, 2015, p. 40). Leaders who embrace transformational leadership as a practice “are highly effectively leaders, who in turn have highly effective teams and strong group culture” (Bernard, 2014, p. 57). The theory of transformational leadership has been significant for a number of years. In his book PrincipleCentered Leadership, Steven Covey (1992) stated that Nursing Leadership Development 10 the goal of transformational leadership is to transform people and organizations in a literal sense, to change them in mind and heart; enlarge vision, insight, and understanding; clarify purposes; make behavior congruent with beliefs, principles, or values; and bring about changes that are permanent, self-perpetuating, and momentum building. (p. 287) Rolfe (2011) discussed her personal leadership journey, outlining why she embraced transformational leadership as a philosophy. She stated, “TLT’s [transformational leadership theory’s] basic premise is that the leader possesses the skills to develop successful relationships with followers in an environment where both leader and follower strive to meet organizational goals necessary to fulfill the vision” (p. 55). Rolfe’s experience emphasized that transformational leadership was dependent on relationship between the leader and the followers which increased the morale and empowerment of the followers. A commitment to the overall organizational vision was also embraced. Transformational leadership is often equated with positive personal and organizational results. Yoder-Wise (2015) stated that “transformational leadership produces positive outcomes in organizations. It is an effective method for managing a diverse nursing workforce, improving patient outcomes, and inspiring staff to perform beyond expectations” (p. 41). Ferguson (2015) asserted that this is applicable on a global scale as well: “The key to strengthening health systems worldwide is transformational nurse leaders” (p. 353). Finally, Rolfe’s (2011) personal experience with this type of leadership found this to be true: “TLT promotes quality improvement environments where the reciprocal relationship between leader and follower benefits organizations” (p. 56). Nursing Leadership Development 11 An important component of transformational leadership may be the leader themselves. As part of their unique study Spano-Szekely, Quinn Griffin, Clavelle, and Fitzpatrick (2016) explored the positive relationship between emotional intelligence and transformational leadership. The authors purported agreement with the theory of transformational leadership but asserted that it is more effective when the leader is emotionally intelligent and this characteristic may even be an indicator of implementing transformational leadership. “Because the presence of EI [emotional intelligence] appears to be an indicator of TL [transformational leadership], and because this study proves that a positive relationship exists, then studies testing EI as a predictor of TL would be a next logical step” (Spano-Szekely et al., 2016, p. 106). There are also some limitations of transformational leadership which should be considered. In a concept analysis, Fischer (2016) stated that one of the problems with the definition of the theory is that it is defined on the basis of what it does, rather than what it is. For a full understanding of the meaning of the term, it is essential to develop a definition based on the traits and characteristics of the leader, rather than based on the impact on followers. (p.2460) A statement by Yukl (2009) in an article reflecting on leadership theories and research made a similar point: “Transformational leadership involves motivating individuals to do something different than before, or to do more than initially expected. It is an important form of leader influence, but the theory does not clearly explain how leaders can influence collective learning” (p. 50). Servant leadership. Servant leadership is similar to transformational leadership in that there is an importance placed on relationship with followers. The emphasis in this theory is on leaders who seek to serve followers for the purpose of empowering individuals who, in turn, Nursing Leadership Development 12 empower organizations and societies (Sipe & Frick, 2009, p. 179). Servant leadership was first introduced by Robert Greenleaf in 1977 and “simply put, it is the leader’s commitment to serving others that matters most of all” (Sipe & Frick, 2009, p. 1). In the book Seven Pillars of Servant Leadership, Sipe and Frick reinforced Greenleaf’s philosophy. They stated that “a ServantLeader is a person of character who puts people first. He or she is a skilled communicator, a compassionate collaborator, who has foresight, is a systems thinker, and leads with moral authority” (Sipe & Frick, 2009, p. 4). When servant leadership as philosophy is embodied by a leader, powerful results can occur. If leaders are focused on serving the people they lead, the people they lead will begin to serve the clients: If you want your team to serve, serve them; if you want your people to care, care about them; if you want your team to love their work, love them; if you want your employees to be their best, give them your best; if you take care of your people, they will take care of your customers. (Gordon, 2012, p. 40) Jenkins and Stewart (2010) discussed the benefit of orienting new managers and leaders to the servant leadership philosophy for the benefit of the leader and the organization. They stated, “The servant leader is different from other leaders who serve personal or organizational goals in that she first strives to serve others and see that their needs are being met” (p. 48). The authors discussed how this is often perceived as a role reversal but should be understood as role inversion or empowerment of the subordinate rather than the leader. Jenkins and Stuart report that role inversion resulted in increased job satisfaction and, “in the context of nursing, role inversion could be described as allowing the nursing professional the autonomy and role of expert with the nurse manager acting as a facilitator of their (the nurses’) work” (p. 49). Nursing Leadership Development 13 Authentic leadership. Authentic leadership arises from the positive psychology tradition and is attributed to Avolio and Gardner (Yoder-Wise, 2015, p. 11). The central premise of this theory is that “authentic leaders are aware of themselves—authenticity does not involve consideration of others” (Yoder-Wise, 2015, p. 11). Leaders who are aware of themselves and true to their own values, beliefs, and vision will inspire others to follow because the values and beliefs of the leader are congruent with their actions (Yoder-Wise, 2015, p. 11). Walumbwa, Avolio, Gardner, Wernsing, and Pedersen (2008) asserted that “an upswing in highly publicized corporate scandals, management malfeasance, and broader societal challenges facing public and private organizations has contributed to the recent attention placed on authenticity” (p. 90). These authors also stated that this theory goes beyond leaders being aware of themselves. Authenticity leaders display the following traits: When individuals come to know and accept themselves, including their strengths and weaknesses, they display high levels of stable, as opposed to fragile, self-esteem. Such individuals are also relatively free of the defensive biases displayed by less mature persons and consequently more comfortable forming transparent, open, and close relationships with others. Furthermore, they display authentic behavior that reflects consistency between their values, beliefs, and actions. (Walumbwa et al., 2008, p. 93) Authenticity in leadership is a characteristic which resonates with many nurses: “Most nurses long to work with authentic nurse leaders who are genuine, transparent, trustworthy, and inspire excellence” (Murphy, 2015, p. 12). The presence of an authentic leader offers nurses an opportunity to express their ideas and disappointments. In a study examining a correlation between authentic leadership and nurses’ perception on interprofessional collaboration, Regan, Laschinger, and Wong (2016) stated, Nursing Leadership Development 14 Leaders who are authentic operate using “balanced processing” by gathering sufficient opinions and viewpoints from others before making important decisions. They reinforce a level of openness with others (relational transparency) that provides them an opportunity to be forthcoming with their ideas, challenges and opinions (p. E55). Mortier, Vlerick, and Clays (2016) conducted a study measuring whether a correlation existed between authentic leadership and thriving among nurses and found that there was a positive association (p. 362). This positive correlation was thought to be attributed to authentic nurse managers being able “to express more empathy for their nurses, which subsequently influences nurses’ well-being, resulting in more invigorated nurses and more job-related learning among their staff” (Mortier et al., 2016, p. 363). This positive association was also found through a study by Walumbwa et al. (2008), who stated that “followers come to internalize many of the leader’s values and perspectives, including a focus on self-discovery, which in turn facilitates the development of internal guiding points for making effective decisions about their work and subsequently individual follower performance” (p. 113). Walumbwa et al. also found that “the findings that the higher order authentic leadership measure was positively related to a variety of follower outcomes, including supervisor-rated follower performance, suggest that training leaders to be more authentic may provide positive returns on the investment” (p. 121). Complexity theory. The application of this recently developed theory requires us to “think about people and organizations as nonlinear, complex, adaptive systems and respond appropriately” (Grossman & Valiga, 2013, p. 4). The premise is that complexity exists between something static and chaos where order can be predicted and obtained even in a seemingly unpredictable situation. This requires leaders to be able to “live at the edge of chaos and collaborate with others to create new futures” (Grossman & Valiga, 2013, p. 4) Nursing Leadership Development 15 The authors of this theory asserted that nurses and nurse leaders work within complex systems which require flexibility and adaptability. Chadwick (2010) stated, “This concept of complexity science is meant to challenge the status quo; leaders must become comfortable with uncomfortable situations, such as facilitating productive conflict” (p. 157). Further, leaders need to be able to embrace continually changing environments such as healthcare environments. Chadwick (2010) stated, Change is inevitable in any environment, so leaders must seize the change, whatever it is, not to control it but to manage it and facilitate the tough dialogues or productive conflicts that need to take place between the key constituents of an issue. (p. 158) Further, this theory considers the interdependency of multiple parts of systems. Interdependency is the “overarching term for relationships, connections, and interactions among parts of a complex system. Interdependencies are the structures and processes through which people interact, exchange information, and interpret observations” (Lanham et al., 2012, p. 196). Complexity theory applies to multiple leadership situations but certainly aligns with the nursing profession, which is almost defined by its unpredictability and chaotic nature: “Nurses come from a place of complexity, a place of understanding lived experiences (suffering, hope, fear, and violence), a place of practices that lurk in the borderlands of other more defined disciplinary fields” (Mitchell et al., 2013, p. 1). Not only is the environment of nursing complex, some individuals who receive nursing care are complex. Thus, complexity theory applies broadly and specifically, in the context of the nursing profession, for nurse leaders across the domains of the profession. “Leadership . . . is aimed at creating changes in what we do and how we do it, which is why leadership requires working outside established goals, procedures, and structures” Nursing Leadership Development 16 (Ibarra, 2015, p. 36). Creating change through challenging the status quo is a distinct characteristic of leadership. Common among all these theories is a presupposition of a leader interacting with followers. One cannot call oneself a leader if one does not have followers, because “without followers there is no leadership; followers therefore are a most significant element in the leadership ‘equation’” (Grossman & Valiga, 2013, p. 3). Leadership Versus Management The topic of leadership is vast and is often tied to the concept of management. Yet books written by Bennis (2009), Grossman and Valiga (2013), Yoder-Wise (2015), and Sipe and Frick (2009) have emphasized that leadership is distinct from management. These authors have also discussed how to identify a “good” or “effective” leader as opposed to a “bad” or “detrimental” one. There is something distinct, they have suggested, about being an effective leader that goes beyond cognitive knowledge of theories and principles, or simply management. In nursing literature, leadership and management are seldom presented as two separate spheres. To be a nursing leader is often equated with being a nursing manager. However, many authors outside of nursing have seemed to resist this notion. These phenomena (leadership and management) are not the same and should not be confused. That is, leadership is not necessarily tied to a position of authority; each of us has the potential, and perhaps the responsibility, to provide leadership (Grossman & Valiga, 2013, p. 4). In his book On Becoming a Leader, Bennis (2009) described differences between leaders and managers as “the differences between those who master the context and those who surrender to it” (p. 41). He provided an extensive list identifying a manager as being one who administers, copies, maintains, controls, focuses on the bottom line, does things correctly, and is a good Nursing Leadership Development 17 soldier. In contrast, a leader is one who innovates, develops, focuses on people, inspires trust, challenges the status quo, and does the right thing (Bennis, 2009, p. 42). The task focus of nursing managers was highlighted in a study by Gould, Kelly, Goldstone and Maidwell (2001) when the managers reported “they had received poor or very poor preparation for a number of [managerial] activities including the ability to hand a budget and other resources confidently” (p.13). In Leading and Managing in Canadian Nursing, Patricia S. Yoder-Wise (2015) defined management as “getting the job done and ensuring that people have the necessary resources to get the job done. . . . [Managers] set goals and objectives . . . and are associated with formal authority positions” (p. 6). She defined leadership as the process of engaging and influencing others. Strong leaders are associated with words such as visionary, energetic, inspirational, and innovative. . . . [It is] about critical thinking, action and advocacy—and it happens in all roles and domains of nursing practice. (Yoder-Wise, 2015, p. 6) These statements are similar to the CNA (2009) position, which stated, “Nursing leadership is about nurses who insist on practicing to their full and legal scope and push the boundaries of practice to innovative new levels” (p. 1). Yoder-Wise (2015) also maintained that there is a distinct role for management within the fiscally constrained Canadian healthcare system. However, she agreed with the CNA that the system needs bold, confident, and courageous leaders who inspire others (Yoder-Wise, 2015, p. 37). Bennis (2009) asserted that in a world as complex and fluid as ours, we cannot function without leaders . . . and we need more than one. As never before, we need leaders in all our organizations and all our institutions. We need leaders in every community, corporation, and country. The Nursing Leadership Development 18 leadership vacuum creates an enormous opportunity. If you’ve ever had dreams of leadership, this is the place, this is the time. (p. 4) Grossman and Valiga (2013) similarly described leadership as something that is distinguished by traits and influence rather than measurable tasks. Again, these statements relate to the CNA (2009) position statement on leadership, which noted that leaders need to be “credible, courageous, visible and inspiring” (p. 1). “In essence, leadership is not tidy; it is more of an art than a science. Management, in comparison, often is thought of as a science in which a series of steps can be followed to implement the role” (Grossman & Valiga, 2013, p. 6). However, it is important to recognize that while the role of management is distinct from the role of leadership, managers have the opportunity to exercise leadership if they manage people. The presence of followers, as discussed above, is an important aspect of leadership. This possibility is significant in the context of nursing since these two positions are often tied together. What Is Leadership? What is leadership? Many authors have sought to expand the dictionary definition of leadership with little consensus as to what the word means. In Chapter 4 of Leading and Managing in Canadian Nursing by Yoder-Wise (2015), Stalbaum and Valadez defined leaders as those who “set a direction, develop a vision and communicate the new direction to staff” (p. 57). In On Becoming a Leader, Warren Bennis (2009) outlined three ingredients that a leader must have: a guiding vision, passion, and integrity, which includes self-knowledge, candor, and maturity (p. 33–34). Similarly, Robert Greenleaf (as cited in Sipe & Frick, 2009) stated, “The first and most important choice a leader makes is the choice to serve, without which one’s capacity to lead is severely limited” (p. 1). Yukl (2012) stated that “the essence of leadership in Nursing Leadership Development 19 organizations is influencing and facilitating individual and collective efforts to accomplish shared objectives” (p. 66). Leadership is a dynamic word that cannot be encased within a single definition. The abundance of leadership literature suggests that it is a concept that is subjectively experienced rather than objectively measured and, as such, a single definition does not suffice. Leadership, as an essence, is contained within individual people and it is not necessarily predictable as to who those individuals will be. Bennis (2009) stated, Billions of dollars are spent annually by and on would-be leaders. . . . I would argue that more leaders have been made by accident, circumstance, sheer grit, or will than have been made by all the leadership courses put together. Leadership courses can only teach skills. They can’t teach character or vision. (p. 36) If leadership is to be expressed at every level and position of nursing as the CNA (2009) position statement has said, then its only containment is within the individual as a leader. Yet, for the sake of this study, a working definition is necessary. For this study, a working definition draws from Yoder-Wise (2015), Grossman and Valiga (2013), Bennis (2009), and Yukl (2012): Leadership is the process by which a self-aware, credible and courageous person engages and influences others toward a collective vision and direction for the purpose of achieving measurable goals. All Nurses as Leaders Achieving measurable goals is an important concept in every aspect of the nursing profession; therefore nurses must embody leadership. Grossman and Valiga (2013) dedicated a chapter to the concept of all nurses as leaders, which they entitled “Leadership as an Integral Component of a Professional Role.” In the opening sentences the authors noted that Nursing Leadership Development 20 “professional nurses can no longer think of themselves as ‘just nurses.’ Nurses are increasingly expected to provide leadership, whether they hold staff positions or are vice presidents, nurse practitioners, or nurse educators” (Grossman & Valiga, 2013, p. 69). Furthermore, “nurses who are just beginning their careers can be excellent leaders and make a great contribution to the profession while at the same time jump-starting their career” (Grossman & Valiga, 2013, p. 71). To Grossman and Valiga, “every individual, not just the nurse manager, dean, or committee chair, has the potential and the responsibility to assume the role of leader and work with others to fulfill the goals of the group or organization” (p. 71). Furthermore these authors state that “one does not have to be in nursing management to be a ‘true’ nursing leader; there are unlimited opportunities for nurses to exercise leadership” (Grossman & Valiga, 2013, p. 80). Leadership should be not only acknowledged in every nurse but expected: “Nurses in every position are expected to demonstrate leadership competencies. The competencies are not role specific. They include oversight for high-quality care, systems improvement, collaboration, communication, teamwork, conflict resolution, advocacy, and policy influence” (Galuska, 2012, p. 333). The notion that all nurses are leaders is not new. Historical nursing leaders purported that all nurses should embody specific characteristics which are now equated with leadership, particularly integrity. For example, the Florence Nightingale pledge states, “I shall do all in my power to maintain and elevate the standard of my profession” (Gretter, 1893, para. 1). Although the pledge does not contain the word leader, there is an implication that maintaining and elevating the profession is integral to the nursing profession—a notion that endures today. The Need for Nursing Leadership This need for strong nursing leadership is not just a necessity within the Canadian context. An article published in Pennsylvania Nurse by Carrick, Clarke, and Thompson (2008) Nursing Leadership Development 21 posed the question “Where will nursing’s next leaders come from?” The authors outlined a similar picture in the United States of a challenging healthcare system that is rapidly changing both at the frontlines and at the executive level. They argued that this swift change necessitates the presence of strong nursing leadership, stating that “rapid transformations in health care delivery . . . have created unprecedented opportunities for nurses to influence the future direction of health and illness care” (Carrick et al., 2008, p. 12). In 2013, Pate wrote an article discussing nursing leadership entitled, “Nursing Leadership: From the Bedside to Boardroom.” She stated that nurses serve as vital interpreters at the critical interface of the reality of patient care and the health system. Such leaders are needed in discussions that challenge the status quo as it relates to patient and family care. . . . Nurses [must be] skilled as leaders and empowered to take on these new challenges. (Pate, 2013, p. 187) Pate (2013) also made the statement that “all nurses are leaders” (p. 186), echoing the CNA (2009) position statement, which said that “Canadian nurses in all positions must develop and exert leadership—from the enthusiastic student to the competent professional clinician, from the excellent team member to the senior executive, and from the novice researcher to the most experienced educator” (p. 2). A study conducted by Brooks, Crawford, Nicklas, and Soldwisch (2014) was motivated by the need for nursing leadership. The authors stated, A shortage of nurse leaders and administrators is occurring at a critical point in time. As healthcare reform creates more autonomy and accountability for nurses, moves healthcare to the community, and changes the structure of healthcare delivery, nurse administrators are challenged to manage change and guide nurses confronted with new roles and Nursing Leadership Development 22 complex opportunities for practice, while envisioning new possibilities. (Brooks et al., 2014, p. 669) The need for nursing leadership is clear and must be addressed for ongoing success of nurses and the profession. Gap in the Literature Although there is a fair amount of literature on leadership theory, there is little on the concept of leadership development or the process of developing leadership characteristics from a nursing perspective. MacPhee et al. (2012) stated, “throughout the world, nurse leaders have the opportunity to make a difference with respect to health systems reforms. Effective leadership depends on effective leadership development” (p. 168). Nurse leaders formally, and all nurses as leaders, need to understand the concepts of leadership and leadership development. Scott and Miles (2013) stated, “despite an international call for embracing leadership as a central component of nursing practice, the discipline suffers from ambivalent definitions of leadership, disciplinary confusion about management versus leadership, and a lack of evidence based strategies for teaching leadership” (p. 78). MacPhee and Bouthillette (2008) completed an evaluation of a leadership development program. In this article they stated, “while we have some evidence that supports nursing leadership development programs, many program evaluations have been limited to pre-post selfand other questionnaires” and “a dearth of research exists with regards to long-term outcomes of nursing leadership development programs” (MacPhee & Bouthillette, 2008, p. 73). The evaluation of the leadership program presented in this article was positive. In particular, the participants cited their experiences with mentors as meaningful (MacPhee & Bouthillette, 2008, p. 72). However, this leadership development program is no longer in existence. Nursing Leadership Development 23 There is also a dearth of information on leadership development during nursing school although leadership as a concept is part of nursing curricula. Yoder-Wise (2015) stated “that the development of leaders must begin in nursing schools and continue throughout the career of every nurse” (p. 37), and yet, “nurses may not have been exposed to leadership development content in nursing school” (Pate, 2013, p. 186). Carrick et al. (2008) suggested that “leadership competency development must begin at the entry level to the profession and across the lifespan of the professional” (p. 12). Canadian nursing schools are required to teach leadership in undergraduate nursing programs. Indeed, leadership is considered an entry-level competency for provincial baccalaureate program approval. The College of Registered Nurses of British Columbia requires nurses to exercise leadership as an entry level competency. For example, “demonstrates leadership in client care by promoting healthy and culturally safe practice environments” and “demonstrates leadership in the coordination of health care” (CRNBC, 2009, p.8 & 15). Leadership in this document is defined as “a process of influencing and inspiring others toward a common goal, whether formally (through a set role) or informally” (CRNBC, 2009, p.20). On the national level, leadership is identified as one of six domains (or expected outcomes) of baccalaureate nursing programs (Canadian Association for Schools of Nursing, 2015). Thus, while leadership is a recognized domain of entry-level-practice, leadership development expectations post-graduation are not as clear. Bondas (2006) stated, “there seems to be a lack of an education for future nurse leaders providing a thorough knowledge of nursing care as an evidence-based practice as well as leadership, organizational and economic issues” (p. 339). An article discussing the evaluation of a leadership program at the Mayo clinic in Minnesota by Abraham (2011) stated, Nursing Leadership Development 24 there is little written about leadership development and even less is noted in the literature as it pertains to the staff nurse at the bedside. The literature demonstrates that effective leadership is the foundation of successful organizations and this leads to greater satisfaction and retention of nursing staff (p. 308). If all nurses should be leaders, regardless of position, ongoing leadership education should be made available. As Curtis, Sheerin, and De Vries (2011) noted, leadership is an essential component of nursing practice in the many aspects of the nurse’s role. . . . The evidence from the literature has shown that where leadership has been effectively taught and integrated into nursing, it has had a positive impact on practice. (p. 351) In regards to the specific role of Chief Nursing Officer, Frederickson and Nickitas (2011) stated, “to prepare future nurse leaders for the role of CNO as well as for stewards of the profession, educational programs must stand ready to equip them with the knowledge, and necessary skills and abilities to meet the demands and pressures of the health care market place, as well as to serve the needs of society. The nurse executive must lead with evidence” (p.347). At the same time, Bennis (2009) and others have noted that being exposed to leadership theory is not sufficient for leadership development. Grossman and Valiga (2013) likened leadership development to clinical skills development and suggested nurses should pursue it in a similar way: Because there is no procedure book on the leadership skills necessary for nurses to acquire (contrary to the clinical skill procedures that are described specifically), nurses must be prepared to help each other lead in the dynamic health-care arena of the future. Nursing Leadership Development 25 They lead based on what had been successful in the past and what they learn from others (e.g., through reading, listening to presentations, observing or studying others). (p. 170) Grossman and Valiga (2013) made an excellent argument for new nurses who are striving to personify leadership to learn from other, more experienced leaders because, as stated in the working definition for this thesis, leadership skills are part of who an individual is, which is expressed through what an individual does. Working alongside a higher level leader, whether in position or experience, exposes developing leaders to character traits and skill sets found in those leaders. This means that, leadership must be everybody’s business. . . . [E]ach nurse has to believe that every nurse does have the power to make a difference with maximizing the health outcomes of patients. Just like nurses work with experienced nurses to gain clinical expertise, nurses need to shadow expert leaders and be mentored by someone who can help an individual nurse grow. (Grossman & Valiga, 2013, p. 171) Fennimore and Wolf (2011) discussed a leadership development program for managers in Pennsylvania which sought to help nursing managers develop leadership skills. The authors identified a need for this program because “frontline managers are often the least prepared to handle these challenges. Leadership development for nurse managers is often loosely structured and fails to offer experiences and mentors that assist nurse managers to develop the competencies of successful leaders” (Fennimore & Wolf, p.204). The program sought to fill a recognized need with the main purpose being “to strengthen the leadership of nurses in leadership roles at the department or unit level. The course focuses on helping nurses understand their preferential leadership styles, strengths, and opportunities for further development” Nursing Leadership Development 26 (Fennimore & Wolf, p.207). The outcomes for this leadership development program were also positive with participants reporting increased confidence in their role and skills as a leader. Gaining leadership skills from an expert leader can be considered to be a key part in succession planning, which is also important to the CNA. This is evidenced by the current president and the president-elect working alongside one another, playing significant roles in how the CNA engages in the political world of the Canadian federal government (Laframboise, 2011). The intrinsic succession planning of the CNA shows its commitment to ongoing leadership development, as stated in the leadership position statement: Leadership does not just “happen” nor is it sustained without intensive, ongoing support. Leadership exists as a continuum that evolves and is strengthened from a combination of innate and learned skills that must be groomed. Nurse leaders must pay particular attention to the needs of multiple generations of nurses in practice. (CNA, 2009, p. 2) Because of this leadership succession structure, the CNA presidents should be able to speak to the ongoing development of leadership specifically and conceptually. This gathered wisdom can then be available to positively influence nursing leaders today and in the future. Succession planning, or one leader passing skills and expertise to the next leader, does not need to happen with the walls of a single organization. Leadership can be understood and passed on through literature, which has the potential to reach a wider audience. This study provides exposure to nursing leaders by sharing the knowledge and wisdom of CNA presidents who characterize leadership as well as hold a position of leadership. Summary A review of the literature was presented in this chapter. Contemporary leadership theories were presented. The literature review revealed that nursing leadership is a topic of interest and Nursing Leadership Development 27 important for the ongoing development of the profession. The concept of leadership is present in all aspects of nursing regardless of position or domain. Yet little is known about how nurses develop as leaders. The next chapter outlines how this study was conducted for the purpose of exploring this gap in the literature. Nursing Leadership Development 28 Chapter 3: Research Design, Method, and Procedures This study was designed with an understanding that, as outlined above, many theories and much information is available about leadership and leaders. However, an area that has had less focus is leadership development. Therefore, the importance of studying how leaders embody leadership, particularly nursing leadership, is imperative for the future of nursing across all the domains of the profession. Research Design and Method A qualitative research design was used for this study because a human phenomenon is being researched. “The tradition of qualitative methods to study human phenomena is grounded in the social sciences. The tradition arose because aspects of human values, culture, and relationships were unable to be described fully using quantitative research methods” (Streubert & Rinaldi Carpenter, 2011, p. 3). This design lends itself to gaining multiple realities and multiple truths from one study: Because people do understand and live experiences differently, qualitative researchers do not subscribe to one truth but, rather, to many truths. Qualitative researchers believe that there are always multiple realities (perspectives) to consider when trying to fully understand a situation. (Streubert & Rinaldi Carpenter, 2011, p. 20) Interpretive Description Interpretive description was used as the method because this method presupposes that some literature is available related to the topic, yet a gap may be present. Knowledge regarding nursing leadership and leaders already exists. However, less is known about nursing leadership development. Thorne (2016) stated, Nursing Leadership Development 29 It is rare that a qualitative study can be justified with the claim that “nothing is known” about the topic. Very likely, quite a lot will be known, but perhaps not within the intellectual circles to which the author is making reference. That which is worth studying qualitatively is credibly argued when the next logical question in advancing disciplinary knowledge is one for which themes and patterns have not been well documented . . . and what is worth studying is that which may have some relevance and utility to the mandate that has been granted to the discipline by the society that supports it. (pp. 49–50) Also, this study seeks to generate an understanding of leadership development in order that others may apply that information to their own experiences and career goal. Thus, again, interpretive description is applicable to this study. Interpretive description is an approach that requires integrity of purpose deriving from three sources: (1) an actual real world question, (2) an understanding of what we do and don’t know on the basis of the available empirical evidence, and (3) an appreciation for the conceptual and contextual realm within which a target audience is positioned to receive the answer we generate. . . . We desperately need new knowledge pertaining to the subjective, experiential, tacit, and patterned aspects of human health experience—not so that we can advance theorizing, but so that we have sufficient contextual understanding to guide future decisions that will apply evidence to the lives of real people. (Thorne, 2016, pp. 40–41) This study seeks to expand on available knowledge by focusing on leadership development as one particular aspect of nursing leadership. Nursing Leadership Development 30 Sampling and Recruitment According to Thorne (2016), “most applied qualitative research relies upon some variation on the theme of ‘purposive or theoretical’ sampling to identify which people or situations will become the central focus of the study” (p. 98). The goal of sampling in qualitative research is not necessarily to be representative of the whole population as is common in quantitative research; rather, we do much better if we understand that representation serves us best as one of those social ideals (like dignity or integrity) that is worth keeping in mind, but is not a thing one can actually achieve. This stance forces us to assume that whatever sample we come up with will not, in any meaningful way, be “representative” but will rather reflect a certain kind of perspective built from an auditable set of angles of vision whose nature and boundaries we can acknowledge and address. (Thorne, 2016, pp. 97–98) Therefore, purposive sampling was used for this study because the CNA presidency is a specific role held by specific individuals. This type of sampling is one “in which the settings and specific individuals within them are recruited by virtue of some angle of the experience that they might help us better understand” (Thorne, 2016, p. 99). These people are not necessarily representative of a phenomenon; rather, the position and the individuals hold a unique perspective related to the broad phenomenon of leadership. One strength of this particular type of sampling is that specific individuals can provide insight to an experience that others cannot. Thorne (2016) referred to these people as key informants: “The rationale for key informants is that some members of the community will be better equipped than others to provide you with access to what is happening and why it is happening” (p. 99). This strength can also be a weakness. If findings are generated from one Nursing Leadership Development 31 narrow sample of the population, it could be argued that the findings could only be applicable to the same population. For this study, the participants have all served as CNA presidents; however, that is where commonality ends. Each individual also has a diverse career unique to him or her, with a vast array of experiences and work environments. Therefore, this purposive sample may be applicable to a variety of populations Inclusion criteria for this study were being a living individual who has served or is serving in the position of president or president-elect of the CNA and was willing and able to be interviewed either in person or via Skype. The exclusion criterion was not having served in this capacity. A detailed email outlining the purpose and method of the study was sent to nine individuals who had served or were serving as president or president-elect of the CNA. Eight individuals replied; one was unable to participate and the other seven agreed to take part. Participants All of the participants have held the title of president of the CNA, a voluntary position that is four years in duration. The first two years are as president-elect and the latter two are as president. This volunteer role is done while continuing to work in whichever capacity the individual holds in his or her professional life. The range of these positions during presidency included chief nursing officer, dean of nursing, nurse manager, portfolio director, vice president, and chief executive officer. Therefore, the leadership skills of these individuals are not limited to presidency of the CNA. Not only do their formal positions of leadership differ, these individuals represent different generations, education experiences, career pathways, and even countries. That is, four countries of origin are represented by the seven participants. Nursing Leadership Development 32 Data Collection Data were collected through semistructured interviews using open-ended questions. These were conducted face to face, via Skype, or over the telephone. Following the first interview, I met with my thesis supervisors to discuss modification of interview questions. One question was modified for the purpose of eliciting specific information. The other six interviews were completed with no modifications to the primary questions. Face-to-face interviews took place in a setting chosen by the participant. These included work offices and homes. All interviews took place at the convenience of the participant. Four interviews were done face to face, two via Skype, and one over the telephone. The length of the interviews varied depending on the depth of answers provided by the participant, but was between 55 and 90 minutes. Each interview was recorded on a digital voice recorder. At the beginning of the interview I provided contextual background of the topic and answered any questions the participant had. After each interview, I wrote in a reflexive journal to capture initial analysis and impressions which were not captured by voice recording alone. At the completion of each interview the digital recording was uploaded to a passwordprotected computer and a password-protected Dropbox for the purpose of transcription. This Dropbox was accessible only by me and a hired transcriptionist. Transcriptionist access has since been removed. The first interview was transcribed verbatim by me, and the six subsequent interviews were transcribed verbatim by the transcriptionist. The written transcripts were returned via a password-protected Dropbox. Participants were identified by their initials on these transcriptions. The written transcripts were verified against the audio recordings for accuracy. Nursing Leadership Development 33 Data Analysis and Interpretive Description Analysis of the data was completed in three ways. First, the transcripts were analyzed while listening to the audio recordings. This was completed five times per transcript. While listening and reading, each interview was coded for themes. Second, the transcripts were read and analyzed five times each without the audio recording. Again, the transcripts were coded for themes. Finally, the audio interviews were analyzed without using the transcripts. This process occurred three times per interview, which included taking notes while listening and revisiting each time. The themes of each interview were then contrasted and compared. The first interview was analyzed in collaboration with my thesis committee. Further engagement with the data occurred throughout the process of collating the findings. Polit and Beck (2012) noted that “the purpose of data analysis is to organize, provide structure to, and elicit meaning from data,” and “the analysis of qualitative data is an active and interactive process” (pp. 556–557). Qualitative researchers typically “scrutinize their data carefully and deliberately, often reading the data over and over in search of meaning and understanding. Insights cannot emerge until researchers become completely familiar with their data” (Polit & Beck, 2012, p. 557). Within the broad category of qualitative research, interpretive description is a method that requires an integrity of purpose deriving from three sources: (1) an actual real world question, (2) an understanding of what we do and don’t know on the basis of all available empirical evidence, and (3) an appreciation for the conceptual and contextual realm within which a target audience is positioned to receive the answer we generate. (Thorne, 2016, p. 40) Nursing Leadership Development 34 Further, this method “offers the potential to deconstruct the angle of vision upon which prior knowledge has been erected and to generate new insights that shape new inquiries as well as applications of ‘evidence’ to practice” (Thorne, 2016, p. 40). Having a deep knowledge of data is imperative in interpretive description. Thorne (2016) described this as “dwelling in it repeatedly and purposefully and developing a relationship with it” (p. 167). According to Thorne, a four-step process of data analysis assists the researcher in engaging with the data. Thorne outlined these steps as comprehending, synthesizing, theorizing, and recontextualizing. First, comprehending means having an understanding of the experiences of the participants in order to understand the data from their perspective. Second, synthesizing is merging typical or composite findings. Third, theorizing is allowing the data to generate questions. Fourth, recontextualizing allows the researcher to express implications of the new knowledge (Thorne, 2016, pp. 184–185). Ethical Considerations Prior to beginning this study, ethics approval was received from the Trinity Western University Research Ethics Board. Participant anonymity was an important consideration although each participant in this study would be considered to be a public figure. Each participant was provided with a written or electronic copy of the consent letter and either signed a copy or consented verbally on the recorded interview. Select permission was sought for particular stories which have the potential to reveal who the participant is, although no names are used throughout this study. All participants are referred to by feminine pronouns. Electronic data will be kept on a password-protected computer for five years; the computer is accessible only to me as the primary researcher. The thesis committee has access, at their request, to the transcribed interviews but not to the recorded interviews. The hired transcriptionist signed a letter of Nursing Leadership Development 35 confidentiality and had limited access to the recorded interviews through a password-protected Dropbox. Transcriptionist access to the recordings and the transcriptions was removed once the transcriptions were complete. Credibility and Qualitative Research Credibility is considered to be the quality or trustworthiness of a qualitative research study. Credibility is important in qualitative research because it speaks to the human, or subjective experience, of a phenomenon. Therefore, confidence in the truth of the data must be established as well as in the interpretation (Polit & Beck, 2012). This is often achieved through auditability and reflexivity. Auditability. Auditability refers to the “systematic collection of materials and documentation that would allow an independent auditor to come to conclusions about the data” (Polit & Beck, 2012, p. 591). Also known as an audit trail, this is achieved through raw data or the interview transcripts, analysis products such as notes, reflexive notes and drafts of the final report (Polit & Beck, 2012). For this study, audio files of the original interviews were saved to a password protected computer by the primary researcher. The transcripts of the interviews were also saved and shared with secondary authors. Data analysis notes were completed and saved as well as a reflexive journal. Each draft of the final product has been saved to the primary researcher’s computer. Reflexivity. “Reflexivity is the process of reflecting critically on the self and of analyzing and making note of personal values that could affect data collection and interpretation” (Polit & Beck, 2012, p. 179). This concept is tied in with the concept of researcher as instrument which “requires an acceptance that the researcher is part of the study” (Streubert & Rinaldi Carpenter, 2011, p.22). Strategies for achieving reflexivity involve awareness and is often achieved through Nursing Leadership Development 36 maintaining a reflexive journal and field notes (Polit & Beck, 2012). Both of these strategies were used for this study. Field notes and reflexive journaling were done following each interview. These field notes were kept on the primary researcher’s computer. Reflexive journaling was completed initially following the interview and highlighted the experience of the interview process and initial impressions. However, this process also continued throughout the data analysis and reporting processes as I became immersed in the data. This was to ensure that “through self-interrogation and reflection, researchers seek to be well positioned to probe deeply and to grasp the experience, process and culture under study through the lens of the participants” (Polit & Beck, 2012, p. 589). Credibility and Interpretive Description Credibility is considered to be the quality or trustworthiness of a qualitative research study. Credibility is important in qualitative research because it speaks to the human, or subjective experience, of a phenomenon. Therefore, confidence in the truth of the data must be established as well as in the interpretation (Polit & Beck, 2012). In interpretive description, credibility can be evaluated in a number of ways. This study ensured credibility through analytic logic, interpretive authority, disciplinary relevance, and contextual awareness. Analytic logic. Analytic knowledge is the process that makes the reasoning of the researcher explicit (Thorne, 2016, pp. 234–235). This should be evident from the proposal through to the interpretation and discussion of the data. The inductive reasoning process must be evident and not left to assumption. Field notes, reflections, and analysis notes comprise an audit trail by which analytic logic could be followed. This is also evident in the presentation of the data in the findings chapter which follows. Nursing Leadership Development 37 Interpretive authority. Quality rests in the assurance that a researcher’s interpretations are trustworthy. This means that it is illustrated that the interpretations are external to the researcher’s bias or experience (Thorne, 2016, p. 235). This particular assurance of credibility was easily achieved because the researcher embarked on this study as a matter of discovery rather than a matter of proof. The initial motivation for the study was related to having little knowledge about nursing leadership development, therefore bias and experience minimally influenced the researcher’s interpretations. Disciplinary relevance. Interpretive description relies on the concept of conducting research which will generate knowledge that is useful and applicable to practice disciplines (Thorne, 2016, p. 236). It could be argued that this particular criterion of credibility should be present in every qualitative research study. As stated throughout this thesis, there is little information available about the process of nursing leadership development. Yet, leadership in nursing is considered to be a high priority throughout Canada. Therefore, to support the ongoing development of the nursing profession, and all nurses as leaders, an understanding of nursing leadership development should prove to be both useful and applicable. Contextual awareness. Contextual awareness refers to the researcher understanding that the study and the findings are completed within a particular context or perspective which inevitably influences the interpretation of the data (Thorne, 2016, p. 237). This study has a few contexts which influence the data including the context of nursing, nursing in Canada, and nursing leadership specifically, as opposed to leadership generally. These contexts allow the researcher to interpret the data within the field and culture from which they were elicited, while acknowledging that the context may or may not influence longstanding relevance of the information. Nursing Leadership Development 38 Summary The study design and the methods used to collect and analyze the data were presented in this chapter. Scientific quality, ethical considerations, and a description of the participants were also discussed. Findings that emerged from the data are presented in the following chapter. Nursing Leadership Development 39 Chapter 4: Findings In this chapter, findings which emerged from immersion in the data will be presented. These findings highlight various aspects of the participants’ leadership journeys, their philosophies, and their experiences of leadership development. In the interviews with seven CNA presidents, it became evident that, for this group, “leadership” and “leadership development” are intertwined. Nurses develop into leaders by doing leadership. Nursing leaders develop into exceptional leaders by pursuing more complex leadership experience. That is, if leadership is defined as “the process by which a self-aware, credible and courageous person engages and influences others toward a collective vision and direction for the purpose of achieving measurable goals” (see chapter 1) then leadership development involves deepening (and drawing upon) one’s self-awareness, credibility and courage while continuing to engage and influence others towards a collective vision. In the case of CNA presidents, the broad collective vision is to contribute to the health of Canadians and the advancement of nursing (CNA, 2017). In order to influence others towards the vision and direction of the organization(s) they served, these CNA presidents pursued their goals through the following six themes: Relentless Incrementalism, Embracing Opportunities, A Service Mindset, Taking the Long View, Enduring Heartbreak, and Taking a Seat at the Table (see Figure 1). The overarching theme was Relentless Incrementalism: Courage and perseverance was of primary importance in achieving their goals. Relentless Incrementalism was continually evident from the journeys of every CNA president as they were shaped into these high –level leaders. Nursing Leadership Development Relentless Incrementalism Embracing Opportunities 40 A Service Mindset Taking the Long View Forged opportunities Service as Philosophy Receiving Mentorship Obligatory Opportunities Service as Embodiment Exending Mentorship Unexpected Opportunities Promoting Nursing Opportunities Lost Promoting Nurses Enduring Heartache Taking a Seat at the Table Figure 1. Themes of leadership development emerging from the interviews. Relentless Incrementalism Two participants in this study used the phrase Relentless Incrementalism, which is the overarching theme that emerged. The others inferred Relentless Incrementalism when they told stories of achieving long-term goals step by step. Relentless Incrementalism is defined as “a process in which something substantial is built through the accumulation of small but incessant additions. The concept of relentless incrementalism derives from economics and social policy and is used in various areas of information technology and business management” (“Relentless Incrementalism,” 2015). Within this concept of Relentless Incrementalism lies the idea of courage and perseverance. Perseverance was emphasized by all of the individuals especially when the goal they were trying to achieve was something they were passionate about. Goals within the context of leadership in healthcare, including presidency of the CNA, affect many Nursing Leadership Development 41 people including the leader. Attempting to accomplish those goals takes perseverance, courage, and step-by-step victories. In response to the question asking for an example of a time when she embodied being a leader who is credible, courageous, visible, and inspiring to others, one participant shared a story about a project that took 7 years to complete. She spoke about the initial resistance of the people she was working for and with. She spoke about multiple meetings and town hall gatherings: It was [XX] who introduced me to this concept of relentless incrementalism. And it’s just like bugging people until they say yes, basically. So we started on this journey and it took 7 years but now this community has what it needs. I could have been lazy, or I could have given up, but I had to maintain my energy even when it was really, really hard and the mayor was cranky and the docs were cranky, but I maintained my energy for a very long time. Seven years of perseverance. When asked what advice she would give to current and future nursing leaders, one participant responded by saying, Definitely, stay engaged. Stay engaged and stay energized. And look for specific outcomes while you are trying to achieve an ultimate goal. But hold on to specific outcomes that you believe you can achieve and work toward those. Be willing to, to, be willing and able to focus on that because the noise around you will always divert you from that. Further, the other individual who used the phrase relentless incrementalism told a story about volunteer work she is involved in: “Impatience is my Achilles heel. I need to remember that complex change is not an overnight change. It’s not a big bang approach to change. It’s more, like it’s relentless incrementalism. It’s complexity.” She expanded by saying Nursing Leadership Development 42 I need to understand that I am only one speck or drop in the big thing that we have to do here so please don’t worry about creating a wave, just worry about creating a ripple. And then I will make a difference and someone else will make their difference and the wave will worry about itself. She found this to be applicable to multiple situations in life and in her career: This concept was life changing to me. Especially as a visionary leader, like you can see the big picture where something should go which can be very challenging because it’s having to figure out what the steps are to get to that end goal. The following is an answer to a question concerning philosophy of leadership and whether or not that had changed over time: How it’s changed over time is that in my, I guess taking on uh, positions of leadership, and the presidency of the CNA was one example, um I realized, uh a leader needs to be very comfortable with conflict, with difference, with change. So, in addition to being able to work with other people, um, having a shared vision with other people, you have to be able to have the courage, perseverance, uh, the conviction of your voice, to stay the course when rough waters hit. And I think that the real, uh, what’s the word, the real um, measure of a leader sometimes is when they’re tested through very challenging times. Part of being courageous and exercising Relentless Incrementalism is learning how to achieve a goal that is supported by very few: When I started my presidency I knew I wanted to hear the national voice of the nurses. It’s the association for the whole country. I had these issues that were my light post, meaning, I am working on that. So, I strategized and engaged with others and made a request and we were denied. Nursing Leadership Development 43 She went on to describe how one individual finally gave her a strategy by which she should accomplish her goal: “So that was again the listening and talking and trying over and over and then this door opened which I wouldn’t have known about otherwise. This changed everything for us at that time.” The concept of having courage to persevere does not only apply situationally. According to the participants in this study, it is also a characteristic that is embodied by a leader. So, not only does a leader need to be courageous in any given difficult situation, they need to be marked as a courageous person: The other important thing, uh for leadership, is courage. I find that a lot of the people that are in a leadership position, that doesn’t mean they’re a leader but they’re in a leadership position, are not courageous. They never call it like it is. They always wrap it up in paper and bows and pretend it’s a, you know they don’t want to give bad news or anything like that so if you don’t have a leader that can speak straight about what it is and what it isn’t and can’t discuss their decision then you shouldn’t be a leader. It takes personal courage to be a leader. One of the other participants articulated this concept this way: You can’t be afraid. Because if I had been afraid to even try it would have been because I was worried about myself. I think that should be another chapter in the book. Don’t just think about yourself. Don’t be afraid. You know? Take a risk. Relentless Incrementalism marked each of the participants regardless of whether they used the phrase or not. They each told stories or shared philosophies which embodied courage and perseverance. Nursing Leadership Development 44 Embracing Opportunities Immersion in the transcripts of the interviews of the seven participants emphasized the importance of recognizing and embracing opportunities. As participants described their leadership journeys toward CNA presidency and throughout their careers, opportunities— whether desirable or not—served as a foundation for leadership development. When these opportunities arose, participants did not allow their perception of themselves to allow them to forego opportunities. For example, one participant took an opportunity for leadership after graduating within the year prior, and another individual stepped up for a role although she perceived being an immigrant as a weakness. Further, many discussions centered on the benefit of being unsuccessful in attempts to move forward. Thus four subthemes emerged. These are Forged Opportunities, Obligatory Opportunities, Unexpected Opportunities, and Opportunities Lost. Forged Opportunities are opportunities which were pursued, desired, or created. Obligatory Opportunities are opportunities taken because of moral conviction. The third subtheme, Unexpected Opportunities, refers to tasks or jobs which the individuals did not see themselves as adequate for. And fourth, Opportunities Lost are opportunities which were attempted but not achieved. Forged Opportunities. The first subtheme within Embracing Opportunities is Forged Opportunities, meaning opportunities which were brought about by concentrated effort or perceived necessity. Throughout the interviews many participants identified times when they sought opportunities for leadership. The prospects were intentionally pursued, welcomed, and even fought for. For example, one participant told a story about when she was early in her career. She had had a difficult pregnancy, which left her with ongoing physical problems. When she attempted to go back to work she was told she should just go work in a doctor’s office. However, Nursing Leadership Development 45 this was unacceptable to her. In the interview she said, “And that moment was like a white light for me because there was no way my nursing career was over. So luckily enough the union stepped in and they got me a job as an IV nurse.” During her stint as an IV nurse she began to ask questions as to why practice happened the way it did. This led her to pursue her first research project, which she presented at a conference before she had even completed an undergraduate degree. She continued to make and take opportunities: Later on I was hired by a woman who was very different than I was. I used to ask her, “Why did you hire me?” and she said, “You were a shit disturber and I needed a shit disturber.” I’m actually very respectful but I know there is, every opportunity is an opportunity that has to be maximized. Another participant cited a time when she was involved in the provincial association and took opportunity to engage with members of the legislative assembly (MLAs) about the topic of title protection for RNs, at topic she was passionate about. And so um, I was asked to go, I had never been to an MLA’s office and I was nervous as all get out, and I didn’t know quite what I was going to do, but anyhow, when I started doing that, and I really enjoyed it, and then further opportunities just came. One of the participants who had immigrated to Canada as a young adult spoke passionately about how that move allowed her to pursue opportunities she and her family would not have otherwise had. For this individual, leadership began long before she became a nurse, as a necessity when her family experienced a tragedy in her childhood. That event was a catalyst to her embracing leadership even at a young age. So it was more life experiences that kind of inspired my need to be in a leadership space. And then, wherever I’ve been, whether in a practice setting or an education setting, it’s Nursing Leadership Development 46 not been at the average. I, people tell me I had leadership tendencies so it’s this, it’s this um, it’s what Florence Nightingale says, it’s this persistent lack of satisfaction with the status quo, and always thinking there is another approach or there is a different possibility. Statements were made which emphasized anticipating and pursuing opportunity. When asked what advice she would give to future leaders, one contributor stated, “Keep your eyes open. Keep your ears open. And when you see an opportunity don’t say no right away. There is so much to take advantage of.” And another, in regard to why she sought new leadership roles, stated, I wanted to help. I really, I mean, that’s why I became a nurse in the first place. You, as a young girl that was the motivation. As well, I want to help and be kind and, you know, those things we think nursing is when we’re little and impressionable. And then I think there was a notion of striving, of striving to stretch myself. Of striving to be the best I could be. Another motivation for building opportunities was because the individual did not want to stay in the job she was in and she wanted to improve the profession: I thought that uh, there was a poor utilization of nurses in those times because you spend some of your time, uh, filling in plates of food and doing all sorts of other things that other categories of workers should be doing and I thought you, you didn’t study three years to do that. So I felt I should fix that. So I went back to school. Once her undergraduate education was complete she continued in a master’s program focusing on nursing administration. However, she soon concluded the problems in nursing included a lack of knowledge. “We were not able to prove the impact we had on patients and so research was Nursing Leadership Development 47 the, the key. So I convinced the hospital in [XX], actually the largest hospital, to create the nursing research position for me.” These forged opportunities allowed each participant to develop as a leader and created unique trajectories for each participant toward leadership roles in all aspects of the nursing profession, including the role of president of the CNA. However, not all opportunities were sought after and desired by the participants but they were nonetheless embraced as necessary, as seen in the next subtheme. Obligatory Opportunities. Another common theme that emerged was Obligatory Opportunities. In other words, these were opportunities which the individual felt required to take on for the benefit of patients, another leader, an organization, or the nursing profession. A sense of obligation to the profession, to patient well-being, and to superiors often meant some of the participants came to a juncture where they were being asked to do something they were not keen about. This perceived obligation, as a nurse, caused them to say yes. This was articulated well by one individual who said, The director at the time came to me and said, “You’ve got to help us here. You don’t have to take it for a lifetime, just take it for a while. So nurses are suckers for people like me to help. You ask a nurse for anything and they will always not think of themselves but help.” Another individual noted, I wanted to help. That was the motivation, and to paraphrase Paulo Coelho in The Alchemist, “one’s only obligation in life is to realize one’s potential.” So, I mean, you can do this so why wouldn’t you? If you think you can, um why wouldn’t you? Why wouldn’t you do it? Nursing Leadership Development 48 Many of the participants in this study described experiencing a sense of obligation and therefore embarked on opportunities reluctantly. However, all of the individuals who agreed to obligatory opportunities consistently looked back and acknowledged that these portions of their career helped shape who they are as leaders and as professionals. There was also an internal understanding that strategically taking a job that was not desired might open doors to achieve other goals. One participant experienced this a few times throughout her career: When the previous manager was fired I was asked to take on the role. And of course my intention was not to be in management. I had other aspirations that were much more important to me. But they sent a survey to the staff asking them who they wanted as a leader for nursing and 90% of them asked for me. So I figured, well I’ll take it because with 90% that’s probably good support to bring about change. But, uh, we have to set out to find somebody else to take that position. I agreed to give them three years so that the next person could get ready and then she didn’t want the job in the end. But I originally took the job with the understanding that they would look for someone else and I wasn’t willing to stay so I ended up finding the replacement person because I wanted out. Another participant said, I never really wanted to be a leader per se, but I wanted to help. It sounds hokey, but I honestly think I wanted to help. So, in order to do that I had a number of jobs and positions I didn’t actually want but they helped others and inevitably I helped myself. The participants’ sense of obligation to the profession, the patients, and individual workplaces was often motivated by a strong sense of morality, moral reasoning, or doing the right thing: “There’s work to be done and you, you, I mean, you can say it’s somebody else’s business but if everybody says that nothing gets fixed.” Further, “the leader is a social Nursing Leadership Development 49 conscience. Leadership is a social conscience.” Another participant said, “I always did what I believed was the right thing to do and worked as hard as I could and I would still do the same thing.” When asked what advice she would give to future nursing leaders one individual responded by saying this: Like really ensure your moral compass is set right. Because that is right, that is nursing. To me, if your moral compass is in the wrong place, you are in the wrong profession. Nursing, nurses must embed themselves in what I always call the blue ocean. It’s our blue ocean space; it’s our values and beliefs and socialization. Another participant emphasized the necessity of morality and integrity by noting, “And that is the most beautiful framework for leadership. Do what you say you will. Because if you don’t you’re letting them down. You’re also not credible. You must have integrity.” Antithetically, when discussing a challenging time as a leader, one person said, “So it was a very difficult time because it was dishonest and dishonesty is the most difficult thing to deal with.” Unexpected Opportunities. Unlike obligatory opportunities, participants also spoke about pivotal moments when their own leaders or supervisors approached them about particular opportunities. This is referred to here as the subtheme Unexpected Opportunities. Many of the participants spoke about how surprised they were about being asked to consider certain roles. For example, one person embraced a vital opportunity early in her career: Within my first year of graduating from the diploma program, I was asked to take over for the head nurse who had a lot of years of experience. I wasn’t sure I could do it, even though they seemed so sure, so I offered to share it with someone else, which is what I Nursing Leadership Development 50 did. I just looked at things like this as a learning opportunity. Each time something would present itself, I would consider it. She went on to say she was offered a job overseeing a region of the province when she was still quite junior in a faculty role. “My office mate said to me, ‘Are you nuts?! You can’t do this’ and I said, ‘Why not? They said they’d help me.’ It’s like the little engine that could. You really just need to believe in yourself.” Opportunities often came when the individual least expected it and did not see potential in herself but grabbed hold of them anyway. I thought, oh my God, this is not what I ever want to do. And the, I had amazing mentors and people saw in me what I have not seen in myself at that stage, and have embraced me and given me opportunities. In response to when she first considered herself to be a leader, this participant said, So I think a lot of, and you’re probably going to hear it from some other people maybe, it’s organic and it’s evolutionary and it’s, it’s being open to opportunities and every opportunity is an opportunity that has to be maximized even when you don’t think you can. Another participant emphasized that she had truly never seen herself as a leader but she knew she wanted to positively influence the profession of nursing and the individuals around her. So that conviction, alongside the potential others saw in her, helped her to overcome her own beliefs about herself. Number one: when people believe in you it is pretty powerful. When they see something in you that you don’t see, because I will be the first to say, I thought I would be a, I never dreamed of this journey when I was a young, a younger person. Nursing Leadership Development 51 For these leaders it was impossible to separate unexpected opportunities from the mentorship they received. They were either being mentored when an opportunity was presented or an opportunity would arise and mentorship would ensue. Regardless of the order, mentorship and unforeseen opportunity were related: “And it’s been amazing. I’ve been blessed with great mentors. People who opened the doors, who see, who see your possibility before you see it. Who give you a leg up. Amazing people.” A different participant said, I was overwhelmed by suggestions from others that I didn’t understand. I mean, my gosh. People were saying, well, you know you can do it. We want you to do it. We want you to run for, for the chair, the first role of chair of this and that or whatever. And I was really excited about the work but I found myself in a very unexpected position. But they promised to help me. These unexpected opportunities stood out as milestones of leadership development for the participants and were recalled with enthusiasm. However, the participants also discussed the importance of not achieving goals they strove for, as seen in the next subtheme. Opportunities Lost. The participants in this study all experienced times when they attempted to move into a new job or a new volunteer position that did not come to fruition as they hoped. Each participant who discussed these disappointing events spoke about how opportunities lost were just as, if not more, formative than opportunities gained. I think opportunities present themselves, and I think that you open yourself to those opportunities and um, you know things, sometimes you have to learn from the opportunities that don’t happen. Like, for example, back in the early ’80s, I think it was 1982, I applied to be the head nurse on the unit I was working in. I had been a charge nurse there for 5 years and I did not even get an interview because I did not have a Nursing Leadership Development 52 degree. That was the first time doors were shut to me and I thought if I’m going to be nursing for 30 years I’m going to have to go back and get a degree. But I think I took opportunities when they came and also when opportunities didn’t happen, instead of getting mad at them you have to look at them and say “Is there something I can do so next time I do get that job?” Another participant recalled a time when she ran for a position but was unsuccessful: So, I’ve had the experience of putting myself out there and thinking okay, I’ve done this and I’ve done that so this seems like the next step and then not having it turn out the way I hoped. But a lot of good came out of that. That disappointment taught me some very valuable things. Strong friendships. A new understanding of the process and ultimately, a chance to try again. And another individual recalled applying for multiple leadership jobs and not getting them: I applied for management jobs and didn’t get them and then someone hired me for a coordinator job which was much higher than what I had applied to. And the woman who hired me became a great mentor. She is part of my life to this day. Another participant reflected on her career in light of being asked what advice she would give to future leaders: I guess I would say to not be as heartbroken as I was over, over what I perceived to be setbacks in my career when I didn’t get the job that I really, really wanted. Or when I had to voluntarily leave a job for circumstances that, that I encountered. I think most of all I would tell myself, trust more. Trust the process more. Trust the journey more and maybe Nursing Leadership Development 53 be a bit kinder to yourself through it all. Again, it probably sounds a little bit hokey, but at this stage in my life that’s, that’s what I would say. Opportunities came about in many ways for each of the participants in this study. Most individuals experienced all four types of opportunity: forged, obligatory, unexpected, and unsuccessful. Each opportunity was at the very least pondered, and more often than not embraced. Moving forward in those opportunities was just the beginning of what it means to develop as a leader. They also spoke of the importance of the third theme, A Service Mindset. A Service Mindset One of the interview questions in this study asked the participants to share their definition or philosophy of leadership. From this question the theme of A Service Mindset emerged. All seven participants either said the word serve or service in relation to their definition, or they spoke about service conceptually or identified themselves as proponents of the theory of servant leadership by Robert Greenleaf. Not only did the participants share a belief in leadership as service, they also shared examples of how they embody that in their jobs and in their lives. These leaders emphasized that the purpose of service is to influence change for the profession and those we serve. Therefore, two subthemes emerged: first, Service as Philosophy and second, Service as Embodiment. Service as Philosophy. One individual answered quickly when asked about her definition of leadership: “My definition of leadership is service. But it is also advocacy.” Expanding on this, this particular participant stated, I wanted to serve. I wanted to help my profession. But when you’re a designated leader by virtue of a position of leadership, then I think you have to serve that role and those people who are looking to you for leadership. You have to serve them. Nursing Leadership Development 54 Another individual stated, It is about synchronizing with the people we serve. To me that’s leadership. Ensuring we understand their needs very deeply. Putting them in the driver’s seat. Being led by those we serve. So it’s a very kind of servant-oriented approach to leadership. I really believe in that concept of servant leadership. It’s in the service of something. A further specific reference was “It really is a servant leader model. The kind of language they used really resonated for me as a nurse.” Some participants did not explicitly use the word serve or service but implied an affinity with this philosophy through various statements: It’s not about me. It is not about me. It’s about us and it’s about what I can do to help you shine or, if I was to describe my job today, I would say that my job is to make it so that those who report to me can do their best. Moreover, another stated, “I think leaders need to make a difference. Your question is how I’m going to make the world a better place for the people I represent” and “When I saw a problem I started to work to fix it.” These statements reflect the desire of these leaders to serve others, whether it was their employees or the people they cared for. All of these participants hold what most would consider to be prestigious roles with a high level of responsibility but they are emphatic that those roles are not actually about them as individuals. One participant said, It’s distressing to me when I see nurses who don’t want to serve. Or leaders who don’t want to serve. And it’s not about me being the, you know, grand poobah or anything, but my job as a leader is to really be humble and to uh, identify what it is that I can do to make the team, uh, really function well and really enjoy work. Nursing Leadership Development 55 She expanded on this concept later when she spoke about leaders needing to be kind: And I expect, and many times I’m disappointed, but I expect a leader to be kind. And, uh, it’s like the, the sign on my, on the other side of my door is “Be nice and work hard.” Their view of the world is they need a lot of gratification to convince themselves they’re doing an okay job. I don’t really, I never really needed that. When speaking about learning about leadership as a concept, one participant stated, “Well, it’s really rooted to the basic thing of what nurses believe in. A nurse leader should ground themselves, I believe, like we do at the bedside, in those we serve.” Service as Embodiment. Not only are these leadership positions, including CNA presidency, not about the participants as individuals, but the participants also emphasized that the positions are about what they could change or influence for the benefit of others and the profession as a whole. Therefore they assert that the underlying philosophy of leadership must be embodied by the individual who purports to believe it. And this embodiment of servant leadership was often first grounded in caring: If you want to be an effective leader, you have to care. If you lose your ability to care, you have to get out of that job. Because if you can’t care and be invested in what you’re doing, you don’t have a right to that job or those people. Another person stated, I’m very oriented to want to make a difference and a difference in terms of what others want. Not what I want. So that’s a big thing. Kind of shared pursuit of results and aspirations of people and then helping others go on that journey with you. Nursing Leadership Development 56 These statements reflect an embodiment of the philosophy of servant leadership and illustrate a deep connection the participants have to their work and to their profession. This is part of the underlying motivation of leadership, which will be discussed later. Personification of this leadership philosophy has led some of these remarkable people to serve outside of their jobs and to encourage would-be leaders to do the same. For example, one individual is working as a volunteer to help establish nursing as a profession in a war-torn nation: One of the projects I’ve been involved in is shaping the credentialing system for nursing in [XX]. And it’s a long process. So we want to shift, we want a proper curriculum and we want a credentialing system. And you cannot do that bing bang. Like there is no way in hell. Another participant spoke about a specific situation where she had the opportunity to be generous and to serve: I offered to pay for this person’s tuition. I would pay for his retro and one semester, which gave him time to figure out the rest. And I asked him to pay me back in the form of donating to a charity because that’s the right thing. All I’m asking is that when you are in a position you do these things for others. It’s not too difficult for us but it will change the life of other people. She expanded later, saying, “But if you don’t make your contribution then it just kind of, it’s just table conversation and what does that mean anyway?” Service as a philosophy of leadership was important to each participant but only if it was embodied by them as leaders. This theme of A Service Mindset set the groundwork for the fourth theme, Taking the Long View. Nursing Leadership Development 57 Taking the Long View Participants in this study were transparent about the internal and external motivating factors which led them to pursue and continue to pursue leadership development and formal leadership roles. While analyzing transcripts from these interviews, the broad theme of Taking the Long View for themselves, other nurses, and the profession emerged. Within this main theme four subthemes emerged. These are Receiving Mentorship, Extending Mentorship, Promoting Nursing, and Promoting Nurses. Receiving Mentorship. When describing their journey to the presidency of the CNA, all of the participants wove other experiences into their stories. Their descriptions often included the initial spark that led them down the road of becoming a leader. More often than not it was the encouragement of another leader, manager, or well-respected peer which started them on the path. One participant said, “Someone tapped me on the shoulder and said, ‘I need you to cover because your manager is away or whatever’ and ultimately that led me to that, that journey.” Another said, “My manager was totally different than me but she wanted me to be a leader because she saw that I could get things done. She was my most influential mentor.” One participant spoke about how her goal of becoming a researcher was initially thwarted by the desire of others for her to become a leader: “And of course my intention was not to be in management. I wanted to be in research. Yet, 90% of the staff had said they wanted me as a leader. How do you say no to that?” This pattern continued through each participant’s story. Each of the study participants is a motivated individual who does not want to do the same thing over and over: “We need to have a different experience every year of our careers. We don’t want to have the same experience 40 times over.” And it was often another person, either a manager or a peer, who encouraged them Nursing Leadership Development 58 or directly asked them to consider a position of leadership. The concept of another person being important to the beginning of the journey was expanded on throughout the interviews. Being mentored was undoubtedly important in the formation of who these leaders are as people. The experience of mentorship seemed to be more important to them than not having received formal education in school. One participant highlighted having learned leadership in the context of clinical practice. She then expanded on that idea: And by watching other people. You know you can, I can still think of head nurses and assistant head nurses where I’m, I’m doing something or I’m making a decision and I’m thinking, okay, I learned that from the head nurse on Unit 72. Mentors can be people who impact others intentionally and unintentionally. One participant describes influence she received from leaders on both ends of the spectrum: I have learned from two groups of people. I have learned more from people who I did not want to emulate in leadership. And then I had amazing mentors and people saw in me what I have not seen in myself at that stage. . . . So, yes, I had leadership courses and so on and I can’t tell you that I profoundly remember what I had learned as theory and so on and so forth, but I had all that exposure along the way, but it’s from the individuals and their reflective observations and discussions. And it continues every day. It never stops. Another individual also spoke about the importance of mentors: Most of what I’ve learned of leadership is not from a school setting. My master’s [degree] shaped me but my leadership skills were all learned in practice. Like it was exposure to mentors and I’ve had brilliant nursing and nonnursing mentors who have showed me how to do it right and not do it right. Another participant added to this concept by stating, Nursing Leadership Development 59 It wasn’t until my undergrad, my postbasic RN. And that, oh my gosh. I mean, I had amazing teachers. And I was introduced to Benner’s [From] Novice to Expert and Simone Roach. So amazing teachers and amazing authors and that’s how I learned about being a leader. Extending Mentorship. Receiving mentorship was formative for each of the participants. However, Extending Mentorship and supporting others in their development as a leader also emerged as an important subtheme. This pay-it-forward attitude seemed to have a profound effect on the ongoing professional development of these outstanding leaders, as well as on those receiving mentorship. One person stated, “I think that’s a good, a sign of a good leader too, is that you’re generous with your time.” Another participant said, Our best leaders, my best, most idolized leaders really believed in mentorship and practiced it. . . . [P]eople who wouldn’t be on your radar at all really showed me the way. Who tapped me on the shoulder and said, “I really think you could do this.” So the notion of a chapter on mentorship and that that mentorship doesn’t mean you wait passively until people come to you. It means you reach out and you see clinical leadership of the unit in a young person and you ask that young person “Would you like to come and talk to me? Come on and see me.” When there are jobs available, so many don’t have the confidence to apply for that job because they can’t see it themselves. A different participant described it like this: Mentoring others looks like caring for others in a deep and authentic way because who they are is something I really believe in and unfortunately nursing as a profession sometimes does not live up to that statement. Real leadership development will be with people who energize each other. Nursing Leadership Development 60 This person went on to describe her desire to be like a mentor she had: And then, with her help, I moved up to being a clinical nurse specialist. She was an exceptional leader. She had a strong orientation to interprofessional care and a strong orientation to mentorship. I cannot tell you how many careers this woman has launched of others. She had a deep caring for those we serve but also the staff who care for people. I hope to be like her one day. Speaking about former students she encounters from time to time, one participant described extending mentorship this way: I get a lot of joy out of seeing people who were my students—I taught nursing for a couple of years at the [XX] and I see now, you know, one of my students is the president of the provincial association. And I have people who come up to me and say “Do you remember when you taught me peds?” or whatever. But to see those people doing so well just brings me so much joy. This individual has continued to mentor both formally and informally. In her current role she is mentoring another nursing leader who lives in a different province. I’m mentoring someone right now. We’re just doing this telephone kind of thing and we talk on the phone once a month. And we had this conversation, um, last Friday and we spent most of our time with me encouraging her to just to be the leader she actually is and not try to be someone else. That’s what a good mentor will do. Receiving and extending mentorship were, and continue to be, important in the lives of the participants in this study. This symbiotic relationship between established leaders and developing leaders lays the foundation for the next two subthemes: Promoting Nursing and Promoting Nurses. Nursing Leadership Development 61 Promoting Nursing. Analysis of the interviews highlighted that one of the primary motives for each of these leaders was, and continues to be, promotion of nursing across all domains of the profession. This correlates to the CNA position statement, which declares that “Canada’s healthcare system needs a steady supply of visionary and energetic nursing leaders across the domains of the discipline” (CNA, 2009, p. 1). This motivation is certainly broad in nature, since nursing is the largest group of healthcare professionals in Canada. Yet, with the principle of relentless incrementalism these leaders worked toward promoting the profession in the time and place they were in. One participant stated, Do you know what? It’s really interesting because one of the things I’ve always been amazed at is about, is how, when the president-elect of the CNA is elected, it’s amazing how the right person gets elected for the issues that will face the CNA when that person actually becomes president. One study participant shared throughout the interview that she was very motivated by wanting to help others and help her profession. The following is her statement about why she ran for the office of CNA president specifically: There were some political issues going on in one of the provinces where there was the threat of division between the regulator, the association, and the union. And I had come to believe strongly that we need all three pillars, as the International Council of Nurses presents. And so these things were happening and there were threats of challenges from another province and I thought, I am really worried. And given what I know and believe and passionately hope for our profession, maybe I can bring some help to these solutions. And that was, without a word of a lie, the reason that I ran uh, for office. Another individual spoke about what motivated her journey to CNA presidency: Nursing Leadership Development 62 I had a pretty tortuous path to presidency for a few reasons but what it came down to is that I’m a really strong federalist at heart and a really, strong, um, Canadian, like “let’s all work together” type of a thing and CNA embodied that. And the more nurses I met from across the spectrum, I just kept thinking this is a powerful body of people who could really change things and that’s why I ran. Another person spoke about needing to decide which change to pursue among the many changes that were needed: I mean, there were so many things we could try to change but we needed to decide. Some of those things are still being done today. So whether it’s working with First Nations or continuing to develop leadership of other nurses or focusing on people from different cultural or religious backgrounds. Those are changes I felt I could influence. One person expressed a belief that all nurses should be motivated to see things change: You need to make a contribution. Go to another country and work there for a bit or get on the board at Oxfam or the Red Cross or something local. Find something you’re passionate about. It’s making the connections and having some substance, having a seat at the table and making a contribution. I mean, that’s why I do most of the things I do. I want to make a contribution. Another contributor to this study repeated the same sentiment throughout the interview: “I could see something was wrong, so I felt I should fix that.” And, “Once I finished my education I realized there were more problems than I initially thought so I started more education because there had to be solutions.” She went on to say, “So I decided to do a PhD to be better at research because, I felt that one of the problems in nursing was we didn’t have enough Nursing Leadership Development 63 knowledge.” The impetus of seeing problems and wanting to find solutions culminates in this statement: “I mean, that’s why I became president. To fix things. It’s always been to fix things.” Promoting Nurses. Along with promoting the profession, the participants were also passionate about promoting nurses. They spoke about the importance of every nurse seeing themselves as a leader. Each participant believed this concept should continue to be supported. One participant described it this way: I believe I have a distinct role as a designated leader. But I believe we are all leaders. And nursing to me, I always say to nurses, you know what, pretty much no one is with you when you are with your patient. You are by yourself with your patient. You are leading your practice. You are a leader in that practice. Another individual was emphatic when she spoke about this: So leadership is very simple. It’s the degree of influence you have over others, uh, toward a common goal. And, I always, that’s why I say every nurse has leadership, the issue is, is to exercise it. A different participant believed that leadership comes from nurses returning to foundational practice: “Return nursing back to its roots [of primary healthcare] and we will lead from that. That’s where nurses will take our leadership from.” The themes presented thus far have been positive and inspirational. However, to present only themes focusing on the optimistic aspects of leadership development would be disingenuous to information shared by the participants. The fifth theme highlights the primary difficulty each participant encountered in the leadership journey. Nursing Leadership Development 64 Enduring Heartbreak The word heartbreak highlights a depth of grief, sorrow, or anguish that cannot be expressed by another word. This word was often used when the participants were asked to “describe the most difficult time for you during your time as president or president-elect of the CNA.” Every participant told a story of division or conflict within the nursing profession. Words and phrases such as profound loss, heartbreaking, demoralizing, sad, and wounding were used to describe these situations. One participant answered this way: Um, there were two things. One was, and I feel very emotional as I speak to this. I’m a nurse in [XX] province and under my leadership we lost that province at the CNA table. Then I, out of principle, I had to withdraw from my own association. It was a very sad situation. She described details about how the process of this separation occurred. She then likened it to the nursing profession as a whole: “These are the things that I hate as a nursing leader. We do these things to each other. I can’t stand it.” Later she expanded: We don’t put wind beneath each other’s wings. We kill each other. I’ve seen it in practice settings. I’ve seen it in academia. And I certainly saw it at CNA and so much of our time at CNA was taken up by people who were wanting to cut us off at our knees. A different participant also spoke about division. Answering the question quickly she stated, So, it was the issue in [XX] province. The issue started when I was president-elect and then continued from there. It was the hardest thing on many accounts. The hardest thing on an emotional level to see that group of nurses. The public members were more supportive than the nurses. Nursing Leadership Development 65 As she described a second experience, she talked about the emotional strain of being a leader during times of divisiveness: Those two things were extremely difficult and needed navigation of the highest order, which leads me to say that, for those types of positions, they should be near the end of your career trajectory and not the beginning. Divisiveness will destroy you if you don’t have experience. Again, another individual described a time of threatened division and separation: The nurses from province [XX] didn’t want to be part of CNA anymore. The provincial association was only telling them part of the truth and so I told them, “You are professionals. You need to provide your membership all of the information for them to vote.” So we went on the road with an invitation from every other riding explaining what the benefit of being a member of the CNA did and when it came time to vote they voted overwhelmingly to stay. This person went on to describe the process over the next year when leadership of the provincial association pushed again for separation from the CNA: The members of the board were so mad that they had lost that vote that they said, “Next time we’re not going to give the members information. We will just tell them our position.” And that’s what they did and we lost that province. It was a very difficult time. It’s still so sad. One participant was president-elect during one of the previously described situations: I think as president-elect I have a really good example. It was difficult for me, it was difficult for me to be part, to work with her, alongside her, when [XX] province wanted to remove itself from the CNA. She tried so hard with letters and meetings, to work with Nursing Leadership Development 66 them but to no avail. She is so composed publicly but behind the scenes I’ve seen her weep. This person expanded further: It was heartbreaking, absolutely heartbreaking. And the angst and the hard feelings and the sabre rattling and the insults. I just kept thinking, are we not better than this? Like, if we treated our patients like this we, we could not call ourselves nurses. But we treat each other in the terrible, bullying way, that I, just, you know, it was heartbreaking, so from a, from a feelings point of view and an emotional point of view that was something that really, uh, was difficult. A different participant also spoke of national division as being a source of distress during her presidency: There’s no doubt for me that it was the [XX] provincial association experience. This was the first rumblings about this province, which I happened to come from. So that my own provincial organization would do that was just devastating to me. And what was further devastating was we had a special meeting because of the outcry. And the eloquence and impassioned pleas of the speakers fell on deaf ears. It truly scared me in the sense of being seared into my memory banks that you could have people that articulate, that eloquent, that committed, that passionate fall on deaf ears. How is that possibly a member-driven organization? She described the situation further: “So we had to, uh, go through a process that challenged that, what was happening and that was very, very difficult. Very, um, very divisive.” She concluded talking about this by stating, “That was very painful to me. It’s actually still very painful.” Nursing Leadership Development 67 Finally, another participant described her most difficult time as president of the CNA this way: Well, within CNA, I think the most difficult challenge is when different provinces question their membership in the CNA. It had a sense of history being changed. One province had decided to go and CNA was still grieving over that. And another province was talking about it. I mean, there were a lot of emotions. And it certainly had impact for CNA in Canada but, more so, it would have impact on CNA’s international voice in ICN [International Council of Nurses]. Each of the participants spoke about division on a national level as it pertained to the CNA and the unity of RNs across Canada. Yet, as noted above, they also spoke about how this division was indicative of division within the profession itself. These happenings of a divisive nature were carried by these people whether they had been president recently or not. The study participants were unanimous in what was most difficult for them as president of the CNA. The heartbreak of division, whether recent or remote, was carried by each of these people, yet it did not impede them from continuing to develop as leaders and to embrace opportunities. Because the participants took opportunities, the final theme, A Seat at the Table, emerged. Taking a Seat at the Table The themes presented thus far were common in all of the interviews. But to present only common themes would not represent the diverse group of people who were interviewed. Each of the study participants has had a unique effect on healthcare in Canada, specifically related to the nursing profession. Their time in the volunteer positions of president-elect and president of the Nursing Leadership Development 68 CNA exposed them to exclusive opportunities. These stories personify the themes but stand out as unique and inspirational. One participant related the following story: The minister had invited the CNA and me to join her delegation to the WHA [World Health Assembly]. The CNA has never been invited in the past. So it was our first. I’ve never been to the United Nations. So we went and I was part of a 20-person delegation with the minister. So, four of those people sit on the floor of the United Nations and the others sit in the level above. So I was supposed to be in the level above until the night before, when the minister sends a note to us saying, “I’ve changed my mind. Instead of this person, I’d like you to be on the floor with us.” And I’m sitting on the floor of the United Nations with, like, so many delegates on the floor. It’s exactly how we see it on TV. With the Canadian flag in front. With the minister, and I’m thinking, how did I get here? And my home country is in the room. It was a magical moment like that where you feel, where did I come from and how did I get to this place? Another encouraging story was from an individual who helped start the first PhD program in Canada. She spoke about this in relation to her own desire to complete a PhD in Canada, and not the United States, for the purpose of promoting the nursing profession: And so, and one of the things I wanted to do was to get money to start a PhD in nursing. There were 52 programs in the States and none in Canada. So I uh, I decided I wanted to do a PhD in nursing now to be better at research because that, I felt, was the problem in nursing. But I didn’t want to be a special-case student. I wanted to have a funded program. And I did a whole bunch of things to make money available for nursing. And Dr. [XX], who was the dean at the university, said, “Will you come as a special-case student?” And I said “No, but I’ll make you a deal. If the PhD isn’t funded by the time Nursing Leadership Development 69 I’m ready to come out there I will get it funded. And once it’s funded you can admit me as the first regular student.” So I got there and started some political action with the students at the master’s degree and the PhD and some faculty and it took us 14 months and we got the PhD funded, which was the first one in Canada. One participant shared stories about two projects she led while she was president of the CNA: I can share two things that I did during my term as president. The first is the Council of [the] Federation and linking with the premiers across the country. And second is the nursing commission on the future of health. I was committed to deliver on my fiduciary responsibility but I’m interested in providing some future vision. The premiers were working very hard on, on communicating messages on how to do things and so, but they were getting nowhere. And I thought that the CNA, with the collective wisdom and experience and the know-how of the system and the care, could contribute to their thinking. But I also realized that going it alone will not work because politicians are afraid of interest groups. So we aligned with the Canadian Medical Association and eventually we got an audience with them. This story embodies Relentless Incrementalism as this person, working with another organization, got herself invited to the table. She created an opportunity where she could share her message and invite herself to work with the government for the purpose of transformation: And basically the message we had was, healthcare is a complex issue. Any transformation will be very difficult and you are better at trying to do the transformation with our two associations and we are willing to work with you and we are willing to take some bullets from our members because we believe transformation is important. Nursing Leadership Development 70 This participant described another initiative which she played a pivotal role in: The commission on health was very important to me. At the time everybody had a report and nursing didn’t. And given that we are the largest healthcare professional group in the country it didn’t serve us well. Because we walked into somebody’s office, a politician or whatever, we didn’t have a manifesto. I didn’t want it to just be from nurses so I lobbied for the commission to be co-chaired, nurse, nonnurse. Through the efforts of a number of people we had some unbelievable people. We had a senator, we had others, and the report was very strong. It made some impact. People still refer to it today. There was involvement by a study participant in a significant government report. This participant emphasized that the right person becomes president of the CNA at the right time: When the president-elect of the CNA is elected, it’s actually 2 years before they become president, and it’s amazing how the right person gets elected for the issues that face CNA at that time. So when I was elected, when I become president-elect, things were on the horizon but there was no concrete work towards like the Royal Commission or anything, and that 2 years, the Chrétien government started that Royal Commission on healthcare which was Romanow’s report. Senator Kirby was doing a mental health review for the country; I’m trying to think what the other big issues were—the whole idea of integrating healthcare within the professions, that sort of thing and yet, when I was running for president-elect, none of that was even on the horizon and when I became president, like there we were, in the lock-up with the Romanow Report and that became where my skills as an educator to take complex issues and communicate them to the public or whatever became key. Nursing Leadership Development 71 Summary The in-depth description of the CNA presidents’ experiences as part of nursing leadership development added context and richness to the existing plethora of philosophical and theosophical discussions regarding this topic. The study participants embody the themes outlined in this chapter and highlight how leadership development has taken place for these individuals. Although the findings of this study arise from a small purposive sample, the next chapter discusses how these themes may be applicable to nursing leaders today across all domains of the profession. Nursing Leadership Development 72 Chapter 5: Discussion In this chapter the themes presented in Chapter Four will be discussed in relation to scholarly literature. The overarching theme of Relentless Incrementalism will be discussed first. Relentless Incrememtalism, as a process for achieving personal and professional goals, demands courage and perseverance from nursing leaders.. The themes of Embracing Opportunities, Taking the Longview, and Enduring Heartbreak in relation to nursing leadership development will be discussed next. A Service Mindset will be discussed in relation to authentic leadership and Taking a Seat at the Table will be discussed as a result of nursing leadership development and advancement. Relentless Incrementalism: Pursuing a Vision According to Kouzes and Posner (2012), “Leaders get people moving. They energize and mobilize. They take people and organizations to places they have never been before” (p. 1). Similarly, Grossman and Valiga (2013) noted that “the ability to see a new world, or a different world, and mobilize others to help make it a reality is one of the hallmarks of leadership” (p. 9). Furthermore, according to De Pree (2008), “leadership can never stop at words. Leaders must act, and they must do so only in the context of their beliefs. Without action or principles, no one can become a leader” (p. 4). Thus, according to these authors, the ability to energize and move people toward a vision is the beginning of leadership. Whether or not leaders can maintain that energy themselves over a long period of time is the stamina of leadership and is related to the theme of Relentless Incrementalism. The concept of relentless incrementalism is primarily connected to businesses and technology in the literature. One article published in 2016 (Corring, Speziale, Desjardins, & Rudnick) referenced relentless incrementalism related to shifting frontline healthcare culture. Nursing Leadership Development 73 Overall, the idea is associated with changing systems or something outside of a person. Relentless incrementalism, as a concept, surfaced in the last decade and is defined as “a process in which something substantial is built through the accumulation of small but incessant additions. The concept of relentless incrementalism derives from economics and social policy and is used in various areas of information technology and business management” (“Relentless Incrementalism,” 2015). The phrase is used when describing the leadership role in a large or long-term project. The emphasis is on how change is achieved in stages or steps and how one person’s change may not achieve the end goal but may be a stepping stone for another individual to effect change. The utilization of relentless incrementalism in this study refers to nurses who are developing as leaders with the vision to effect change by their ability to persevere and the embodiment of moral courage, according to the experiences of participants in this study. Building something substantial through the accumulation of small but incessant additions is reinforced by the findings in this study. Relentless Incrementalism is also related to transformational leadership theory because the goal of this theory is attempting to inspire others to fulfill a vision (Rolfe, 2011). Visions of organizations are often overwhelming and may seem out of reach. However, creating achievable goals within the vision may help the leader inspire others to move toward the collective goal. This could be achieved by embracing the concept of relentless incrementalism and could prove to be beneficial to those who align with this leadership theory because transformation of systems, ways of thinking, behaviors, and attitudes are lofty objectives (Covey, 1992). Relentless Incrementalism is not only important in the positional or organizational aspects of leadership. It is also imperative in character development. Each of the participants in Nursing Leadership Development 74 this study showed relentless incrementalism in their personal growth as a leader which coincided with positional advancement. The characteristics of the authentic leader, genuineness, transparency, trustworthiness, and inspirational, presented by Murphy (2015) are characteristics which each of these leaders matured in over time, or incrementally. The development of these characteristics transpired in the context of Embracing Opportunities and Enduring Heartbreak while Taking the Longview and required these leaders to be courageous and to persevere. This supports the CNA (2009) position statement on nursing leadership, which stated that the nursing profession needs leaders who are courageous. Courage is an important factor in being able to apply relentless incrementalism. What does it mean to be courageous? Is this considered to be important in the literature? Interestingly, much of the nursing literature which refers to courage as necessary for nurse leaders are one-page opinion articles, addresses by editors of journals, or online blog posts written by nurses that attempt to inspire nurses to be courageous. In an interview in Nursing Leadership, Ginette Lemire Rodger stated, Nurse leaders need to be courageous. In a time of so much movement in society, when leaders cannot see precisely what the future looks like, they need to be driven by a vision. They need to have the courage to speak out about beliefs and values. (“Ginette Lemire Rodger: On Knowledge and Influence,” 2006, p. 20) Business sources also highlight courage as an important leadership quality. Arshavskiy (2016) stated, “True leaders have the courage and determination to pursue their endeavors by either surmounting or circumventing the barriers to their accomplishments” (p. 11). A study that evaluated the efficacy of an authentic leadership course in an undergrad program (Waite, McKinney, Smith-Glasgow, & Meloy, 2014) highlighted that one of the pillars of leadership is the self-pillar: “The self-pillar encompasses developing one’s self and truly Nursing Leadership Development 75 recognizing one’s authentic purpose, values, vision, and courage” (p. 284). No further explanation of what courage means was provided. An opinion article in the British Journal of Healthcare Assistants did delineate what courage means and asserted that it is imperative to being able to advocate for patients: The NHS Commissioning Board Chief Nursing Officer and DH Chief Nursing Adviser (2012) suggest courage enables us to do the right thing for those we offer care to, to speak up for them when we have concerns and the personal strength and vision to innovate. (Peate, 2015, p. 218). Business sources highlight the characteristic of courage as a necessity for leadership. A search on the Ivey Business Journal website returns more than 70 articles either highlighting or referencing courage, and on the Harvard Business Review website, the same search returns 65 results. One of those articles, titled “Courage as a Skill” written by Reardon (2007), stated that in business, courageous action is really a special kind of calculated risk taking. People who become good leaders have a greater than average willingness to make bold moves, but they strengthen their chances of success—and avoid career suicide—through careful deliberation and preparation. Business courage is not so much a visionary leader’s inborn characteristic as a skill acquired through decision-making processes that improve with practice. In other words, most great business leaders teach themselves to make high-risk decisions. They learn to do this well over a period of time, often decades. (pp. 2–3) The findings of this study reinforce the business assertions that courage is the ability to work toward a goal which we know to be right and beneficial for the profession and the people we serve. Nursing Leadership Development 76 If courage is required of a leader, as identified in business literature, in some nursing literature, and in the CNA (2009) position statement on leadership, why is this characteristic not more readily discussed within the context of nursing leadership? Courage must be present in all nurses, from nursing school to retirement, within multiple practice settings. Thus, encouraging nurses to be courageous in an editorial or opinion article is lacking. Nurses must be empowered with an understanding of what courage is, be encouraged by nurses who have been courageous, and be given the opportunity to be courageous themselves. The other characteristic related to Relentless Incrementalism in the findings is perseverance. Perseverance is similar to but not the same as relentless incrementalism. It is defined as “continued effort to do or achieve something despite difficulties, failure, or opposition” (“Perseverance,” n.d.). Perseverance is practically realized through relentless incrementalism as goals are achieved one step at a time. This practice of perseverance helps leaders to accomplish excellence and fulfill their vision. A commitment to pursuing excellence does not just happen; it does not just randomly occur. Doing whatever it is that must be done requires an ongoing attention that is initiated and maintained. . . . [T]he pursuit of excellence must be vigorously and relentlessly incorporated into everything we think, say and do. (Grossman & Valiga, 2013, p. 207) The combination of courage and perseverance, as Relentless Incrementalism, empowers leaders to work toward goals and vision. This step by step approach is woven throughout all aspects of leadership and is applicable to all domains of nursing practice. Relentless Incrementalism can empower all nurses as leaders to grow personally and professionally in order Nursing Leadership Development 77 to embrace opportunities, endure heartbreak, take the long view, have a service mindset and ultimately take a seat at the table. Embracing Opportunities: Opportunities Are the Paths to Success Merriam-Webster defines opportunity as a “favorable juncture of circumstances and a good chance for advancement or progress” (“Opportunity,” n.d.). Bennis (2009) equated opportunity with empowerment, and Yoder-Wise (2015) agreed when they stated that individuals “become empowered when they gain access to opportunities” (p. 190). For the purpose of this study, opportunity is considered to be a fortuitous event which empowers an individual toward leadership advancement. Victor Chasles, a French writer in the early 1800s, is credited with saying “The surefire way to miss success is to miss opportunity” (as cited in Hess, n.d). The participants in this study would agree. Each of them emphasized that without embracing opportunities they would not have developed as leaders or achieved high-level leadership positions. Leaders are people who make leadership opportunities happen and encourage others to join them in those opportunities. “A leader is an individual who works with others to develop a vision of the preferred future and to make that vision happen” (Yoder-Wise, 2015, p. 37). In the findings, leadership sometimes arose out of forged opportunities or opportunities that were intentionally pursued, welcomed, and even fought for. Forging an opportunity is what Herminia Ibarra (2015) described as acting like a leader in order to think like a leader. She stated, I have found that people become leaders by doing leadership work. Doing leadership work sparks two important, interrelated processes, one external and one internal. The external process is about developing a reputation for leadership. . . . The internal process concerns the evolution of our own internal motivations and self-definition. . . . The cycle Nursing Leadership Development 78 of acting like a leader and then thinking like a leader—of change from the outside in— creates what I call outsight. (p. 4) The findings of this study show that the participants forged opportunities for themselves not because they were seeking to be leaders or to obtain a position of leadership. Inspiration came from personal necessity when one participant was fighting to save her career after ongoing health problems. Another participant forged an opportunity by lobbying for a nursing research position for the purpose of improving the nursing profession. A third participant was motivated by a need to protect the title of RN. Forging an opportunity was not about seeking positional leadership; however, exercising leadership skills often resulted in leadership positions. Perhaps knowingly, or unwittingly, these leaders were embracing the concept of transformational leadership. Leaders who embrace this theory “are visionaries, catalysts, motivators, and goal oriented, futuristic leaders who invoke group respect, shared vision, and improved culture” (Rolfe, 2011, p.56). Forging opportunities continues to be a possibility for nursing leaders who seek influence transformation across the domains of the profession. Further, being a transformational leader may inspire others to forge opportunities for themselves as an impact on the followers (Fischer, 2016). In a systematic review of leadership styles, Cummings et al. (2010) found that, “factors reflecting individual, team and organizational productivity and effectiveness were reported to be higher, in 13 of 18 studies in this category, in association with charismatic, transformational and change oriented leadership” (p.378). Embracing opportunities of every kind caused each of the participants to become increasingly cognizant of themselves and what they hoped to achieve as a nurse and ultimately a nursing leader. This byproduct of opportunities resulted in these leaders becoming more authentic or aware of themselves and their values and beliefs which are important aspects of Nursing Leadership Development 79 authentic leadership (Yoder-Wise, 2015). When self-awareness and transparency happens others are more likely to follow (Murphy, 2015). Therefore, the opportunities were not only important in a hierarchical sense of climbing the ladder but were important in a developmental sense of character and skills. This affirms Ibarra’s (2015) theory that acting like a leader can result in thinking like a leader. She asserted that leadership opportunities are given by a leader to a would-be leader for the purpose of creating a leader. The participants in this study often created opportunities where none had existed in the past and exercised leadership skills they already embodied, thus affirming and contradicting Ibarra’s theory. Forging opportunities is often achieved because of a sense of obligation. Thus, forging opportunities and obligatory opportunities are joined by common motivations outside of the individual. In every profession there are times when individuals must do things they don’t want to do, or are encouraged along a path they had not foreseen. Further, there are times when individuals feel obligated to a leader or a boss. Then there is nursing obligation, which plays a key role throughout a nurse’s career. Storch, Rodney, and Starzomski (2013) stated, “Nursing obligations are the site where the integral connection between responsive relationships and ethical practice comes to the foreground” (p. 147). Peter and Liaschenko (2004) highlighted that proximity to others is one way that nurses understand what their obligations are: “Proximity beckons moral agents to act and therefore has an impact on moral responsiveness” (p. 219). Obligation, also called duty, is built into practice standards of the College of Registered Nurses of British Columbia (CRNBC), the regulatory body for RNs throughout the province (CRNBC, 2012). Duty has been defined as the binding or obligatory force of something that is morally or legally right; moral or legal obligation (“Duty,” n.d.). Nursing Leadership Development 80 The participants in this study often agreed to opportunities because of this sense of moral obligation. Statements such as “Nurses are suckers for anyone who needs help”; “So, I mean, you can do this, so why wouldn’t you?; “I never really wanted to be a leader but I wanted to help”; and “There’s work to be done and you, I mean, you can say it’s somebody else’s business but if everybody says that then nothing gets fixed” emphasize the pull of the study participants toward what they perceived to be right or good. These statements also reveal that obligations may arise from an external need but are responded to because of an internal drive. Storch et al. (2013) contended that obligations are local events—they are matters of flesh and blood. Obligation is the feeling that comes over us in very binding ways when others need our help or support and we feel obligated to respond (Storch et al., 2013, p. 149). Obligation, or duty, is not only present in modern regulatory language. In 1893, Lystra Gretter wrote a pledge in honor of Florence Nightingale. Nurses often take this pledge upon graduation and vow to be loyal to God, to the profession, and to those being cared for. From the inception of nursing, obligation to things outside themselves has been encouraged in nursing and nurses. Yet, actualizing the response arises from something internal. Obligatory opportunities, as presented in the findings, do not differ fundamentally from forged opportunities. Both are a result of responding to an internal drive regarding an outward circumstance. Both are embarked upon because of a sense of loyalty. This is also seen when an individual is presented with an unexpected opportunity. Unexpected Opportunities, or opportunities encouraged or provided by a leader or peer, emerged as a unique subtheme. This type of opportunity was commonly among the first, if not the first, leadership experience of the participants. The opportunity arose early in their career when they still considered themselves novices. They stated they felt unprepared for these Nursing Leadership Development 81 opportunities but embraced them nonetheless as learning experiences. A case study of deans of nursing states, It is important that talented people are recognized as leaders of the future as early as possible in their careers. In addition, these future leaders should be given every chance to grow and develop through exposure to opportunities to develop the skills and the attributes necessary for effective deanship (Wilkes, Cross, Jackson, & Daly, 2015, p. 284). Bennis (2009) discussed a similar concept. To Bennis, opportunities are something to be given by established leaders to those who may become leaders: “Leadership opportunities should be offered to all would-be leaders early in their careers, because they build drive, trigger a can-do spirit, and inspire self-confidence” (p. 179). Unexpected opportunity is incumbent on the ability of leaders to recognize leadership potential in others. Without leaders being able to identify who future leaders may be, leadership development will be hindered. The ability of nursing leaders to be able to recognize future leaders is imperative for the success of the profession in years to come because the profession requires leaders. Nursing leadership plays a pivotal role in the immediate lives of nurses and it has an impact on the entire health system and the Canadians it serves. Therefore, Canada’s health system requires a steady supply of visionary and energetic nursing leaders across the domains of the discipline who are credible, courageous, visible and inspiring to others and who have the authority and resources to support modern, innovative and professional nursing practice. (CNA, 2009, p. 1). Nursing Leadership Development 82 The provision of leadership opportunities is crucial to growth as a leader, as stated by Ibarra (2015) and Bennis (2009). Without the unexpected, first opportunities, the participants in this study would not have grown as leaders. Kouzes and Posner (2012) stated, Let’s get something straight. Leadership is not preordained. It’s not a gene, and it’s not a trait. There is no hard evidence to support the assertion that leadership is imprinted in the DNA of only some individuals and that everyone else missed out and is doomed clueless. Leadership can be learned. It’s an observable pattern of practices and behaviors and a definable set of skills and abilities. (pp. 334–335) Literature clearly supports the argument that great leaders need opportunities to learn and practice leadership skills. These opportunities should be encouraged early in an individual’s career to allow time for leadership skills and abilities to grow within the supportive context of mentoring. Unlike forged and obligatory opportunities, unexpected opportunities are often accepted because another person suggests they are possible, not because participants sense a moral obligation to the task. The unexpected opportunities offered to the participants in the study allowed them to exercise an intrinsic motivation. The “it” factor in this type of opportunity is an individual’s desire to excel. Kouzes and Posner (2012) said, Although leadership can be learned, not everyone wants to learn it and not all those who learn about leadership master it. Why? Because becoming the very best requires having a strong desire to excel, a strong belief that new skills and abilities can be learned, and a willing devotion to deliberate practice and continuous learning. No matter how good you are you have to always want to be better. (p. 335) Nursing Leadership Development 83 Forged, obligatory, and unexpected opportunities are opportunities which are contingent upon internal drivers. For example, these drivers could be ethical and moral obligation to the profession and to those who are being served, or motivation to learn and improve. Those who embrace opportunities not only take a risk on behalf of others, they also risk themselves and find themselves disappointed occasionally. The participants in this study asserted that unsuccessful attempts at opportunity were just as, if not more formative. Trapp (2014) affirmed this, stating, “It is now conventional wisdom that we learn as much—if not more—from failure as from success” and “the notion of ‘intelligent failure’ is increasingly being regarded as an essential component in the innovation process” (para. 1). Kadlic (2016) stated, “If you fail, as long as you learn something you have not lost. People need to get more comfortable with missing the outcome they wanted” (p. 16). This idea that failure can be beneficial for success is understood but not necessarily embraced. Failures are often revealed after success is achieved. Bennis (2009) dedicated a section in his book to failures and success. He presented the stories of a number of successful people such as actors and business executives. Bennis stated, There are lessons in everything, and if you are fully deployed, you will learn most of them. . . . The point is to use your experiences rather than being used by them, to be the designer, not the design, so that the experiences empower rather than imprison. (p. 92) This path of failure can also help achieve authenticity in leaders. Murphy (2015) stated, dredging up memories of early experiences and relationships can be painful, which is why this journey of personal transformation requires courage. However, what was once seen as a devastating experience may now be viewed as “a gift” because it prompted a new and positive direction in one’s life or career (p. 15). Nursing Leadership Development 84 The common theme among these individuals and the participants in this study is that they turned failure into a stepping stone toward their goals. The opportunity lost did not hinder them. They fashioned the impediment into an instrument of growth, leading to success. Once opportunities are embraced, leaders will need to have courage to endeavor to persevere one relentless increment at a time. Taking the Long View A common theme in the literature reviewed for this study stresses that one of the primary characteristics of a leader is someone who has vision, is able to set a vision, and can mobilize others toward a long-term goal. “Leadership is the process of engaging and influencing others. Strong leaders are associated with words such as visionary, energetic, inspirational and innovative” (Yoder-Wise, 2015, p. 6). These are qualities that will motivate people to follow, and without followers there is no leader. “To be effective, nurse leaders . . . must be visionaries, strategic thinkers, effective planners and managers of change” (Ferguson, 2004, p. 8). However, being able to articulate a vision so that others will join you is a skill that is often learned in a mentorship relationship. Mentorship. Mentorship is an important element of growing as a professional whether clinically, administratively, or as a leader. Yoder-Wise (2015) stated that “mentorship is a formal supportive relationship between two, or more, health professionals that has the potential to result in professional growth and development for both mentors and mentees” (p. 509). This formal relationship has the potential to influence staff retention. “[Mentors] can be a tremendous source of guidance for new nurses, nurse managers, and nurse educators in transition, serving both career and psychosocial functions” (Yoder-Wise, 2015, p. 509). Bennis (2009) said, Nursing Leadership Development 85 I know of no leader in any era who hasn’t had a mentor: teachers who found things in them they didn’t know were there, parents or older siblings, senior associates who showed them the way to be, or in some cases, not to be, or demanded more from them than they knew they had to give. (p. 85) All of the CNA presidents who were interviewed for this study emphasized that their leadership journey was influenced by a mentor, which is defined as “a trusted counselor or guide” (“Mentor,” n.d.). Receiving mentorship was central to how these leaders developed over the course of their careers. Learning from another leader, either positively or negatively, helps shape individual leaders who become mentors for future leaders. “Mentorship is integral to leadership development and is therefore a priority among diverse professional groups. It refers to learning in the context of career development and usually manifests as a supportive relationship with someone senior to the mentee” (Jeans, 2006, p. 29). Receiving and extending mentorship are both important in the development of leaders and in the continuance of vision. A study by McCloughen, O’Brien and Jackson (2009) concluded saying, it is anticipated that, when nurses who aspire to leader roles and hold positions of leadership gain a broader understanding of how mentoring relationships with this particular focus are created, they will be better positioned to recognise opportunities to develop these relationships and to action them (p. 334). The CNA (2009) position statement highlighted that mentorship is a characteristic of leadership: Leadership encompasses mentoring, coaching, supporting, rewarding and attracting leaders at all levels. Leadership does not just “happen” nor is it sustained without Nursing Leadership Development 86 intensive, ongoing support. Leadership exists as a continuum that evolves and is strengthened from a combination of innate and learned skills that must be groomed. (p. 2) Extending mentorship begins with a leader recognizing possible future leaders and with those future leaders embracing opportunities. Once an opportunity is embraced, the developing leader needs to be supported. The Dorothy Wiley Health Leaders Institute, a partner of the CNA, exists for this purpose, and has noted that “leadership development is both an investment in the present—by helping system leaders step up to new requirements and challenges—and an investment in the future – by providing for necessary leadership succession” (Dorothy Wiley Health Leaders Institute, n.d., para. 6). Ginette Lemire Rodger, a prominent nursing leader in Canada, noted the following about nursing leadership: It would be almost like layered mentoring. Who are the people who we can invest in for the first layer and what do we do for them to grow their leadership and to maintain so that they feel sustained and valued? So, you invest in that first wave and it’s up to them to invest in the second wave. (“Ginette Lemire Rodger: On Knowledge and Influence,” 2006, p. 20). Mentorship is significant in contemporary leadership theories but not explicit. Mentorship is often implicit because of the leader having close proximity and engagement with followers. This is true of transformational leadership which was found to have followers who felt more supported, were more likely to stay at a job and were inspired to help fulfill organizational goals (Yoder-Wise, 2015). Further, followers who have leaders sought to be transformational were more likely to engage in transformational leadership themselves which resulted in a positive impact on work environments (Yoder-Wise, 2015). Mentorship is also implicit in Nursing Leadership Development 87 authentic leadership and servant leadership theories which emphasize the importance of engaging with followers which has a positive impact on the follower and the work environment (Mortier, Vlerick & Clays, 206; Sipe & Frick, 2009). Mentorship is an important aspect of developing leadership regardless of which theory a leader chooses as a guiding principle. In an evaluation of leadership development program, MacPhee, Skelton Green, Bouthillette & Suryaprakash (2011) found, “all the interviewees acknowledged that the programme had helped them address their leadership challenges and their comments reinforced the importance of mentorship supports” (p. 166). Further, “mentorship is a two way street. In a mentoring relationship, aspiring leaders soak up knowledge and experience and should expect to return it by serving as a mentor to a young, aspiring leader in the future” (Yoder-Wise, 2015, p.43). Receiving Mentorship and Extending Mentorship are two key pieces of the larger vision of promoting nurses and the nursing profession. Promoting Nurses and the Nursing Profession. In a section called “Projections for the Future,” Yoder-Wise (2015) discussed a document called Toward 20/20: Visions for Nursing by Villeneuve and MacDonald, who completed a consultation for the CNA in 2006: “The authors observed: ‘Nurses can be at the forefront of the coming changes, setting the agenda to create a health care system that truly serves and reflects the priorities of Canadians but no one will appoint them to the task’” (p. 564). In keeping with a long-term vision or Taking the Long View, perhaps the most appropriate response to such documents is to promote the nursing profession itself, as opposed to, or at least in collaboration with, suggested solutions to current needs for reform in the healthcare system. Being appointed to the task should be of primary concern for the leaders of the nursing profession because we have been identified as change leaders. Nursing Leadership Development 88 Promoting Nursing and Promoting Nurses coincide. Each has an impact on the other. Nurses influence how the profession is viewed and experienced by those who are served. This directly aligns with the CNA (2009) position statement on nursing leadership, which stated that “Canada’s healthcare system needs visionary and energetic nursing leaders across the domains of the profession” (p. 1). Individual nurses embracing the characteristics of leadership across all practice domains will positively promote the nursing profession: “Nurses shape the public’s view of the profession, the organizations in which they work, and health care in general. Nurses influence interdisciplinary views of what it is to be a professional, and they create expectation for the profession’s potential” (Yoder-Wise, 2015, p. 559). The findings of this study align with the literature. In Canada, the nursing profession is made up of hundreds of thousands of RNs along with other members of the nursing family such as nurse practitioners. Promoting the profession is correlated to promoting an understanding that all nurses are leaders. This vision, for nurses and nursing, needs to be communicated across the domains of the profession. The following is from an American project but captures the importance of promoting nurses as leaders. Although the public is not used to viewing nurses as leaders, and not all nurses begin their career with thoughts of becoming a leader, all nurses must be leaders in the design, implementation, and evaluation of, as well as advocacy for, the ongoing reforms to the system that will be needed. Additionally, nurses will need leadership skills and competencies to act as full partners with physicians and other health professionals in redesign and reform efforts across the health care system. (Shalala et al., 2011, pp. 221– 222) Nursing Leadership Development 89 The CNA (2009) position statement reinforced this concept: “Nursing leadership is about critical thinking, action, and advocacy—and it happens in all roles and all domains of nursing practice” (p. 1). Promoting the profession and promoting nurses requires all nursing leaders to embrace the complexity of the system and the profession because healthcare is an ever changing environment. It is also a multi-faceted environment with the possibility of uncomfortable outcomes. Complexity theory requires leaders to be comfortable with uncomfortable situations (Chadwick, 2010) and to consider the interdependencies of the multiple parts of systems, in this case the nursing profession (Lanham et al, 2012). Engaging in the complexity of promoting nursing and nurses would require nursing leaders to apply relentless incrementalism in order to work toward achieving this goal one step at a time. Vision is an important aspect of all leadership theories because it is a defining characteristic of leaders. Bennis (2009) outlined three key ingredients for a leader: “a guiding vision, passion and integrity” (p. 33-34). Authentic leaders are “aware of themselves and true to their own values, beliefs, and vision” (Yoder-Wise, 2015, p.11). Studies have found that leaders who embody this theory positively influence their followers which results in increased interprofessional collaboration, being invigorated and are more positive about their work (Regan, Laschinger & Wong, 2016; Walumbwa et al. 2008; Mortier, Vlerick & Clays, 2016). Transformational leadership is also bound to vision. Production of a vision or transforming results is how the theory is defined as Yukl (2009) stated, “transformational leadership involves motivating individuals to do something different than before, or to do more than initially expected” (p.50). Therefore, casting a vision and inspiring others to join is a key aspect of a leader regardless of which leadership theory that leader embodies. Nursing Leadership Development 90 Much like promoting the nursing profession, promoting nurses as leaders is a topic which has not generated much literature. It is, at times, a recommendation for the purpose of achieving other goals as seen above in the Toward 20/20 report. In the current climate of Canada, and throughout the world, healthcare has many hurdles to overcome and goals to achieve. Perhaps nurses, the largest number of healthcare professionals, need to promote the profession and themselves as a solution to those problems. Taking the Long View, by giving and receiving mentorship, and promoting the profession and nurses will need to be led by nursing leaders who are able to create and realize a vision with courage and perseverance. This will also require relentless incrementalism and embracing step by step changes for future leaders to continue to build on. However, nurses who embark on a leadership journey need to be prepared for the possibility of disappointment and heartbreak. The Heartbreak of Horizontal Violence Being a leader can place an individual in a position of possible heartbreak. Leaders are often criticized and seldom praised. Two prominent leaders where I work have both separately stated to me, “People forget that I’m a person. No one ever asks me how I am.” The weight of the responsibility can weigh heavy on some. The participants in this study revealed that the primary source of heartbreak for them was division within the profession itself. They used examples such as nurses working against each other, bullying, harsh words, and dishonesty. A few of the participants expressed ongoing sadness or regret when discussing this part of their presidency experience. Yet, this was when many of the participants discussed the concept of relentless incrementalism or being empowered to persevere. Nursing Leadership Development 91 Horizontal violence, or lateral violence, “is an act of aggression that’s perpetuated by one colleague toward another colleague” (Longo & Sherman, 2007, p. 35). Eggertson (2011) cited a 2005 statistic: “In Canada, 44 per cent of female nurses and 50 per cent of male nurses report being exposed to hostility or conflict from people they work with” (para. 3). This is a phenomenon many nurses have experienced but few discuss. The article by Eggertson emphasized the prevalence of these behaviors: In 2010, Toronto researcher Claire Mallette led a study on horizontal violence at the University Health Network. Of the 160 nurses involved in the study, 95 per cent had observed horizontal violence and 71 per cent identified themselves as targets. (para. 6) Horizontal violence is not something that is experienced only by the young and inexperienced. Behaviors of violence and incivility, as seen in the statistics and in the experiences of the study participants, are frighteningly common in the nursing profession. If horizontal violence continues to abound, promoting the nursing profession could become increasingly difficult. Uncivil behaviors contribute to toxic workplaces and affect retention of nurses. The results of a study by Houshmand, O’Reilly, Robinson, and Wolff (2012) reveal that nurses not bullied directly, but who worked in an environment where workplace bullying occurred, felt a similarly strong urge to quit as those being bullied: “As a result of this moral uneasiness, bullying at large within a work unit will increase employee intentions to quit their work” (p. 906). Provision of education and opportunities for nursing leadership development may influence the incidence of horizontal violence in nursing. As leaders engage with and embody leadership theories such as authentic leadership, servant leadership and transformational leadership, there are often positive outcomes on work environments and organizations (Rolfe, 2011; Curtis, Sheerin and De Vries, 2011). A study by Mortier, Vlerick and Clays (2016) found Nursing Leadership Development 92 “that authentic leadership and leaders’ empathy, as perceived by their subordinates, are relevant in the nursing context. Authentic nurse managers express more empathy for their nurses, which subsequently influences nurses’ well-being, resulting in more invigorated nurses” (p. 363). While this does not discuss horizontal violence explicitly, invigorated nurses are unlikely to be experiencing or witnessing such behavior. Further, as Gordon (2012) stated, “that organizations that deliver the best service also have the best culture—where employees are valued, listened to and cared for, and, in turn, these employees value, care for and serve their customers” (p.40). This may also translate to how employees treat one another. Nurses, regardless of rank or experience, can display uncivil behaviors. However, as seen above, leaders who practice authentic servant leadership have been instrumental in the creation of moral communities that do not tolerate incivility and do focus on collaborative teamwork to enhance patient care. Also, as leaders treat their followers and each other, their followers will often imitate. Acknowledgement of horizontal violence is the beginning to creating solutions and to being able to work toward a common goal of promoting the future of nursing. However, leaders who embrace the long view of a profession without horizontal violence will need to be courageous and persevere with relentless incrementalism. A Service Mindset: An expression of authenticity The participants in this study aligned themselves with the theory of servant leadership which reflects an important aspect of nursing. The nursing profession, at its core, is about serving others. This is the CNA (2015) definition of an RN: RNs are self-regulated health-care professionals who work autonomously and in collaboration with others to enable individuals, families, groups, communities and populations to achieve their optimal levels of health. At all stages of life, in situations of Nursing Leadership Development 93 health, illness, injury and disability, RNs deliver direct health-care services, coordinate care and support clients in managing their own health. RNs contribute to the health-care system through their leadership across a wide range of settings in practice, education, administration, research and policy. (p. 5) Phrases such as collaboration with, support clients, and contribute to emphasize that nursing is an outward act for the purpose of benefitting others. And, as seen in the definition, this should occur across the domains of the profession as an expression of leadership. Being a servant leader embraces the characteristic of authenticity as part of being “insightful, ethical and principle centered” (Sipe & Frick, 2009, p.15). Servant leaders are people who are aware of themselves and their values and beliefs which are also imperative in authentic leaders. Other similar core concepts between servant leadership and authentic leadership are being genuine, having integrity and being transparent (Murphy, 2015, Sipe & Frick, 2009). Further, Walumbwa et al. (2008) discussed the importance of consistency between actions and beliefs which was also presented as an integral part of servant leadership (Sipe & Frick, 2009). Yancer (2012), who wrote an incredible article in Nursing Administration Quarterly, told her story of a being a newly appointed RN-CEO to a hospital that had given the previous administration a nonconfidence vote. The staff did not trust the administration, nor did the public. The title of the article is “Betrayed Trust: Healing a Broken Hospital Through Servant Leadership.” As RN-CEO, there were decisions that could have ended my career because of the political intricacies. Navigating those difficult courses, I relied on the advice of medical staff, both formal and informal leaders, and at times went against my personal comfort. Change sometimes took longer, but together we accomplished good, meaningful change Nursing Leadership Development 94 in a way that served the common interest. We were free to learn from each other, to show our vulnerabilities, and to coach each other. The more successful we were, the more successful we became. Over time the relationships deepened such that we could anticipate what the other would do or say. It is what you hope for in every team but rarely experience. (Yancer, 2012, p. 71) Yancer (2012) provided an amazing example of how servant leadership has the power to transform care and build trust. Likewise, a participant in the study described servant leadership as follows: Our policy comes from those we serve. We went into public spaces like town halls. Like nurses interacting with ordinary citizens of Canada to seek their input on—we’re educating them but we’re also seeking their input. Like, brilliant dancing here. And they shaped out the entire advocacy program for homecare. That’s what the citizens of Canada did. And then when you go with that to the politician, advocating for senior care with a senior at your side. That’s powerful. It’s serving people to empower them. The leaders in this study who embraced servant leadership as a guiding philosophy seemed to also become authentic leaders who inspired confidence in their followers. The inspirational presence of integrity and trustworthiness created a climate which led to fundamental changes in workplace culture and political culture as seen in the findings. Nurses who embody servant leadership as part of key administrative positions also have the possibility of transforming healthcare services, including nursing practices where nurses provide care for patients and their families. This could inspire nurse leaders who do not hold a positional leadership role to be servant leaders who are authentic in their workplace and at the bedside, Nursing Leadership Development 95 which could result in patient-centered care and increased satisfaction for the nurse and the patient. Taking a Seat at the Table: Inspired by the Past, Empowered for the Future Having a Seat at the Table is a distinct finding that is embedded in the stories and experiences of the study participants. The stories are personal to the study participants and embody the results of being a leader who was willing and able to relentlessly pursue goals and vision for the betterment of themselves and the nursing profession. The stories reveal the impact that being in leadership can have on government policy, workplaces, Canada-wide healthcare, and an individual life and offer inspiration to future nursing leaders. The power of telling stories as discussed in the literature is often related to education strategies or engaging employees. However, storytelling has been part of human history for eons and continues to be part of our everyday lives in the form of television, movies, books, social media, and interactions with others. John Kotter (2006) wrote, “Over the years I have become convinced that we learn best—and change—from hearing stories that strike a chord within us” (para. 1). Storytelling has been an effective means of communicating important substantive and cultural messages for thousands of years. The Bible is one of the best examples of how stories create a rich visual imagery in our minds, and great storytellers invite us to walk the landscape that is created by this imagery. Consciously or not, these are undoubtedly some of the reasons that storytelling has emerged as the preferred approach for teaching leadership effectiveness in many companies today. (Ready, 2002, p. 64) Wadsworth, Colorafi, and Shearer (2017) stated, “Storytelling is an ancient practice that has functioned to maintain history, deepen empathy and understanding, and empower groups and Nursing Leadership Development 96 individuals” (p. 1). The authors also stated, “Throughout our lives, we tell stories in various contexts and settings to communicate with others and construct meaning. Storytelling helps us develop our sense of coherence about the world in which we live” (p. 1). Stories can be compelling, especially when we can relate to them and find our own possibilities in them. When asked the question, “What would you include in a handbook on leadership?” one of the study participants answered, My leadership book would be a collection of stories from other people. I learned so much from stories and I love to tell stories too. So I think my leadership book would be a book of stories from leaders I admire and driving home the fact that you have to be yourself. Powerful stories of nurse leaders embodying Taking the Long View, Embracing Opportunities, Relentless Incrementalism, and A Service Mindset are evident as part of the CNA history. CNA presidents who sat on the floor of the United Nations at the World Health Assembly, contributed to the Romanow Report, and influenced the creation of the first PhD nursing program in Canada are but a few examples of this type of leadership embodiment. These stories serve to inspire nurses to develop and grow in their role as nurse leaders. Summary In this chapter the findings were discussed in relation to relevant literature. The findings affirm, challenge, and add to the literature on leadership development. Nursing research, education, and ongoing education are impacted by these findings. These implications, as well as limitations and recommendations, are discussed in the next chapter. Nursing Leadership Development 97 Chapter 6: Limitations, Implications, and Recommendations In this chapter, a summary of the research are provided and limitations of the study are presented. Implications and recommendations for nursing research, nursing education, and nursing practice will also be offered. Summary of the Study In the previous chapters the background, impetus, and question for this study were presented. The design and methodology were also presented, along with a review of the literature, which identified a gap. This gap is the professional development of nurse leaders. In reviewing the literature, it was also discovered that presidents of the CNA had not been interviewed about their personal and professional journeys of leadership development. The purpose of this study was to provide insight into the nuances of leadership development in nursing through an exploration of the professional experiences, characteristics, and reflections of CNA presidents. This study also examined how being a high-level nursing leader provides a gateway for change. This examination assisted to broaden the understanding of nursing leadership development and how nursing leadership can facilitate change that will serve as a valuable resource for the development of nurses as leaders. The purpose of this study was met through the following research objectives: 1. To explore and describe the leadership journeys of CNA presidents through semistructured interviews, including their leadership development, philosophy of leadership, and words of wisdom to nurses. 2. To gain an in-depth understanding of leadership development in nurses by drawing on the themes of these interviews in combination with scholarly literature. Nursing Leadership Development 98 Using a qualitative design, the method of interpretive description allowed me to purposefully select and interview CNA presidents for this study. Using semistructured interviews, data were collected through digital recording. The recordings were then transcribed verbatim and analyzed using an interpretive description method. Immersion was accomplished by repeated reading of the transcripts, listening to the interviews, and revisiting field notes. Through data analysis six themes emerged: Embracing Opportunities, Relentless Incrementalism, A Service Mindset, Taking the Long View, Enduring Heartbreak, and A Seat at the Table. The discussion of these themes showed there are implications and recommendations to be made for nursing research, nursing education, and nursing practice. Studying the nuances of CNA presidents’ leadership development, through an exploration of their personal and professional journeys, resulted in findings that could be concretely paired with scholarly literature. The findings also elicited implications and recommendations for the ongoing development of nursing leaders. Limitations One limitation of this study is the sampling procedure, which was a small, purposive sample of CNA presidents. Because this type of sampling is drawn from a particular population, with a particular angle on the experience of leadership and leadership development, the transferability of the findings to any population outside of those who seek to serve as president of the CNA may be limited (Thorne, 2016, p. 99). A second limitation of this study is interviewing as a means of data collection. “Because discourse is so intertwined with the dynamics of human social experience, it is quite easy for a qualitative health research interviewer to capture findings that, in effect, reflect simply the popular thinking about human experience” (Thorne, 2016, p. 139). The possibility that both the Nursing Leadership Development 99 researcher as instrument and the study participants engaged with the interview with specific presuppositions limits the data transferability. Therefore, it is important that qualitative researchers who rely heavily on interviews therefore must retain some humility about what it is they are uncovering and have an obligation to reflect the particular relationship to time and place that their findings reflect. And this becomes one important reason for restraint in generalization, both in the doing of the research and in the reporting of the implications of your eventual findings. (Thorne, 2016, p. 139) These limitations may impede the transferability of the findings of this particular study. However, implications and recommendations for nursing research, nursing education, and nursing practice did arise from the findings. Implications for Nursing Research The findings of this study suggest there are multiple areas where research could increase the understanding of nursing leadership development. CNA presidents were, and to a certain extent remain, an untapped resource of knowledge. This is also true of other positional leaders such as chief nursing officers and nurses who serve as executive directors and vice presidents of hospitals and health authorities across Canada. However, because all nurses are leaders, research focusing on nursing leadership development across the domains of the profession would elicit some interesting findings. As presented throughout this study, the CNA (2009) statement asserted that nursing leadership is important for the future of the profession. According to the findings, opportunities are crucial for nurses to develop their leadership skills, and more often than not, those opportunities are provided by another leader. Research examining how a future leader can be objectively recognized by a current leader would benefit positional nursing leaders and would-be Nursing Leadership Development 100 nursing leaders across the country. This could have positive implications for focused leadership development and succession planning, both of which are needed in nursing today. Many successful leaders today have experienced failures in the past. This includes nursing leaders who hold significant positions of power and trust. However, discussions about the positive effects of failure are often avoided in healthcare. Research exploring how failure and success are linked may serve to remove the perception of shame surrounding failure, while also empower nursing leaders of today, and tomorrow, to pursue nursing leadership development opportunities. Implications for Nursing Education While nursing leadership is taught in baccalaureate nursing programs across Canada, the primary focus tends heavily toward historical theories and leadership being equated to nursing management. According to the findings, the crux is shifting this focus to include leadership characteristics, including all nurses as leaders, which may prove to be beneficial to individual students and the nursing profession as a whole. Nursing education has a distinct opportunity to address the subject of nursing leadership development. This could be reinforced, much like clinical practice, with the provision of leadership opportunities and exposure to leadership mentors. Nursing education continues past graduation as continuing education. Abraham (2011) stated, “It is essential that organizations implement strategies related to nursing leadership development and enhancing professionalism among staff nurses” (p. 306). Ongoing professional development provided by employers, associations, regulators, and unions should focus on nursing leadership development for all nurses as leaders. Courses and workshops should be well advertised and marketed to nurses across all practice settings. As stated previously, would-be Nursing Leadership Development 101 leaders often need an opportunity to realize their potential; therefore, continuing education opportunities should be encouraged by a positional leader. Provision of this type of professional development would benefit the employer and employee while ensuring the presence of nursing leadership for the benefit of the whole profession. However, it is also important to remember that “nurse leadership education is a complex, multifaceted process that encompasses a world of knowledge and experiences beyond formal education” (O’Connor, 2011, p. 336). Implications for Nursing Practice There are almost 400,000 RNs in Canada. The majority of these nurses work in areas other than research and education, although they are affected by both. Practice settings range from urban to rural to remote, from community to acute to residential care, and from newborn to geriatric. Every domain of nursing requires and produces leaders. The findings of this study suggest that it is the responsibility of all nurses across the domains of the profession to seek to develop leadership characteristics regardless of their title or position. The Professional Standards for Registered Nurses and Nurse Practitioners in British Columbia, published by the CRNBC (2012), stated that each nurse “is accountable and takes responsibility for own nursing actions and professional conduct” (pp. 8–9). This professional standard infers that every nurse exercises leadership in his or her own practice. However, nursing leaders who hold formal positions of leadership have a distinct responsibility. As seen in this study, leaders need to cast a clear vision for those they lead. This produces an environment of trust and loyalty. Leaders who are able to create and communicate vision will empower those they lead to be courageous and persevere, realizing goals one step at a time. Nursing Leadership Development 102 Identifying would-be leaders and providing opportunities for them to develop leadership skills and characteristics are also important for positional leaders. Erickson (2013) stated, There are some qualities and characteristics of great leaders, inspiring, honest, intelligent, influential, trustworthy, and visionary that are inherent in that person. Tasks can and inevitably will be learned. Identifying, developing, fostering, exposing and mentoring those persons with inherent leadership qualities can serve as a trial period for leadership succession evaluation and can simultaneously bolster the organization. (p. 48) Empowering leaders early in their career through opportunities and mentoring is wise succession planning and beneficial for staff morale. This would serve to inspire nurses throughout their careers and across all practice settings. Of utmost importance, for all nurses as leaders, is to seek to eradicate horizontal violence in all practice settings. The ethical practice standard published by CRNBC (2012) stated that all nurses are to practice in an ethical manner. Each nurse “treats colleagues, students and other health care workers in a professional manner and recognizes and respects the contribution of others on the health care team” (CRNBC, 2012, pp. 18–19). Setting high expectations which align with the regulatory body for professional behavior and respectful workplaces is fundamental for professional and leadership development to flourish. Positional leaders should cast a vision for a work environment that is free of horizontal violence across all levels and areas of nursing practice. Summary This study of seven nursing leaders, who have all served as CNA president, addresses a gap in the literature through the exploration of the development of leadership skills and characteristics of nurses as leaders. The findings of this study shed light on the nuances of Nursing Leadership Development 103 leadership development as experienced and understood by the study participants. In combination with scholarly literature, the findings serve to provide wisdom to nursing leaders across the domains of the profession. This study provides an example of the benefits of exploring untapped leadership resources in the nursing profession. Ongoing nursing research regarding the process of nursing leadership development across all practice areas and nursing positions would provide insight into how all nurses as leaders would serve to promote the nursing profession. Leadership in nursing education should be separated from the position of manager and discussed as a concept which every nurse embodies. Leadership training during nursing education should also provide opportunities for nursing students to exercise leadership skills. Nursing leadership in nursing practice, in both position and character, should be identified and encouraged through the provision of ongoing education and opportunities. Identifying nurses as leaders has the potential to transform the culture of nursing practice in every aspect of practice. Embracing all nurses as leaders and learning from the wisdom of those who have served in leadership positions, such as CNA president, will help to address the ongoing need for self-aware, courageous, credible, and inspiring nursing leaders for today and in the years to come. Nursing Leadership Development 104 References Abraham, P. J. (2011). Developing nursing leaders: A program enhancing staff nurse leadership skills and professionalism. Nursing Administration Quarterly, 35(4), 306–312. Arshavskiy, M. (2016). Great leadership: Skills and traits for highly effective leaders. Leadership Excellence Essentials, 12, 10–11. Bennis, W. (2009). On becoming a leader: The leadership classic. New York, NY: Basic Books. Bernard, N. (2014). Who’s next? Developing high potential nurse leaders for nurse executive roles. Nurse Leader, 12(5), 56–61. Bondas, T. (2006). Paths to nursing leadership. Journal of Nursing Management, 14, 332–339. Brooks, B. A., Crawford, L. H., Nicklas, G. E., & Soldwisch, S. (2014). Nursing leadership education: An innovative executive solution. Journal of Nursing Administration, 44(12), 669–672. Canadian Association of Schools of Nursing. (2015). National nursing education framework: Final report. Ottawa, Canada: Author. Canadian College of Health Leaders. (2010). Key points for leadership growth: A checklist for leaders. Ottawa, Canada: Author. Canadian Nurses Association. (2009, October). Nursing leadership [Position statement]. Ottawa, Canada: Author. Canadian Nurses Association. (2015). Framework for the practice of registered nurses in Canada. Ottawa, Canada: Author. Canadian Nurses Association. (2017). About CNA. Retrieved from: https://www.cnaaiic.ca/en/about-cna. Nursing Leadership Development 105 Carrick, L., Clarke, S., & Thompson, J. (2008). Solving the leadership dilemma: Where will nursing’s next leaders come from? Pennsylvania Nurse, 63(1), 12–13. Chadwick, M. M. (2010). Creating order out of chaos: A leadership approach. Association of Perioperative Registered Nurses Journal, 91(1), 154–170. College of Registered Nurses of British Columbia. (2011). Practice standard for registered nurses and nurse practitioners: Duty to Report. Vancouver, Canada: Author College of Registered Nurses of British Columbia. (2012) Professional standards for registered nurses and nurse practitioners. Vancouver, Canada: Author. College of Registered Nurses of British Columbia. (2013). Competencies in the context of entry level registered nurse practice in British Columbia. Vancouver, Canada: Author. Corring, D. J., Speziale, J., Desjardins, N., & Rudnick, A. (2016). Relentless incrementalism: Shifting frontline culture from institutional to recovery-oriented mental healthcare. Healthcare Quarterly, 18, 17–21. Covey, S. (1992). Principle-Centered Leadership. New York, NY: Summit Books. Cummings, G. G., MacGregor, T., Davey, M., Lee, H., Wong, C. A., Lo, E., . . . & Stafford, E. (2010). Leadership styles and outcome patterns for the nursing workforce and work environment: A systematic review. International Journal of Nursing Studies 47(3), 363– 385. Curtis, E. A., Sheerin, F. K., & de Vries, J. (2011). Developing leadership in nursing: The impact of education and training. British Journal of Nursing, 20(6), 344–352. De Pree, M. (2008). Leadership jazz. New York, NY: Random House. Dorothy Wiley Health Leaders Institute. (n.d.). History. Retrieved from http://healthleadersinstitute.ca/about/history/ Nursing Leadership Development 106 Duty. (n.d.). In Merriam-Webster’s online dictionary. Retrieved from https://www.merriamwebster.com/dictionary/duty Eggertson, L. (2011, June). Targeted. Canadian Nurse. Retrieved from https://www.canadiannurse.com/articles/issues/2011/june-2011/targeted Erickson, J. I. (2013). Reflections on leadership talent: A void or an opportunity? Nursing Administration Quarterly, 37(1), 44–51. Fennimore, L., & Wolf, G. (2011). Nurse manager leadership development: Leveraging the evidence and system-level support. Journal of Nursing Administration, 41(5), 204–210. Ferguson, S. (2004). Developing nurse leaders for today and tomorrow. Nursing Management, 10(9), 8–9. Ferguson, S. L. (2015). Transformational nurse leaders key to strengthening health systems worldwide. Journal of Nursing Administration, 45(7/8), 351–353. Fischer, S.A. (2016). Transformational leadership in nursing: A concept analysis. Journal of Advanced Nursing, 72(11), 2644-2653. Florence Nightingale quotes. (n.d.). In Biography online. Retrieved from http://www.biographyonline.net/humanitarian/quotes/f-nightingale-quotes.html Frederickson, K., & Nickitas, D. (2011). Chief nursing officer executive development: A crisis or a challenge? Nursing Administration Quarterly, 35(4), 344–353. Galuska, L. A. (2012). Cultivating nursing leadership for our envisioned future. Advances in Nursing Science, 35(4), 333–345. Ginette Lemire Rodger: On knowledge and influence. (2006). Nursing Leadership 19(4), 17–21. Gordon, J. (2012, July/August). Leadership: Being a servant leader. Healthcare Executive, 40. Nursing Leadership Development 107 Gould, D., Kelly, D., Goldstone, L., & Maidwell, A. (2001). The changing training needs for nurse managers: Exploring issues for continuing professional development. Journal of Advanced Nursing, 34(1), 7-17. Gretter, L. (1893). Nightingale pledge. In Wikipedia. Retrieved from https://en.wikipedia.org/wiki/Nightingale_Pledge Grossman, S. C., & Valiga, T. M. (2013). The new leadership challenge: Creating the future of nursing. Philadelphia. PA: F. A. Davis. Hess, B. (2015, November 9). The sure way to miss success is to miss an opportunity [Blog post]. Retrieved from http://www.visionsolar.com/blog/tag/victor-chasles/ Houshmand, M., O’Reilly, J., Robinson, S., & Wolff, A. (2012). Escaping bullying: The simultaneous impact of individual and unit-level bullying on turnover intentions. Human Relations, 65(7), 901–918. Ibarra, H. (2015). Act like a leader, think like a leader. Boston, MA: Harvard Business Review Press. Jeans, M. E. (2006). Strengthening mentorship for leadership development. Nursing Leader, 19(2), 28–30. Jenkins, M., & Stewart, A. C. (2010). The importance of a servant leader orientation. Health Care Management Review, 35(1), 46–54. Kadlic, J. (2016, August). Failing is not losing, if you learn. Smart Business Cleveland, 16. Kotter, J. (2006, April 12). The power of stories. Forbes. Retrieved from http://www.forbes.com/2006/04/12/power-of-stories-oped-cx_jk_0412kotter.html Kouzes, J., & Posner, B. (2012). The leadership challenge: How to make extraordinary things happen in organizations. San Francisco, CA: Jossey-Bass. Nursing Leadership Development 108 Laframboise, L. E. (2011). Making the case for succession planning: Who’s on deck in your organization? Nursing Leadership, 24(2), 69–79. Lanham, H. J., Leykum, L. K., Taylor, B. S., McCannon, C. J., Lindberg, C., & Lester, R. T. (2013). How complexity science can inform scale-up and spread in healthcare: Understanding the role of self-organization in variation across local contexts. Social Science and Medicine, 93, 194–202. Leader. (n.d.). In Merriam-Webster’s online dictionary. Retrieved from https://www.merriamwebster.com/dictionary/leader Leadership. (n.d.). In Merriam-Webster’s online dictionary. Retrieved from https://www.merriam-webster.com/dictionary/leadership Longo, J., & Sherman, R. O. (2007). Leveling horizontal violence. Nursing Management, 38(3), 34–51. MacPhee, M., & Bouthillette, F. (2008). Developing leadership in nurse managers: The British Columbia nursing leadership institute. Nursing Leadership 21(3), 64–75. MacPhee, M., Skelton-Green, J., Bouthillette, F., & Suryaprakash, N. (2012). An empowerment framework for nursing leadership development: Supporting evidence. Journal of Advanced Nursing, 68(1), 159–169. McCloughen, A., O’Brien, L., & Jackson, D. (2009). Esteemed connection: Creating a mentoring relationship for nurse leadership. Nursing Inquiry, 16(4), 326–336. McDonagh, K. J., & Paris, N. M. (2013). The leadership labyrinth: Leveraging the talents of women to transform health care. Nursing Administration Quarterly, 37(1), 6–12. Mentor. (n.d.). In Merriam-Webster’s online dictionary. Retrieved from https://www.merriamwebster.com/dictionary/mentor Nursing Leadership Development 109 Mitchell, G. J., Cross, N., Wilson, M., Biernacki, S., Wong, W., Adib, B., & Rush, D. (2013). Complexities and health coaching: Synergies in nursing. Nursing Research and Practice, 2013, 1–7. Mortier, A. V., Vlerick, P., & Clays, E. (2016). Authentic leadership and thriving among nurses: The mediating role of empathy. Journal of Nursing Management, 24, 357–365. Murphy, L. G. (2015). Becoming an authentic leader. OR Nurse, 9(4), 12–15. O’Connor, M. (2011). Beyond the classroom: Nurse leader preparation and practices. Nursing Administration Quarterly, 35(4), 333–337. Opportunity. (n.d.). In Merriam-Webster’s online dictionary. Retrieved from https://www.merriam-webster.com/dictionary/opportunity Pate, M. F. D. (2013). Nursing leadership: From the bedside to the boardroom. AACN Advanced Critical Care, 24(2), 186–193. Peate, I. (2015). Without courage the other C’s will crumble. British Journal of Healthcare Assistants, 9(5), 218. Perseverance. (n.d.). In Merriam-Webster’s online dictionary. Retrieved from https://www.merriam-webster.com/dictionary/perseverance Peter, E., & Liaschenko, J. (2004). Perils of proximity: A spatiotemporal analysis of moral distress and moral ambiguity. Nursing Inquiry, 11(4), 218–225. Polit, D. F., & Beck, C. T. (2012). Nursing research: Generating and assessing evidence for nursing practice. Philadelphia, PA: Lippincott Williams & Wilkins. Ready, D. A. (2002, Summer). How storytelling builds next-generation leaders. MIT Sloan Management Review, 64–69. Reardon, K. K. (2007, January). Courage as a skill. Harvard Business Review, 2–7. Nursing Leadership Development 110 Regan, S., Laschinger, H. K., & Wong, C. A. (2016). The influence of empowerment, authentic leadership and professional practice environments on nurses’ perceived interprofessional collaboration. Journal of Nursing Management, 24, E54–E61. Relentless incrementalism. (2015, February). In WhatIs.com. Retrieved from TechTarget website: http://whatis.techtarget.com/definition/relentless-incrementalism Rolfe, P. (2011). Transformational leadership theory: What every nurse leader needs to know. Nurse Leader, 9(2), 54–57. Scott, E. S., & Miles, J. (2013). Advancing leadership capacity in nursing. Nursing Administration Quarterly, 37(1), 77–82. Shalala, D. E., Burnes Bolton, L., Bleich, M., Brennan, T., Campbell, R. E., Devlin, L., . . . Vladeck, B. C. (2011). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Sipe, J. W., & Frick, D. M. (2009). Seven pillars of servant leadership: Practicing the wisdom of leading by serving. Mahwah, NJ: Paulist Press. Spano-Szekely, L., Quinn Griffin, M. T., Clavelle, J., & Fitzpatrick, J. J. (2016). Emotional intelligence and transformational leadership in nurse managers. Journal of Nursing Administration, 46(2), 101–108. Storch, J., Schick Makaroff, K., Pauly, B., & Newton, L. (2013). Take me to my leader: The importance of ethical leadership among formal nurse leaders. Nursing Ethics, 20(2), 150– 157. Storch, J.L., Rodney, P., & Starzomski, R. (2013). Toward a moral horizon: Nursing ethics for leadership and practice. Toronto, Canada: Pearson. Nursing Leadership Development 111 Streubert, H. J., & Rinaldi Carpenter, D. (2011). Qualitative research in nursing: Advancing the humanistic imperative. Philadelphia, PA: Lippincott Williams & Wilkins. Thorne, S. (2016). Interpretive description. New York, NY: Routledge. Trapp, R. (2014, March 31). Successful leaders celebrate their failures. Forbes. Retrieved from https://www.forbes.com/sites/rogertrapp/2014/03/31/successful-leaders-celebrate-theirfailures/#6d14c65a6d14 Wadsworth, P., Colorafi, K., & Shearer, N. (2017). Using narratives to enhance nursing practice and leadership: What make a good nurse? Teaching and Learning in Nursing, 12, 28–31. Walumbwa, F., Avolio, B., Gardner, W., Wernsing, T., & Peterson, S. (2008). Authentic leadership: Development and validation of a theory based measure. Journal of Management, 34(1), 89–126. Waite, R., McKinney, N., Smith-Glasgow, M. E., & Meloy, F. (2014). The embodiment of authentic leadership. Journal of Professional Nursing, 30(4), 282–291. Wilkes, L., Cross, W., Jackson, D., & Daly, J. (2015). A repertoire of leadership attributes: An international study of deans of nursing. Journal of Nursing Management, 23, 279–286. Yancer, D. A. (2012). Betrayed trust: Healing a broken hospital through servant leadership. Nursing Administration Quarterly, 36(1), 63–80. Yoder-Wise, P. S. (2015). Leading and managing in Canadian nursing. Toronto, Canada: Elsevier. Yukl, G. (2009). Leading organizational learning: Reflections on theory and research. The Leadership Quarterly, 20(1), 49–53. Yukl, G. (2012). Effective leadership behavior: What we know and what questions need more attention. Academy of Management Perspectives, 26(4), 66–85. Nursing Leadership Development Yukl, G., & Mashud, R. (2010). Why flexible and adaptive leadership is essential. Consulting Psychology Journal: Practice and Research, 62(2), 81–93. 112 Nursing Leadership Development 113 Appendix A: Literature Search Date Database Keywords Used Results October 2015 CINAHL Complete "Nurs* lead*" and "professional develop*" and Canada 39 results “Nurs* lead*”and “professional develop*” and “lead* educat*” 123 results “Nurs* lead*” and “lead* educat*” and “Canada” 73 results “Nurs* lead*” or “manage” or “lead* educat*” 366,221 October 2015 October 2015 Medline Biomedical Reference (17 Articles chosen to review) "Nurs* lead*" and "professional develop*" and Canada 43 “Nurs* lead*”and “professional develop*” and “lead* educat*” 9 “Nurs* lead*” and “lead* educat*” and “Canada” 1 “Nurs* lead*” or “manage” or “lead* educat*” 56,956 (8 Articles chosen to review) "Nurs* lead*" and "professional develop*" and Canada 2 “Nurs* lead*”and “professional develop*” and “lead* educat*” 0 “Nurs* lead*” and “lead* educat*” and “Canada” 3 “Nurs* lead*” or “manage” or “lead* educat*” 10,649 Nursing Leadership Development October 2015 October 2015 ERIC Business Source Complete 114 (0 articles chosen to review) “Nurs* lead*” and “professional develop*” and “Canada” 2 “Nurs* lead*”and “professional develop*” and “lead* educat*” 0 “Nurs* lead*” and “lead* educat*” and “Canada” 1 “Nurs* lead*” or “manage” or “lead* educat*” 8,422 (0 articles chosen to review) “Nurs* lead*” and “professional develop*” and “Canada” 20 “Nurs* lead*”and “professional develop*” and “lead* educat*” 0 “Nurs* lead*” and “lead* educat*” and “Canada” 0 “Nurs* lead*” or “manage” or “lead* educat*” 81,762 (0 articles chosen to review) Nursing Leadership Development 115 Appendix B: Letter of Invitation Principal Investigator: Laura Colley, BScN, RN Masters of Science in Nursing Student, TWU [contact information deleted] Faculty Advisor: Maggie Theron, DCur, RN Assistant Professor, School of Nursing, Trinity Western University 7600 Glover Road Langley, BC Canada V2Y 1Y1 To Whom it may concern: You are invited to participate in a study called “Leadership Journeys of High Level Nursing Leaders: A Case Study of CNA Presidents” because you have served or are serving in the capacity of President or President Elect of the Canadian Nurses Association (CNA). The purpose of this study is to provide insight into the nuances of leadership development in nursing through an exploration of the professional experiences, characteristics and reflections of CNA presidents. These experiences may broaden the understanding of nursing leadership development and should serve as a valuable resource for the development of nurses as leaders. If you agree to take part in this study you will be asked to take part in a 45 to 90 minute interview with the Principal Investigator regarding your personal journey of nursing leadership from graduation from nursing school to your term as CNA President. This interview will take place in person or by Skype at your convenience. Nursing Leadership Development 116 A consent form outlining details of the study will be sent to you for you to review prior to the interview taking place. If the interview is done in person you will be asked to sign the consent form. It the interview takes place over Skype, the consent form will be reviewed with you and verbal consent will be recorded as part of the interview process. Please respond to the Principal Investigator, Laura Colley, at [email deleted] as to whether or not you agree to take part in this study. I look forward to the possibility of learning from your expertise as a high level nursing leader. Sincerely, Laura Colley, BSN, RN Nursing Leadership Development 117 Appendix C: Consent Principal Investigator: Laura Colley, BScN, RN Masters of Science in Nursing Student, TWU [contact information deleted] Faculty Advisor: Maggie Theron, DCur, RN Assistant Professor, School of Nursing, Trinity Western University 7600 Glover Road Langley, BC Canada V2Y 1Y1 You are invited to participate in a study called “Exploring the Leadership Journeys of High Level Nursing Leaders: A Case Study of CNA Presidents” because you have served or are serving in the capacity of President or President Elect of the Canadian Nurses Association (CNA). If you agree to take part in this study you will be asked to take part in a 45 to 90 minute interview regarding your personal journey of nursing leadership from graduation from nursing school to your term as CNA President. Your participation is entirely voluntary, so it is up to you to decide whether or not to take part in this study. Before you decide, it is important for you to understand what the research involves. This consent form will tell you about the study and why the research is being done. Nursing Leadership Development 118 If you wish to participate, you will be asked to sign this form. If you do decide to take part in this study, you are still free to withdraw at any time and without giving any reasons for your decision. If you do not wish to participate, you do not have to provide any reason for your decision not to participate. Background: The CNA is the national organization which serves the Registered Nurses of Canada by promoting nursing as a profession and protecting healthcare through the influence of public policy at the federal level. In 2014, the CNA published a position statement on leadership which emphasizes the importance of nurses functioning as leaders at every level of nursing. Leadership development is also highlighted. This is described as a continuum of leadership. One example of intentional leadership development is the CNA succession plan of former president, current president and president-elect serving concurrently. Nurses throughout Canada, at every level, could benefit from the collective wisdom of high level nursing leaders such as those who have served, are serving or will serve as the President of the CNA. What is the purpose of this study? The purpose of this study is to provide insight into the nuances of leadership development in nursing through an exploration of the professional experiences, characteristics and reflections of Nursing Leadership Development 119 CNA presidents. These experiences may broaden the understanding of nursing leadership development and should serve as a valuable resource for the development of nurses as leaders. Participation: Participation is limited to individuals who have served or are serving as President or President Elect of the CNA. Involvement: The study involves engaging in a 45-90 minute semi-structured interview which will be face to face or via Skype at the convenience of the participant. What are the risks involved with this study? Although leadership may not considered a sensitive topic, a debriefing discussion will be available upon request to address any unforeseen emotional experiences that may be elicited during the interview. What are the benefits of being in this study? No one knows whether you will benefit from this study, however, you may experience positive exposure as an example of professional development. There is also hope this study will be used to benefit the development of nursing leaders. You may also gain a greater understanding of your leadership skills and philosophy. What happens if I choose to withdraw from this study? Nursing Leadership Development 120 Your participation in the study is entirely voluntary. Should you decide to withdraw from the study, the information gathered during the interview will not be included in the analysis, discussion or conclusion of the study. No explanation will be necessary. What happens after the study is complete? Participants in this study will have the opportunity to read the completed thesis study once it has been approved by the thesis committee. An electronic copy of the completed thesis will be emailed to each participant. Do I have the option to be anonymous? Although this study involves public figures, pseudonyms will be used. Will the interviews be kept confidential? The original interview material will be heard by the Principal Investigator and a hired transcriptionist. The thesis committee will be privy to the transcribed interviews only. The recorded interviews and transcriptions will be kept on a password protected computer that will only be accessible to the Principal Investigator for 5 years. Nursing Leadership Development 121 Questions If you have any questions or require further information with respect to this study, you may contact Laura Colley at [contact information deleted] or her Faculty Advisor Maggie Theron at 604 513 2121 ext. 3018 or Maggie.Theron@twu.ca If you have any questions or concerns about your treatment or rights as a research participant, you may contact Ms. Sue Funk in the Office of Research, Trinity Western University 604 513 3142 or sue.funk@twu.ca Subject Consent to participate: Your signature below indicates that you have had your questions about the study answered to your satisfaction and that you have received a copy of this consent form for your own records. Your signature indicates that you consent to participate in this study: ___________________________________ __________________________________ Printed Name Signature Principal Investigator: ___________________________________ ___________________________________ Printed Name Signature Nursing Leadership Development 122 Appendix D: Interview Questions 1) Please describe your journey to becoming the President of the CNA. 2) Do you recall what you learned about leadership in nursing school? 3) Please describe when you first considered yourself to be a nursing leader. What motivated you to become a leader? 4) What is your definition or philosophy of leadership? Describe how this philosophy has changed over time. 5) The CNA published a Position Statement on Nursing Leadership in 2014. It states that “Nursing leadership plays a pivotal role in the immediate lives of nurses and it has an impact on the entire health system and the Canadians it serves. Therefore, Canada’s health system requires a steady supply of visionary and energetic nursing leaders across the domains of the discipline who are credible, courageous, visible and inspiring to others and who have the authority and resources to support modern, innovative and professional nursing practice.” Please tell me about a time when this was true about yourself or another nursing leader. 6) Is there a story that embodies what it means to be a ‘visionary and energetic nursing leader’? 7) Describe the most difficult time for you in nursing leadership. 8) If you could go back and give advice to yourself earlier in your career what would it be? 9) From your experience in becoming a high level nursing leader, what is the best advice you can give to Nursing Leaders today and in the future? Nursing Leadership Development 123 10) In their book, The New Leadership Challenge: Creating the Future of Nursing, Sheila Grossman and Theresa Valiga state, “Because there is no procedure book on the leadership skills necessary for nurses to acquire (contrary to the clinical skill procedures that are described specifically), nurses must be prepared to help each other lead in the dynamic health-care arena of the future. They lead based on what had been successful in the past and what they learn from others (e.g) through reading, listening to presentations, observing or studying others)”. If you could write a handbook for leadership what would it contain? What have been imperative leadership skills for you? 11) Finally, in your role as CNA President what did you change about Nursing Leadership if you had the opportunity? How would this effect Nursing and future Nursing Leaders?