Copyright is owned by the Author of the thesis. Permission is given for a copy to be downloaded by an individual for the purpose of research and private study only. The thesis may not be reproduced elsewhere without the permission of the Author. A process evaluation of a shared leadership model in an intensive care unit by Clare Lynette Eden Turner A thesis submitted to Massey University in partial fulfilment of the requirements for the degree of Master of Arts in Nursing. Massey University, New Zealand 2001 Abstract Shared leadership has been touted in the United States and United Kingdom as a model of staff management that fosters active involvement of staff, in this case nurses as experienced professionals, in patient management. This study uses process evaluation for the examination of a shared leadership model in an intensive care environment following a period of significant change and restructuring. The model was based on the shared leadership literature (Porter-O'Grady, 1992) which focuses on clinical practice as a key accountability and on decentralised clinical leadership at the point of service. The model aligned with the skill acquisition framework used by the employer organisation called the Professional Development Programme (PDP). This programme aims at enhancing the development of expertise in clinical practice and supports the principles of shared leadership. This research study was undertaken to evaluate the process of implementation of the model and to discover whether there is evidence nurse involvement in the management of patient care. The results are based on the responses of 104 registered nurse respondents (56%) working in the intensive care unit of a specialised hospital. Documentation was also examined for evidence of nursing input into indirect patient management process development. The results indicate that nurses are becoming more settled in their working environment and feel more confident in their ability to provide an active role in the management of their patients within a multidisciplinary team. 11 Acknowledgement I wish to acknowledge the encouragement and support I have received from fami ly, friends, colleagues and academic staff over the past years. In particular I would like to thank my husband David, and son Dale for their support and understanding. I would like to acknowledge my supervisor, Mary Finlayson, who has encouraged me as I have worked to bring together my considerable data and ideas. She has been challenging and questioning of my work and has raised my awareness and reflection in my academic work. Finally, I would like to dedicate thi s work to the nursing leaders of the past who pioneered the professionalism of nursing and fostered autonomy of practice, and to the future nursing leaders who will continue working at the frontiers of change. iii Title page Abstract Acknowledgement Table of contents Appendices Table of Contents List of tables and figures Chapter One Introduction Context of thesis ........... . .. .. .... ......... . ......... .... ...... . Thesis construction, style and flow ..... . .... . .. . . .. . . ................ . . The influence of the researcher . ... ...... ... ... ................. . .. . . . Conclusion .............. .. ................ .... . ... ... .... . .. ........ . .. .. . Chapter Two Literature Review Leadership .............. ... .... ................. . .. .. ..... . .. . ........... . . Leadership in nurs ing ............. .... ................... . ........ . ... . . Shared leadership . .............. . ......... .. . .. . .. . ... .. ................ . . Conclusion ................ .. .............. . .... . ....... . ......... .... .. . . Chapter Three Methodology 11 Ill IV V I Vil 1 - 18 2 15 17 17 19-42 20 22 25 41 43 - 65 Programme evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 The research framework used for the study . . . . . . . . . . . . . . . . . . . . . . 52 The research approach: process, monitoring or implementation evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Ethical considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Analysis of data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 IV Table of contents, continued Chapter Four Results and Analysis 66 - 113 The questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Response data: General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Response data: Direct involvement in patient management 75 Relationships with other health care disciplines . . . . . . . . . . . . . . . . . . 82 Indirect patient management......................... . . . . . . . . . . . . . . . . . . . 88 General clinical practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Analysis of comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Examination of documents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 Chapter Five Discussion 114 - 127 Planned approach to the change process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 l 5 Relationships, decision making and teamwork . . . . . . . . . . . . . . . . . . .. 116 The use of Benner skill acquisition model . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Management of change . ............... .. .. ... .......................... 125 Comparison and reflections on the study.............. . . . . . . . . . . . . . 126 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Chapter Six Conclusions and Recommendations 128 - 135 Involvement with patient management.................................. 128 Strengths and limitations of the study.......................... . . . . . . . . . . 130 Recommendations. ..... . .. ..... ..... .. .. .. . .. ... . . ........ . ..... .. ..... . ... 133 Reference List 136-139 V Table of contents, continued Appendices Page l Therapeutic Intervention Scoring System (TISS) 140 - 142 2 Service Structure (ICU Review, 1997) 143 3 Intensive Care Leadership Model (March, 1998) 144 4 Shared Leadership Model in relation to Service (March, 1998) 145 5 Questionnaire: Survey of nurses 111 the Cardiothoracic 146-150 Intensive Care Unit to assess the level of active involvement in patient management (Oct/Nov, 2000) 6 Information sheet (Oct/Nov, 2000) 151-152 7 Approval letter from Massey University Human Ethics 153-155 Committee 8 Approval letter from "The Hospital" 156 9 Third party access to patient information 157 VI List of tables and figures Tables, t,J.~ 1 ,; Titles ' ,''' . 11 T,l. . ;' Page ( ij, ··~' ··"' . {\- •t ,, ·~ ·' ,, .. •-,, '" ~· Table I Professional Development Programme categories 13 Table 2 Diagrammatic representation of the process followed for this 16 study Table 3 Overview of total results from the questionnaire 68 Table 4 Length of time registered nurses have worked in ICU 69 Table 5 Total critical care experience 70 Table 6 Experience of nurses from other speciality areas 73 Table 7 Secondments to other nursing positions 73 Table 8 Ward rounds 76 Table 9 Response regarding multidisciplinary team meetings 78 Table 10 Total results from the section on relationships with other 82 healthcare disciplines Table 11 Comments categorised into sections corresponding closest to 98 questions Table 12 Categorisation of documents which were examined 100 Table 13 Table showing summary of documents examined 104 N Figttre ,.,,.., Figure 1 Comparison between nurses' length of stay in ICU and 71 critical care experience Figure 2 Comparison between length of stay in study ICU and total 72 years of critical care experience in senior nurses Figure 3 Secondment by levels 74 Figure 4 Comparison of ward rounds and MDT meetings 80 Figure 5 CNS responses to Ward Rounds and Multidisciplinary team 81 meetings Figure 6 Senior responses to Ward rounds and Multidisciplinary team 81 meetings Vll Figures, continued Fi~urt\ w i H~ )i}{\1} ,i,:~· ·1~".V ,~,\if /'' .. ~; /f' Titles ,- ·d~ ' •¥" 1s1 \ .. ~ages " .½~ tj •. . ' ' :Ii: ,. y .. ,. . , " Figure 7 Junior responses to Ward rounds and Multidisciplinary team 82 meetings Figures Responses to approachability & opinions by medical staff 85 8&9 Figures Nursing staff opinions & approachability 86 10 & 11 Figures Allied Health staff opinions and approachability 87 12 & 13 Figure Responses of nurses to their involvement in documentation 89 14 processes Figure Division of responses between nurses' level of practice 91 15 regarding the question on nurses ' involvement in documentation development Figure Nurses ' responses to involvement in the quality of nursing 93 16 practice Figure Nurses involvement in quality of nursing practice by levels . 94 17 Figure Confidence in own clinical practice by levels of professional 95 18 development Figure Comments from nurses divided into level of practice 99 19 Figure Changes supporting nurses' autonomy of practice in 103 20 documentation development Vlll