Journal of Nursing Management, 2009, 17, 1525

Nursing leadership and management effects work environments

ANN MARRINER TOMEY
PhD, RN, FAAN

Professor Emeriti, Indiana State University, College of Nursing, Health and Human Services, North Fort Myers, FL, USA

Correspondence Ann Marriner Tomey Indiana State University College of Nursing, Health and Human Services 13001 Turtle Cove Trail North Fort Myers Florida 33903 USA E-mail: atomey@indstate.edu

TOMEY A.M.

(2009) Journal of Nursing Management 17, 1525 Nursing leadership and management effects work environments

Aim The aim of this literature search was to identify recent research related to nursing leadership and management effects on work environment using the 14 forces of magnetism. Background This article gives some historical perspective from the original 1983 American Academy of Nursing study through to the 2002 McClure and Hinshaw update to 2009 publications. Evaluation Research publications were given a priority for references. Key issues The 14 forces of magnetism as identied by Unden and Monarch were: 1. Quality of leadership, 2. Organizational structure, 3. Management style, 4. Personnel policies and programs, 5. Professional models of care, 6. Quality of care, 7 Quality improvement, 8. Consultation and resources, 9. Autonomy, 10. Community and the hospital, 11. Nurse as teacher, 12. Image of nursing, 13. Interdisciplinary relationships and 14. Professional development.. Conclusions Correlations have been found among positive workplace management initiatives, style of transformational leadership and participative management; patient-to-nurse ratios; education levels of nurses; quality of patient care, patient satisfaction, employee health and well-being programmes; nurse satisfaction and retention of nurses; healthy workplace environments and healthy patients and personnel. Implications for nursing management This article identies some of the research that provides evidence for evidence-based nursing management and leadership practice. Keywords: environment, evidence-based practice, leadership, management, quality
Accepted for publication: 6 September 2008

Introduction
In 1990, the American Nurses Credentialing Center started a programme to recognize hospitals using standards of nursing service administration and nursing care based on the results of the American Academy of Nursing magnet hospitals study (American Academy of
DOI: 10.1111/j.1365-2834.2008.00963.x 2008 The Author. Journal compilation 2008 Blackwell Publishing Ltd

nursing 1983) and subsequent research. Urden and Monarch (2002) identied 14 characteristic of magnetism as: 1. Quality of leadership, 2. Organizational structure, 3. Management style, 4. Personnel policies and programs, 5. Professional models of care, 6. Quality of care, 7 Quality improvement, 8. Consultation and resources, 9. Autonomy, 10. 15

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Community and the hospital, 11. Nurse as teacher, 12. Image of nursing, 13. Interdisciplinary relationships and 14. Professional development.. This paper presents research and literature related to those 14 characteristics to promote evidence-based practice for creating desirable work environments.

Quality of leadership
Excellent nursing leaders were perceived to be knowledgeable risk takers who were guided by an articulated philosophy in doing the daily operations and were strong advocates for nursing and supportive of staff (Urden & Monarch 2002). Nursing leaders can be strong advocates for staff by being risk takers in the development of healthy work environments. Workplaces are important settings for addressing the mental, physical, social and economic welfare of the employees. There is a link between the health of the workplace and the well-being of the personnel (Kearsey 2003, Chang et al. 2005) and healthy workplaces are correlated with healthier patients (Kearsey 2003). Organizations with unhealthy work forces may have a cost burden from high rates of absenteeism, presence at work but inadequate work performance, loss of productivity, work-related accidents, high levels of stress and high incidence of health-related litigation (Clegg 2001, Rodham & Bell 2002, Johnson et al. 2003, Olofsson et al. 2003, Kessler et al. 2004, Musich et al. 2004, Whitehead 2006). Comprehensive organizational reform for healthy workplaces generally include health information education, smoking/alcohol/drug ceasation programmes, exercise and tness activities, healthful eating availability, weight control efforts, stress management, back care, prevention, early detection and screening for serious disease (Secker & Membrey 2003, Holdsworth et al. 2004, Cleary & Walter 2005). Unfortunately, behaviourally oriented workplace programmes have only had moderate positive results (Holdsworth et al. 2004). Inversely, workplace health programmes foster reduced absenteeism, motivated workers with higher morale, reduced personnel welfare problems and industrial relationship disputes, increased efciency, improved organizational performance, better competitiveness and improved public image (Kramer & Cole 2003). Sustainable workplace health interventions are needed and may include organizational development; good health and safety practices and records; supportive interpersonal relationships and organizational culture; orientation, training and support to learn jobs; good 16

human resource management; good communications; marketing; multidisciplinary collaboration; and multimethod evaluation (Clegg 2001, Secker & Membrey 2003, Whitehead 2006). Poor leadership and management styles; impatient, defensive, unsupportive leadership; lack of supervision and guidance; control; and lack of recognition of contributions have been identied as major stressors (Jinks et al. 2003, Olofsson et al. 2003). On the other hand, positive workplace management initiatives such as shared organizational goals, learning opportunities, career development, reward schemes, autonomy, participation and empowerment strategies, employee health and well-being programmes, job satisfaction, open management styles and participation and empowerment strategies that are consistent with transformational leadership foster healthy staff-focused workplaces (Clegg 2001, Yeatman & Nove 2002, Kramer & Cole 2003, McVicar 2003, Secker & Membrey 2003, Thyer 2003, Aust & Ducki 2004, Joffres et al. 2004, Jooste 2004, Park et al. 2004). Magnet hospital nurse leaders identied the following leadership traits as essential: accessible, collaborative, communicative, exible, good listener, honest, inuential, knowledgeable, positive, supportive and visible. These traits empower people (Upenieks 2003). Pearson et al. (2008) found that both a top-down and a bottom-up approach to spreading a nursing innovation can be successful. The top-down can work for a predened innovation especially when the innovation has been previously tested, tried in the organization and when consistent adoption throughout the system is desired. That may be particularly successful if frontline staff were involved in the original design and pilot test. The bottom-up approach allows frontline staff to play a major role in identifying areas and strategies for improvement. That fosters staff ownership for the innovation and effective adaptation to specic settings. In that case, risk taker leaders are practicing participative management and transformational leadership. Professional nurse councils have been developed to decentralize activities and help engage staff. Common councils include Operations Council, Policy and Procedure Council, Quality Council and Research and Education Council (Gokenbach 2007).

Organizational structure
Excellent organizational structures were perceived to be at with decentralized nursing departments that had strong nursing representation in the organizational structure. The nursing leader served at the executive

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level of the organization and reported to the chief executive ofcer (Urden & Monarch 2002). Many hospital leaders are now faced with building new facilities or renovating existing ones to accommodate new technology, different patient types and more private and family-oriented rooms instead of the multibed units. Stichler (2007) indicated that leaders need to widen the sphere of inuence and involvement by interfacing with boards of directors to get acceptance of designs and to get approval for capital funding; interact with community leaders to gain political and nancial support; and network with other nurse leaders to learn about best practice examples and completed projects that demonstrated positive outcomes. A structure for the project needs to be created that claries the levels of authority, lines of communications and decision making and roles and expectations. Some healthcare leaders have been developing and testing new care delivery models by involving nurses and other health care providers in various roles across the continuum of care (Kimball et al. 2007). These include the 12-Bed Hospital model (Shinkus 2004), the Primary Care Team Model (Batcheller et al. 2004, Kimball et al. 2007), the Collaborative Patient Care Management Model (Kimball et al. 2007), the Transitional Care model (Naylor et al. 1999, Kimball et al. 2007), the Hospital at Home model (Leff et al. 2005, Kimball et al. 2007), the Acuity Adaptable Beds model and the Selforganized Agile Team Model (Morjikian et al. 2007). Kimball et al. (2007) found that these new models elevated the registered nurse (RN) role to primary care manager from admission to discharge and often back into the community. They sharpen the focus on the patient. The care is nurse managed and patient directed. Patient and family involvement are used. There is smoothing of patient transitions and handoffs and overseeing patients care beyond hospital discharge. Use of specialized tools for assessment, measurement and teaching has increased. Technology is getting used to reduce labour-intensive documentation, improve communications by access to information and reduce steps and wasted time. The models are driven by measurement of outcomes. The early and regular involvement of care givers in the design and implementation of the new models has been important. Replicable models have been isolated and include hospice care, hospitalist-led care for acute medical inpatients and the all-inclusive care for elderly. Clancy (2007) indicates that modern organization theory assumes that an organization is an integrated system with integrated parts. Because of the complexity and changing circumstances, there is not one best

organizational structure. The design should help coordinate resources to achieve the organizational goals. Institutions need to be adaptive, creative and robust to solve the ever-changing challenges.

Management style
Excellent management styles were perceived to be participative that encouraged and valued feedback from staff at all levels in the organization. Nursing leaders were visible, accessible and committed to communicating effectively (Urden & Monarch 2002). Patients in teaching hospitals reported higher perceptions of quality, health benets and level of independence with activities of daily living than patients in community hospitals. That was perceived more for surgical than medical patients which may reect a difference in the care required. Patients reported higher perceptions of health benets on units with a higher percentage of casual nurses suggesting that satisfaction with work arrangements may inuence patient care. Many articles have been published during the 2000s regarding hospital stafng, nurse-to-patient ratios, staff mix, patient outcomes, organizational support, work organization, doctornurse communication, work environment and relationships to quality of care and nurse satisfaction including, but not limited, to the following: American Nurses Asociaton 2000, Sovie and Jawad 2001, Aiken et al. 2002a,b, Needleman et al. 2002, Adams and Bond 2003a,b, McGillis Hall 2005a,b, McGillis Hall et al. 2003, 2004, 2006, Kazanjian et al. 2005, Manojlovich 2005, Smith et al. 2005, McGillis Hall and Doran 2007, Hall et al. 2008. Skytt et al. (2007) found that reorganization and other changes were major reasons for resignations. Organizational bureaucracy, hierarchy, authoritarian leadership and poor access to information were found to limit empowerment and lead to dissatisfaction, burnout and absenteeism (Kuokkanen et al. 2007). Staff was found to want empowerment, opportunities for education and development, access to information and opportunities for advancement (Kuokkanen et al. 2007, Skytt et al. 2007). Kane-Urrabazo (2006) has published a theoretical paper regarding the importance of trust and trustworthiness, empowerment, delegation, consistency and mentorship. She speaks of the importance of the manager inuencing the culture through role modelling the desired attitudes, values and behaviours and through communication. Trust and job satisfaction were signicant predictors of commitment and intent to stay (Way et al. 2007). Day et al. (2007) found a relationship between morale and team interaction, 17

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consultation, professional recognition and less patient abuse in Australia. Stapleton et al. (2007) suggest that ability to inspire moral in staff is a good leadership quality. Recognition for achievements and outstanding performance can be used to encourage retention (Abualrub & Al-Zaru 2008). Management support, transformational leadership, empowerment, participatory management, communication, accessible and visible leaders contributed to job satisfaction, retention of nurses and better patient outcomes (Brabant et al. 2007, Manojlovich & Laschinger 2007, Paliadelis et al. 2007, Rosengren & Segesten 2007, Wong & Cummings 2007).

Personnel policies and programmes

Personnel policies were created with staff involvement and were perceived as competitive. Administrative and clinical promotional opportunities were provided (Urden & Monarch 2002). In the 1980s, nurses indicated that they wanted exible work schedules that allowed blending personal and professional lives and accommodated individual needs. Nurses wanted competitive salaries and benets, participation in recruitment activities and social and recognition programmes (American Academy of Nursing 1983). With participative management and a focus on evidence-based practice, staff can also be involved in the development of policies in general. Oman et al. (2008) have outlined level and quality of evidence from the strongest evidence of meta-analysis or systematic review of multiple-controlled studies or clinical trials through, individual experimental studies with randomization, quasi-experimental studies, non-experimental studies, programme evaluation, to the weakest which is opinions of respected authorities. They also present steps to create and review policies and select the policy to make or review; search for evidence; evaluate the evidence; compare evidence to the current policy and make necessary changes; have the policy reviewed by stakeholders and experts; make revisions based on the feedback; obtain approval signatures; submit the policy to the appropriate committees; educate staff as needed and consider web submission.

nursing practice and facilitated interdisciplinary planning and coordination of care to the home and other settings. They also developed and conducted health education programmes (American Academy of Nursing 1983). In the United States, case management had its roots in psychiatry and social work in the 1920s. It was used by community health nurses in the 1930s. Case method was the primary care delivery model in the 1930s and re-emerged during the 1980s. Functional nursing was used in the 1950s and beyond when few registered nurses were available and much of the care was given by less qualied staff of practical nurses and nurses aides. Team nursing was introduced in the 1950s to improve nursing services in hospitals and nursing homes by using professional nurses to lead the teams of less qualied staff. Private duty nursing existed before intensive care units and was the precursor of primary care. Primary total patient care grew during the 1980s before a nursing shortage. By 2000, professional nurses were assuming positions to lead interdisciplinary teams (Marriner Tomey 2009). In research involving 80 acute care adult units in 40 randomly selected US hospitals, Minnick et al. (2007) found that no nursing practice model was implemented fully and non-intensive care units demonstrated a wide variety of assignment patterns. Patterns differed intrainstitutionally. Siu et al. (2008) found that positive professional practice environments and high-core selfevaluation predicted nurses constructive conict management and greater unit effectiveness.

Quality of care
Providing quality care was perceived as an organizational priority; nursing leaders were seen as responsible for developing an environment that fostered qualityof-care delivery while staff nurses thought they were providing high-quality care (Urden & Monarch 2002). Aiken et al. (2007) analysed data from Pennsylvania nurse surveys to determine whether nurse outcomes and adverse events differed in hospitals with varying proportion of non-permanent nurses. Temporary nurses had qualications similar to the permanent staff nurses. Decits in patient care environments in hospitals employing more temporary nurses may explain the association between poorer quality and temporary nurses thus giving the unwarranted negative perceptions about temporary nurses. Storfjell et al. (2008) focused on how nurses spend their time rather than just raising stafng levels to improve patient outcomes. They found nurses spent

Professional models of care

Nurses had the responsibility and authority for the provision of patient care, were accountable for their own practice and were the coordinators of care (Urden & Monarch 2002). In the original magnet hospital study, nurses found primary nursing to be satisfying. They felt in control of 18

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considerable time doing non value-added activities, more time on support activities than providing patient care and the least amount of time teaching patients and providing psychosocial support. They believe there is an opportunity to improve clinical outcomes and cut costs at the same time by increasing support activities and patient care time particularly in patient teaching and psychosocial support while reducing the time on non value-added activities. Pappas (2008) believes that adverse events add costs to patient care and should be measured at the unit level to adjust stafng to reduce adverse events and to avoid costs. She did a regression analysis on actual direct cost of adverse events. She reports the cost of some specic adverse events and notes that the odds of pneumonia occurring in surgical patients decreased with additional registered nurse hours per patient day. Aiken et al. (2008) analysed the net effects of nurse practice environments on nurse and patient outcomes after accounting for nurse stafng and education. They found that nurses reported fewer concerns with care quality, more positive job experience and that patients had signicantly lower risks of failure to rescue and death in hospitals with better care environments. They conclude that care environments must be optimized as well as the nurse stafng and education levels to achieve high quality of care.

Quality improvement
In the original magnet study, nurses valued quality assurance and the accountability associated with the review and evaluation of nursing care (American Academy of nursing 1983). Nurses participated in quality improvement that was perceived to be educational and was done to improve the quality of care delivered in the organization (Urden & Monarch 2002). Historically, quality assurance transformed to continuous quality improvement (Marriner Tomey 2009). Research, quality improvement and evidence-based practice are related but different. Newhouse (2007) denes research as A systematic investigation, including research development, testing and evaluation, designed to develop or contribute to generalizable knowledge. Quality improvement is a process by which individuals work together to improve systems and processes with the intention to improve outcomes. It is a data driven systematic approach to improving care locally. She denes evidence-based practice as A problem-solving approach to clinical decision-making within a health care organization that integrates the best available scientic evidence with the best available experiential

(patient and practitioner) evidence, considers internal and external inuences on practice, and encourages critical thinking in the judicious application of such evidence to care of the individual patient, patient population, or system. The integration of research and evidence-based practice into clinical and operational processes plays a major role in obtaining Magnet hospital status (Reigle et al. 2008). Albert and Siedlecki (2008) described the development and implementation of a nursing research team in a large healthcare system. They identied that nurses are able to generate and use nursing knowledge to improve practice when there is a clear direction from leadership, access to nurse researchers that coach and mentor, infrastructure resources and leadership support. The Massachusetts General Hospital reengineered the Nursing Research Committee to promote research-based practice and overcome the barriers of insufcient time to access and implement research; lack of condence to read, interpret, and understand research ndings; and a lack of support to introduce research ndings into practice (Larkin et al. 2007). The Nursing Research committee membership is open to all registered nurses in the hospital, members are self-selected into subcommittees, and those members provide a link between direct care providers and product lines. Larkin et al. (2007) identied the use of a Did you know? poster series to disseminate integrative reviews of the research literature; a journal club to discuss the developing and conducting of research studies and the researchers personal journey in building programmes of research; a nursing research day celebrated during Nurse Recognition Week; display of research posters during Nurse Recognition Week; and a nursing research day with a nursing research visiting professor and research lecture. Rundall (2007) identied the need for developing a questioning culture; training managers in evidence-informed decision-making, establishing relationships with individual researchers, universities, research centres, consulting rms and other knowledge brokers. Nursing leaders can improve attitudes about and participation in research utilization by internally marketing the support available for researchrelated activities (Larrabee et al. 2007). However, change in the organizational culture needs support from both the leaders and the clinicians (McNicholl et al. 2008). Ulrich et al. (2007) noted that many organizations applying for Magnet status rated higher than Magnet organizations regarding hospitals responses to the nursing shortage, characteristics of the work environment and professional relationships indicating there is much to do to maintain the comparative advantages of magnet hospitals. 19

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Patient satisfaction with nursing care is a nurse-sensitive indicator that was collected to monitor quality of care at a central New Jersey impatient Magnet healthcare system. Nurses collected data and tracked the frequency and nature of call bells and the success of interventions that worked best on their units. They added 2-hour rounding and developed strategies to reduce the patients need to use a call bell by anticipating their needs. Patient satisfaction was improved (Torres 2007). Meade et al. (2006) also found that nurses aids could do most of what was needed when call lights were used and fewer falls occurred when nursing rounds were done. Staff received instructions that they were to tell the patient when they entered the room that they were doing rounds; assess pain level; offer prn meds when due; offer toileting assistance; assess position; make sure the call light, telephone, TV remote control and call light were within the patients reach; put bedside table next to the bed; put Kleenex box and water within reach; put trash can next to the bed; ask Is there anything I can do for you before I leave?, and tell the patient who will be back in the room in 1 or 2 hours.

Autonomy
In the original study, nurses thought primary nursing allowed for independent judgment and freedom to function. Nurses saw making decisions of when to call doctors, leading teaching programmes and coordinating care as autonomy (American Academy of Nursing 1983). Autonomous independent judgment was expected to be used within multidisciplinary approaches to patient care (Urden & Monarch 2002). Autonomy is related to power and empowerment. Empowerment can be either a process or an outcome. Power is having inuence and control whereas empowerment is ability to act. A nurses power can come from a workplace structure that promotes empowerment; from a psychological belief that one has the ability to be empowered; and from understanding that there is power in the relationships and caring that nurses provide (Manojlovich 2007). Nurses are practicing autonomy when establishing standards, setting goals, monitoring practice and measuring outcomes. Patient care programmes such as nurse-managed clinics, outreach programmes to educate nurses in other settings, exchange programmes for staff nurses in hospitals and nursing homes, support services for elderly, counselling services for pregnant adolescents and preadmission programmes for children allow nurses to be autonomously creative and innovative. This contributes to enhanced selfesteem and self-actualization and improved image of nurses and the hospital in the community (McClure et al. 2002).

Consultation and resources

In the original magnet study, participants identied the head nurse, supervisor, clinical nursing specialist, psychiatric liaison nurse, ethicist, philosopher and other health care disciplines as needed consultants and resources (American Academy of Nursing 1983). Consultation and resources were perceived to be adequate and available. Peer support was given both within and outside the nursing division and advanced practice nurses were available and used as knowledgeable experts (Urden & Monarch 2002). Rundall (2007) has also specically identied nursing professors and researchers as resources to hospital nurses. Thompson and Lulham (2007) have helped clarify the roles of the clinical nurse leader and the clinical nurse specialist. The clinical nurse leader is responsible for coordination and implementation of patient care; using evidence-based practice in caring for patients; providing education to staff and patients; developing and rening of outcome goals; working with a multidisciplinary team for planning, implementing and coordinating care of high-risk patients; and serving as a resource to staff. On the other hand, the clinical nurse specialist is responsible for designing and evaluating programmes of care; providing education and training, participating in research; developing and rening hospital goals for education of staff; serving as a resource and consultant for high-risk volume; and serving as a resource for obtaining information. 20

Community and the hospital

Hospitals that maintained a community presence were better able to recruit and retain nurses. Institutions with a variety of ongoing, long-term outreach programmes were perceived as strong, positive and productive corporate citizens (Urden & Monarch 2002). In the original magnet study, nurses viewed professional practice as extending into the community such as discharge planning and visiting patients in nursing homes and their homes. They believed that inpatient care and programmes could be used to promote health in the community (American Academy of Nursing 1983). Health organizations can develop a democratic and empowering partnership with the community that allows the community to identify and address priority health concerns (Whitehead 2006). Community programmes are likely to include screening and teaching.

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Nurse as teacher
Nurses were expected to incorporate teaching into all aspects of their practice and reported getting considerable professional satisfaction from the teaching (Urden & Monarch 2002). Nurses realized they could make a large contribution to teaching patients and their families, had a professional obligation to teach students, nurses and other health professionals and that teaching advanced their own learning (American Academy of Nursing 1983). Nurses did patient and family teaching and peer-focused activities such as developing learning modules, leading grand rounds and providing in-service education to colleagues (McClure et al. 2002). Nurses also do health teaching in the community.

Image of nursing
In the original magnet study, nurses were aware of the importance of their image. The general image of nurses was good. Nurses had a positive feeling about themselves. Patients acknowledged that the nurses provided good care. Various departments supported nursing (American Academy of Nursing 1983). Nurses were viewed as integral to providing patient care services and were viewed as essential by other members of the health care team (Urden & Monarch 2002). Nurses were viewed as competent, credible, valued, respected and necessary for the survival of the hospital. The single exception to the overall positive image of nurses was the physicians perceptions of nursing. The doctornurse relationships require attention and nurturing (McClure et al. 2002).

Interdisciplinary relationships
There was mutual respect among disciplines, and the interdisciplinary relationships were viewed as positive (Urden & Monarch 2002). Nurses need to interact with many disciplines including, but not limited to, clinical nurse specialists, psychiatric nurse liaisons, physicians, pharmacists, dieticians, inhalation therapists, radiology technicians, physical therapists, occupational therapists, speech-language specialists, discharge planners, social workers, chaplains, personal care aides, transporters, etc. Massachusetts General Hospital staff has developed a multidisciplinary clinical recognition programme that offers direct care practitioners a dened pathway for clinical development that recognizes and celebrates all levels of practice from the beginning practitioner to the experts from six different disciplines (Erickson et al. 2008).

An important variable in nurses satisfaction was the nature of the nursephysician relationships (American Academy of Nursing 1983). Expert cultures such as physicians are motivated by accomplishment and power instead of afliation. Experts have competed for good grades, the best schools and the best jobs. Success was obtained by outperforming the competition instead of through teamwork. Achievement, stamina, intense focus, quick decision making and personal accountability are reinforced for experts. Teamwork, consensus building and interdependency are not part of the expert culture (Atchinson & Bujak 2001, Marriner Tomey 2009). The trend is towards interdisciplinary education of professionals with some focus on teamwork. Manojlovich and Antonakos (2008) noted that nurses particularly appreciated understanding, open and accurate communication from attending-level physicians. While nurses are subject to incivility and violence from physicians and other health care providers, staff, patients, visitors and suppliers, they are apparently most concerned about the aggression from their colleagues. Incivility may include physical aggression, bullying, intimidation, passive/aggressive behaviour, antagonism, criticism, innuendos, gossiping, scapegoating and undermining and withholding information. It is also associated with power struggles from conicts of values related to leadership styles, work expectations and organizational conditions (Standmark & Hallberg 2007). Horizontal violence has been correlated with decreased morale, satisfaction and job performance (Baltimore 2006). There is an incivility spiral when one thoughtless act is perceived as incivility, which causes a negative reaction and creates the desire for reciprocation by doing another uncivil act. That chain keeps repeating itself. There is a need for leaders and managers to decrease toxic workplaces by such means as role modelling professional behaviours, validating assumptions and perceptions before drawing conclusions, using open communication, socializing new staff members, using conict resolution, rewarding nurses for supporting each other, nurturing a culture of recognition and having a policy of zero tolerance for violence (Baltimore 2006, Hutton 2006, Peck 2006, Vivar 2006, St-Pierre & Holms 2008). The increased complex care coordination needs makes interdisciplinary relationships particularly important as clients are passed from unit to unit and recommended to various services. The clinical nurse leadership role has been implemented to ensure safe handoffs between providers (Tachibana & NelsonPeterson 2007). 21

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Professional development
Most successful hospitals placed a signicant emphasis on orientation, in-service education, continuing education, formal education and career development. Personal and professional development was valued and there were opportunities for competency-based clinical advancement and resources to maintain competency (Urden & Monarch 2002). The original magnet study found that nurses appreciated orientation programmes that could last a few weeks to several months. Many inservice programmes were provided at the work site, but in hospital systems, some nurses attended programmes offered in other institutions. Nurses viewed continuing education as programmes developed by agencies outside the hospital. However, some brought those programmes to the hospital. Magnet hospitals nurses were encouraged to get BS degrees and there was accommodation in scheduling, leaves of absence, tuition reimbursement and, in some cases, full scholarships provided to pursue degrees. Career ladders were used to foster career development (American Academy of Nursing 1983). McClure et al. (2002) indicated that growth and development of nurses was emphasized to improve quality of nursing care. Nurses were expected to teach and were assisted in aspects of learning and teaching. Baccalaureate and higher degrees were valued and education was facilitated in numerous ways. Reiter et al. (2007) found that the Health and Environmental Sciences Institute (HESI) examination was an effective predictor of workplace competency for new graduates assigned to acute care and critical care units. Conley et al. (2007) recommend a three-component orientation for nursing leaders including nurse manager competencies, precepting by the supervisor and written and classroom resources. Shanley (2007) found that literature about change management in organizational studies can be valuable for nurses professional practice. Torstad and Bjork (2007) found that most of the 19 nurse leaders sampled in Norway had not thought strategically about promoting clinical ladders, but those who did found motivational work rewarding. Marchionni and Richie (2008) in a small quantitative pilot study found variability in best practice guideline implementation despite transformation leadership and culture of organizational learning. Storey et al. (2008) found the four directors chosen by their peers as practicing at a high level articulated leadership practices supportive of the Propel Professional Model at St Vincent Womens Hospital in Indianapolis, Indiana. Watson and Foster (2003) indicated that abstract conceptualizations of nursing need to be 22

translated into concrete examples of the preferred future. Wolf et al. (2004) used strategic visioning and decision making, assessment, building support structures, administration and evaluation to implement a transformational model. Hardwood et al. (2003) used mentoring, education and support to help leaders change from exercising control to guiding and facilitating group decisions.

Summary
Tends during the past 25 years have included but are not limited to moving from nursing in the hospital to nursing in the community; from centralized structures to decentralized and global structures; from nursing care to multidisciplinary care; from bedside care to coordination of care; and from transactional autocratic leadership to transformational leadership and participative management. Correlations have been found among positive workplace management initiatives, style of transformational leadership and participative management; patient to nurse ratios; education levels of the nurses; opportunities for learning and professional development; reward schemes; quality of patient care, patient satisfaction, employee health and well-being programmes; nurse satisfaction and retention of nurses. A correlation has been found between healthy workplace environments and healthy patients (Kearsey 2003) and the well being of personnel (Kearsey 2003, Chang et al. 2005).

References
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