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Staff perceptions of leadership during implementation oftask-shifting in three surgical units
AMANDA HENDERSON B . S c , P h D1, KARYN PATERSON B S c ( N u r s ) , M E d .
2, LIZ BURMEISTER R N , M S c3,
BERNADETTE THOMSON B N , M E d4 and LOUISE YOUNG B N
5
1Queensland Health Research Fellow, 2Nurse Educator, 3Nurse Researcher, 4A/Nursing Director (Education) and5Clinical Nurse, Princess Alexandra Hospital, Woolloongabba, Brisbane, Queensland, Australia
Introduction
Registered nurses (RNs) are difficult both to recruit and
to retain, and the number of RNs needed in the work-
force is projected to exceed availability. There are also
increasing costs associated with the predominance of
RNs in the workforce. Task shifting, the rational
redistribution of tasks which can assist in maximizing
efficiency in the health workforce (World Health
Organization 2008) is a worthwhile consideration.
Correspondence
Amanda Henderson
Princess Alexandra Hospital
Ipswich Road
Woolloongabba 4102
Australia
E-mail: amanda_henderson@
health.qld.gov.au
H E N D E R S O N A . , P A T E R S O N K . , B U R M E I S T E R L . , T H O M S O N B . & Y O U N G L . (2012) Journal of
Nursing Management
Staff perceptions of leadership during implementation of task-shifting in threesurgical units
Background Registered nurses are difficult to recruit and retain. Task shifting,which involves reallocation of delegation, can reduce demand for registered nurses.
Effective leadership is needed for successful task shifting.
Objective This study explored leadership styles of three surgical nurse unit man-
agers. Staff completed surveys before and after the implementation of task shifting.
Task shifting involved the introduction of endorsed enrolled nurses (licensed nurses
who must practise under registered nurse supervision) to better utilize registered
nurses.
Methods Implementation of task shifting occurred over 4 months in a 700-bed
tertiary hospital, in southeast Queensland, Australia. A facilitator assisted nurse
unit managers during implementation. The impact was assessed by comparison of
data before (n = 49) and after (n = 72) task shifting from registered nurses and
endorsed enrolled nurses (n = 121) who completed the Ward Organization Features
Survey.
Results Significant differences in leadership and staff organization subscales across
the settings suggest that how change involving task shifting is implemented influ-
ences nurses� opinions of leadership.
Conclusion Leadership behaviours of nurse unit managers is a key consideration in
managing change such as task shifting.
Implications for nursing management Consistent and clear messages from leaders
about practice change are viewed positively by nursing staff. In the short term,
incremental change possibly results in staff maintaining confidence in leadership.
Keywords: change, leadership, skill mix, task shifting, workforce
Accepted for publication: 6 February 2012
Journal of Nursing Management, 2012
DOI: 10.1111/j.1365-2834.2012.01401.xª 2012 Blackwell Publishing Ltd 1
Appropriate delegation of tasks to less highly educated
nurses can reduce the number of RNs in the workforce
and assist with fiscal management and maintain quality
of care (Deshong & Henderson 2010).
In Australia, two different levels of nurses are em-
ployed to assist registered nurses at the bedside: en-
dorsed enrolled nurses (EENs) and assistants-in-nursing
(AINs). Endorsed enrolled nurses are licensed staff
members with educational preparation and competence
for practice under the supervision of an RN. An EEN
will have completed an 18-month competency-based
diploma course. They can reduce the workload of an
RN by working as an associate and under the supervi-
sion of the RN. Assistants-in-nursing are unlicensed
employees whose roles include carrying out non-com-
plex personal care tasks. They are valued members of
the health-care team whose role and relationship with
registered nurses and midwives varies according to their
employment contract. They must work with the support
and supervision of an RN when carrying out tasks
delegated to them in accordance with a documented
patient care plan (Anderson 2010).
The use of a stratified workforce is commonly used in
many different countries, for example, the UK and the
USA. In these countries there are a number of unli-
censed workers within the health-care system that work
in conjunction with licensed or regulated practitioners
(Anthony et al. 2001). The contentious factor is that
quality of care has been directly linked with increased
higher education qualifications of staff, favouring a
predominately RN workforce (Kutney-Lee & Aiken
2008). However, recent studies across Belgian hospitals
found that significant differences in quality of care were
attributable to the work environment rather than the
educational qualifications of staff (Van den Heede et al.
2009). These findings support that disparity in care
provision between different grades of staff can be re-
duced when higher-graded staff work successfully in
combination with lower-graded staff (Carr-Hill et al.
1992). Arguably, quality care can be achieved with
well-organized task shifting.
Effective leadership is critical to guide any change in
the clinical practice setting (Buonocore 2004). Leader-
ship practice that supports and guides RNs in delega-
tion and creating cohesive teams is important so that
less skilled staff can be productively integrated into the
clinical team. Effective integration of staff into teams in
order that they can demonstrate enactment of their
scope requires efficient leadership, including planning of
roles, realistic and manageable workloads, clear com-
munication and approachable ward managers or team
leaders. The presence of these factors in the work
environment has been associated with reduced clinical
errors (Ramanujam & Rousseau 2006). Effective com-
munication and good team processes are important if
nurses are to perform their full scope of practice asso-
ciated with task shifting. In particular, local leaders,
nurse unit managers (NUMs) are pivotal in the success
of change management (Duffield et al. 2009). Positive
local leadership establishes, guides and responds
appropriately to the organization of nursing staff in the
local context and can, therefore, have a direct impact on
factors such as teamwork, workload and organization
of care delivery (Cummings et al. 2010).
The necessary steps for successful change include:
determining the need and assessing the readiness for
change; the redesign of work processes within the
organization that identify the skills needed by staff and
factors that can assist or create impediments to the
acquisition of these skills; and the reinforcement of
change (Buonocore 2004). This sequence is congruent
with Lewin�s theory of force field change (Lewin 1951).
Lewin�s approach commences with �unfreezing� – the
need to examine the existing situation, overcoming
inertia and dismantling the dominant thinking. In the
second stage �moving� occurs; this is characterized by a
range of various work-related issues that staff can often
find challenging. It is dependent on factors such as
evidence of the value of the change and �champions�readily adopting and thereby persuading others about
the value of changed practices (Greenhalgh et al. 2004).
The third and final stage is �refreezing�, where the al-
tered work processes are embedded (Lewin 1951).
This study explored the leadership style of each of the
NUMs of three surgical units when implementing task
shifting. Three surgical areas adopted a stratified nurs-
ing workforce, comprising RNs and EENs. Whereas
previously the workforce consisted of all RNs, a small
number of EENs (1–4) were employed in each area to
support patient care. Each surgical area had similar
access to supernumerary staff support through a facili-
tator; however the NUMs adopted different approaches
to progressing changes to work allocation necessitated
by the addition of EENs to the skill mix.
Methods
This task-shifting project, which included the employ-
ment of EENs, supported with a change facilitator
(a clinical nurse from the ward area who became
supernumerary during the implementation phase) took
place between February 2008 and June 2008 across
three surgical areas in a major tertiary facility in
southeast Queensland.
A. Henderson et al.
ª 2012 Blackwell Publishing Ltd2 Journal of Nursing Management
Comparison across the three areas was deemed
appropriate as the three areas are similar in terms of size
(26- to 28-bed wards) and the nature of the clinical
service. All three wards have a similar mix of multiple-
bed bays and single rooms, and are comparable in terms
of clinical space, corridors, and other nursing work
areas. Ratios of nursing staff were similar across all
three areas (an average of one nurse for 4–6 patients
that varies slightly according to acuity).
The task-shifting process
The project team, comprising the nursing director,
NUMs, the project facilitator and two experienced staff
from the Nursing Practice Development Unit developed
a plan to determine staff needs, identify required re-
sources and activities to address these needs, and
strategies to embed the initiatives that would enable
task shifting. A designated project facilitator familiar
with clinical practice across the three participating
wards assisted the NUMs with the implementation
process based on Lewin�s (1951) theory of change
management.
Assessing the readiness for change
To determine staff needs the NUMs held meetings and
informal discussions with their nursing teams about the
issues that arose for them with the addition of EENs to
the nursing team. The EENs commenced employment
in early 2008. The RNs identified that they lacked
awareness of the potential role of the EEN. They lacked
knowledge of the �Scope of Practice – Framework for
Nurses and Midwives�, Queensland Nursing Council,
which has since been superseded by the �Nursing Prac-
tice Decisions Summary Guide� (Australian Nursing &
Midwifery Council 2010), skills to interact with the
EENs to build a collegial relationship and how to
appropriately delegate patient care episodes to EENs.
This was particularly important given that RNs are
responsible for ensuring that EENs are capable of
completing the task safely and determining that it is
within their scope of practice. The team recognized that
these activities would need to be supported through in-
service education, and sessions to provide feedback and
problem-solve emerging issues.
Strategies to enable the desired change
The NUMs, with the assistance of the project facilitator,
identified the need for clear, effective communication
across the entire ward team, educational in-service ses-
sions and assistance with management of the workload.
Information and communication about the changed
skill mix that was the impetus for task shifting was
conveyed to staff in the clinical area over the 4-month
period. Flyers were displayed locally in the tea rooms,
treatment rooms and nurses� stations. Reference was
made at the commencement of most shifts about the
requirement for RNs to work together with EENs and
AINs and to delegate appropriately. Discussions arose
at the monthly staff meetings and the nature of the
communication shifted from an emphasis on the need to
task shift to how best to achieve this during the 4-month
period.
Educational in-service sessions were conducted for
approximately 45 minutes after handover every day in
one of the wards in response to RNs indicating that
they did not feel prepared to delegate to EENs. These
sessions focused on the EEN�s scope of practice, in
particular, differences in individual scope of practice
and, subsequently, how to establish what to delegate
and how to delegate to the EEN. Discussions also ex-
plored the notion of �working together�, an important
consideration for error reduction (Ramanujam &
Rousseau 2006). This included advice to the RNs
about engaging with EENs through regular dialogue
and feedback. Simulated patient handover sheets pro-
vided a means to encourage nurses to collaborate and
discuss how they would organize the workload be-
tween themselves. The majority of staff attended these
sessions at least once a fortnight over the 12-week
period during which education sessions were con-
ducted.
The RNs felt that these practice changes increased
their workload. Through weekly discussion forums in
each ward area, RNs were encouraged to explore how
they could effectively share the work. They identified
the importance of recognizing EENs� scope of practice,
delegating work within their capabilities, and the hos-
pital guidelines and policies. The teams consisted of two
nurses for eight or nine patients. Nursing tasks and
responsibilities were clearly articulated so that the RN
and EEN worked as a team for the specific shift. Guides
for the use of skill mix based on the �Scope of Practice –
Framework for Nurses and Midwives� (QNC 2008)
were developed.
The project facilitator role-modelled practices that
support effective team nursing during one-on-one
engagement with RNs as they worked with EENs.
Reflection on these practices was encouraged in the
weekly education and discussion forums to demonstrate
the impact the EEN could have in reducing the RN�sworkload.
Staff perceptions of leadership during task-shifting
ª 2012 Blackwell Publishing LtdJournal of Nursing Management 3
Reinforcing change
The NUMs embedded the processes through rostering,
team allocation of work and on-going provision of
assistance through one-on-one support to RNs by the
project facilitator.
Nursing workforce and task allocation across thethree surgical areas
Six months before commencement of the project (June
2007) the workforce across the three wards was pri-
marily RNs with one or two AINs. The RNs provided
all the direct nursing care. The AINs did not provide
direct care to patients but rather assisted RNs by
completing tasks such as collecting and delivering
messages and physically stocking the ward with neces-
sary items and supplies, etc. Two wards (B and C) had
recently employed an EEN but they tended not to be
required to fully enact their scope. Before commence-
ment of task shifting, RNs cared directly for 4–6
patients. A team leader was present to assist the RN
problem-solve specific issues.
By April 2008 the staffing composition was skewed to
a more novice skill mix. Table 1 details the composition
of wards and nursing workforce before and during the
study.
With the employment of the new EENs, task shifting
was adopted. The leadership style of each NUM varied.
Each NUM approached the implementation of task-
shifting differently. Each approach was given a broad
descriptor based on review of the facilitator�s journal
during the implementation phase. The facilitator doc-
umented observations, situations and conversations
with staff (summarized in Table 2). While the processes
(outlined earlier) included communication, education,
support in practice through workload discussion and
one-on-one assistance, there were particular variations
dependent on knowledge, understanding and experi-
ence of individual NUMs.
Ward A experienced difficulty engaging existing staff
and identifying champions despite the planned processes.
The NUM did not stipulate that RNs engage with EENs
and plan the workload for their shift together; neither did
RNs initiate teamwork with EENs. The RNs and EENs
continued to provide care to their own specific group of
patients. Little task shifting occurred and this tended to
be only for those patient care tasks dictated by the scope
of practice; for example, the giving of intravenous drugs
that must be administered by an RN. There was minimal
collaboration between the RNs and EENs to undertake a
team approach to meet patient needs.
The leaders on Wards B and C recognized the value of
the altered skill mix and were knowledgeable about
benefits of task shifting. The leader in Ward B used
democratic and inclusive leadership practices, such as
seeking staff feedback. Through feedback this NUM
Table 1Composition of nursing workforce byward before and after the task-shiftingprocess
Ward A, frequency(%)
Ward B, frequency(%)
Ward C, frequency(%)
Before After Before After Before After
Clinical nurse 8 (29) 8 (21) 9 (29) 9 (24) 7 (21) 7 (18)Registered nurse 16 (57) 16 (42) 13 (42) 13 (34) 25 (74) 25 (64)Registered nurse graduate* 4 (14) 11 (29) 8 (26) 14 (37) 1 (3) 3 (8)Endorsed enrolled nurses 0 3 (8) 1 (3) 2 (5) 1 (3) 4 (10)
Ward A and B had 28 beds, Ward C had 26 beds.*Registered nurse in first year of post-registration.
Table 2Summary of leadership style and staff perception
Ward Leadership characteristics during implementation How staff perceived leadership and ward organization
A Consistent with laissez-faire style, i.e. only interveningwhen non-compliance with directives was compromisingpatient safety
Perception of less ward organization and reduced satisfactionand confidence in nurse unit manager leadership
B Consistent with democratic-participatory, i.e. encouragingpeer monitoring and feedback to make adjustments toimplementation process
Increased perception of ward organization and satisfactionand confidence in nurse unit manager
C Consistent with autocratic, i.e. less flexible in the approachto implementation
Perception of less ward organization and reduced satisfactionand confidence in nurse unit manager leadership
A. Henderson et al.
ª 2012 Blackwell Publishing Ltd4 Journal of Nursing Management
recognized that staff felt they needed skills and time for
adjustment to develop relationships to work as a team,
and that this was perceived as extra workload. There-
fore, the NUM in Ward B stipulated that a team nursing
approach with clear delineated tasks was to be imple-
mented only when an EEN or graduate RN was ro-
stered on duty. This approach was used so the perceived
�burden� was reduced. The leader in Ward C recognized
the benefits of consistent team nursing regardless of the
skill mix and therefore stipulated that a team nursing
approach be introduced across all shifts; and, accord-
ingly, organized the work allocation sheet to reflect this.
Measurement tool
Staff opinion of work organization was undertaken
both before and after the project. The Ward Organi-
sation Features Survey (Adams et al. 1995) measures
discrete dimensions of acute hospital wards that tran-
scend different grades of staff and was used to collect
information. This tool has been demonstrated to be a
reliable and valid comprehensive set of measures about
ward organization. It comprises 14 subscales that have
been tested for the internal consistency and reliability:
staff organization; ward leadership; job satisfaction;
nurse–medical staff professional relationships; nurse–
allied health professional relationships; nurse–nurse
professional relationships; timing of ward and patient
events; human and financial resources; ward manage-
ment; ward layout; ward facilities; quality of nursing
ward services; professional practice; and quality of
general ward services. All except two subscales achieved
a Cronbach�s a > 0.7 in its initial development (Adams
et al. 1995). In the present study Cronbach�s alpha was
0.96. A five-point Likert scale was used to score re-
sponses from strongly agree to strongly disagree, with
lower scores indicating that respondents strongly
agreed, or for degree of influence, with lower scores
indicating �greater� influence or influence being �easy�.
Sample size
Sample size was unable to be determined from similar
studies given the paucity of quantitative research in this
area. Given previous studies in the broad domain of
changing nurses� practices, it was reasonable to expect
that an intervention such as this might result in a small
effect size. As a result, the study had 80% power to
detect a difference in mean values of 0.4, with a stan-
dard error of 0.7, at a significance level of 0.05 (two-
tailed), using a sample size of at least 49 participants in
each before and after task-shifting group.
Statistics
The data was analysed using S T A T A 10 (Statacorp,
College Station, TX, USA), a PC-based software sta-
tistical package. Descriptive statistics were used to
examine survey respondents� characteristics. Survey
data was checked for missing and out-of-range values;
for negatively-worded questions the scores were re-
versed. Distributions of subscale scores were examined
with means and standard deviations computed. t-Tests
were used to compare before and after data for each of
the ward areas across all 14 sub-scales.
Results
Respondents
All nurses were approached to complete the survey. Of
the 115 nurses working across the three units, 49
(43%) completed the before task-shifting survey and
72 (63%) the after task-shifting survey. The higher
response rate post-survey may be attributable to
greater staff motivation, namely, staff desiring to feed
back after completion of the implementation. The
demographic characteristics of the respondents across
the three wards are detailed in Table 3. These demo-
graphics largely reflect that of the clinical staff em-
ployed in acute-care facilities in metropolitan areas of
southeast Queensland, Australia, that is, mostly an RN
workforce (69%), with the majority of staff in the age
range of 19–44 years (87%), and with a bachelor de-
gree (77%). The groups were well-matched for age
and qualifications.
The feedback from the surveys indicated that three of
the scales, �ward leadership�, �staff organisation� and
quality of ward services, as measured in the Ward Or-
ganisational Features Scale (Adams et al. 1995), altered
during the intervention. This indicates that leadership
strategies and staff organization are particularly signifi-
cant when introducing change around task shifting.
Quality of ward services pertains to non-nursing staff,
therefore, this aspect of the questionnaire has not been
discussed in relation to task shifting. Task shifting, based
on these results, does not have an impact on nurses�opinions about other aspects of ward organization, such
as physical environment of the ward, professional nurs-
ing practice, professional working relationships between
nurses, nurses� influence and job satisfaction. The results
for all subscales are listed in Table 4.
Only the results for subscales �ward leadership� and
�staff organization� are presented in Table form for each
of the three areas (see Table 5), as these differences are
Staff perceptions of leadership during task-shifting
ª 2012 Blackwell Publishing LtdJournal of Nursing Management 5
directly relevant to leadership and task shifting within
nursing.
Ward leadership and staff organization
Questions on the subscale pertaining to ward leadership
focused on the attributes and behaviour of the NUM,
while those on the subscale of staff organization asked
questions about allocation of staff. The difference in
results pertaining to �ward leadership� and �staff orga-
nization� were both statistically significant across the
three areas. Differences, depending on the ward, indi-
cated positive or negative attitudes relative to the period
at the commencement of the intervention toward the
leadership behaviours of the NUM, and how the NUM
allocated staff. Results are displayed in Table 5.
In Wards A and C, there were significant unfavour-
able increases in the scores of both ward leadership
(P < 0.001) and staff organization (P < 0.02) from be-
fore the intervention to the period afterwards, indicat-
ing that staff perceived the leadership of the NUM as
less supportive, and ward allocation less efficient
following the intervention period. It is notable that staff
satisfaction with leadership was already quite high in
Ward C (pre-survey, ward leadership mean = 1.61,
staff organization mean = 1.77). Ward B indicated that
staff perceived the leadership of the NUM was
more supportive following the intervention period
(pre-survey mean = 2.49, post-survey mean = 2.18),
and staff organization efficiency improved (pre-survey
mean = 2.49, post-survey mean = 2.09).
Discussion
Through a facilitator working alongside the NUM,
systematic ward-based strategies were used to respond
to the contemporary challenges of implementing task
shifting.
The different results are arguably a reflection of how
staff responded to the leadership practices of each
NUM. While task shifting occurred across the wards,
how this was enacted – which is largely dependent on
the leadership in each area – was quite different. Dis-
cussion and reflection with the NUMs to explore and
clarify these processes has continued following the
implementation.
In Ward A where staff did not readily engage with
practices associated with effective task shifting, for
example, minimal cooperation between RNs and
EENs, there was a significant difference in staff orga-
nization and staff perception of ward leadership,
indicating dissatisfaction with the NUM. The leader
ostensibly supported task shifting, but it appeared the
local behaviours did not engage effective change pro-
cesses as deemed necessary by Greenhalgh et al.
(2004). A functional partnership existed between RNs
and EENs only on occasion during the shift to ensure
Table 3Characteristics of respondents (n = 121)
Characteristic Frequency (%)
Ward areaA 42 (35)B 32 (26)C 47 (39)
Level of nurseEndorsed enrolled nurses 4 (3)Registered nurse 83 (69)Clinical nurse 31 (26)Nurse unit manager 3 (2)
Age group (years)18–24 32 (26)25–34 41 (34)35–45 33 (27)More than 45 13 (11)Missing 2 (2)
Qualification levelHospital certificate 9 (7)Diploma 11 (9)Bachelor degree 94 (77)Post-graduate qualifications 8 (7)
Table 4Mean scores for each subscale before and after the task-shiftingprocess
Before(n = 49)
After(n = 72)
P(t-test)
Staff organization* 2.11 2.44 0.02Ward leadership* 1.92 2.27 0.02Job satisfaction* 2.22 2.28 0.57Professional relationships:nurses–medical staff*
2.67 2.85 0.10
Professional relationships:nurses–allied health*
2.47 2.47 0.98
Professional relationships:nurses–nurses*
2.50 2.63 0.33
Influence: timing of wardand patient events�
3.03 3.24 0.21
Influence: human andfinancial resources�
3.78 3.84 0.82
Influence: ward management� 3.25 3.42 0.38Ward layout� 2.30 2.54 0.04Ward facilities� 2.57 2.75 0.26Quality of wardservices – nursing�
2.27 2.68 0.02
Quality of wardservices – services§
2.50 2.67 0.13
Professional practice§ 2.58 2.69 0.40
Low scores are positive.*1 = Strongly agree, 5 = Strongly disagree.�1 = Great deal influence, 5 = No influence.�1 = Very easy, 5 = Very difficult.§1 = Almost always, 5 = Almost never.
A. Henderson et al.
ª 2012 Blackwell Publishing Ltd6 Journal of Nursing Management
that the work was performed according to legislative
requirements.
Ward B results indicated that staff attitudes toward
the leadership and staff organization changed positively
in relation to the organisation of work allocation. The
NUM was proactive in facilitating task shifting through
clear delineation of roles; however, through leadership
that recognized and considered staff concerns about
increased workload, the NUM also directed that task
shifting occur only when EENs or graduate RNs were
rostered. This strategy appears to have been effective,
given that the leadership practices of the NUM were
viewed more positively after the intervention period.
Sustained change for effective working relationships
needs to be gradual, cumulative and embraced by the
team (Ramanujam & Rousseau 2006) which may have
been the perception in Ward B.
Ward C staff indicated less approval of leadership
practices of the NUM and a perception of reduced staff
organization. Here, the NUM was proactive in task
shifting from a patient/nurse allocation model of care to
a team-based model through structured ward processes.
Clear systematic processes around change are important
for successful continuation (Davidson et al. 2006). The
team-based model was a different mode of working for
the RNs and, from the survey results, appeared to create
some anxiety among staff. Staff indicated that they felt
allocation was less organized. In Ward C a few staff
members were thought to have actively subverted the
team approach process (notes from facilitator docu-
mentation). Staff feedback was less favourable towards
the leadership after the intervention period, yet still
quite high when compared with the other areas.
The presence of a facilitator to assist the management
team was a proactive strategy to assist the local leader
(NUM) and change arrangements around patient allo-
cation; however ultimately, it is largely the influence of
the leader that affects how much staff will engage with
the assistance provided.
Limitations of the project and its evaluation
The processes around team building and delegation
recognized as important were partly successful in
implementing this change (Ramanujam & Rousseau
2006, Cummings et al. 2010); however, given the dif-
ferences across the three clinical areas, further investi-
gation of the enablers (for example, leadership inclusive
of staff and engaging champions that contributed to
increased staff engagement) would have been worth-
while. Increased demand for clinical services because of
heavy workloads sometimes made it difficult to ensure
the requisite time for adequate communication, educa-
tion sessions and one-on-one support for staff.
Undertaking an evaluation of this nature is neces-
sarily limited, as many variables influence staff opin-
ions. It is only by circumspect observation that the
authors conclude the intervention had a particular effect
on staff perceptions of ward leadership and ward
organization. Despite this, the authors are confident in
the findings because many of the other factors measured
in the study remained the same. Leadership and ward
organization scores that altered during the intervention
period would seem to be directly linked to the imple-
mentation process.
The scope of this study was limited, but future work
could explore, through focus groups and discussions,
the rationale for why staff felt positive or negative
toward the leadership behaviours of the NUM. While
the intervention project provides helpful insights into
the type of activities that can assist in implementing
changes to practice, greater insight could be obtained
Table 5Ward leadership and staff organiza-tion subscale mean scores for eachward before and after the task-shiftingprocess
Responses,frequency
Ward leadershipscore, mean (SD) P (t-test)
Staff Organizationscore, mean (SD) P (t-test)
Ward ABefore 15 1.75 (0.14) <0.001* 2.17 (0.81) <0.02*After 27 2.68 (0.17) 2.94 (1.08)
Ward BBefore 15 2.49 (0.20) <0.001� 2.49 (0.35) <0.002�After 17 2.18 (0.16) 2.09 (0.33)
Ward CBefore 19 1.61 (0.13) <0.001* 1.77 (0.50) <0.02*After 28 1.86 (0.13) 2.15 (0.53)
t-test (mean comparison test) between before and after ward leadership and staff organizationmean scores.*The significant difference indicated a less positive response.�The significant difference indicated a more positive response.
Staff perceptions of leadership during task-shifting
ª 2012 Blackwell Publishing LtdJournal of Nursing Management 7
from further investigation of why staff felt uncertain
about ward leadership by the NUM after the inter-
vention.
Conclusions
The need for task shifting often arises from necessity
rather than the nursing staff being desirous of change.
This evaluation of a change process, namely, task
shifting emphasizes the strategic role of leadership in
implementing changes to practice. The research findings
indicate that staff maintained greater satisfaction in the
leadership of the NUM, and more confidence in staff
organization when change was introduced gradually (in
stages) negotiated through leadership practices that
consulted and included staff in decisions. Leadership
behaviours can be facilitated by local champions. The
voice of local champions needs to be strong so other
staff who may be resistant to changed practices do not
subvert the communication of information.
Implications for nursing management
The behaviours that nurse leaders exhibit during change
processes are important if requisite changes to work
practices are to be effectively adopted. This study
demonstrates that while specific processes are similarly
agreed across different clinical practice areas, the ap-
proach adopted by the nurse leader for their imple-
mentation can differ. The perceived quality of
leadership by staff during implementation is important
in maintaining a positive work environment (Malloy &
Penprase 2010). Positive work environments support
staff to deliver optimal care, therefore, leadership is
important for quality care (Cook & Leathard 2004).
Leadership practices consistent with a laissez-faire
approach, that is, intervention primarily only in demand
situations, result in reduced satisfaction with leadership
(Malloy & Penprase 2010). Alternatively, if there is
limited flexibility in how messages are upheld then this
can also result in staff dissatisfaction. The findings of
this study support that leadership behaviours consistent
with democratic participatory leadership practices
contribute to staff organization and improve staff
satisfaction with the NUM. The specific behaviours
observed in this study were open communication, lis-
tening to the concerns of staff and, in particular, modi-
fying the change process according to staff concerns. In
this case, a more sequenced approach was adopted.
Clinical practice is dynamic largely owing to work-
force issues and the available evidence that informs
health delivery. Nurse leaders play a significant role in
supporting staff to adopt practice changes to deliver
care in accordance with political and social imperatives
and contemporary knowledge. When leadership prac-
tices are consultative and negotiations are continued
through the change implementation process, favourable
outcomes for staff and patients are more likely to result.
Source of funding
The authors thank the Queensland Nursing Council,
Australia, for their financial contribution in the facili-
tation of task-shifting implementation.
Ethics approval
Ethical approval for this project was granted by the
Hospital Human Research Ethics Committee. Nurses
agreed to complete their demographic details and the
Ward Organization Features Survey (Adams et al.
1995), an anonymous questionnaire on different aspects
on their working situation. No personal details or
identifying factors were collected.
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