Negotiating Nursing Leadership

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Research ArticleNegotiating, Navigating, and Networking:Three Strategies Used by Nursing Leaders to Shapethe Adoption and Incorporation of Simulation into NursingCurriculaA Grounded Theory Study

Karyn Taplay,1 Susan M. Jack,2 Pamela Baxter,2 Kevin Eva,3 and Lynn Martin1

Department of Nursing, Faculty of Applied Health Sciences, Brock University, Glenridge Drive, St. Catharines,ON, Canada LS A

School of Nursing, Faculty of Health Sciences, McMaster University, Main Street West, Hamilton, ON, Canada LS K Centre for Health Education Scholarship, Faculty of Medicine, University of British Columbia, West th Avenue, Vancouver,

BC, Canada VZ M

Correspondence should be addressed to Karyn aplay; [email protected]

Received February ; Accepted March ; Published April

Academic Editors: S. Keeney, S. Kennerly, and A. B. Wakeeld

Copyright Karyn aplay et al. Tis is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background. Implementing simulation requires a substantial commitment of human and nancial resources. Despite this, littleis known about the strategies used by academic nursing leaders to facilitate the implementation of a simulation program innursing curricula.Methods. A constructivist grounded theory study was conductedwithin nursing programs in Ontario,Canada.Perspectives of key stakeholders( = 27)including nursing administrators( = 6), simulation leaders( = 9), and nursing faculty( = 12)were analyzed using the constant comparison method. Results. Nursing leaders, specically nursing administrators andsimulation leaders who successfully led the adoption and incorporation of simulation into nursing curricula, worked together andutilized negotiating, navigating, and networking strategies thatimpacted the adoption and incorporation of simulation into nursingcurricula.Conclusions. Strategies that were found to be useful when planning and executing the adoption and incorporation of aninnovation, specically simulation, into nursing curricula provide practical approaches that may be helpful to nurse leaders whenembarking upon an organizational change.

1. Introduction

Te use of simulation as a teaching strategy in nursingeducation has developed signicantly within the past decade[]. Despite the increased use of simulation and theattention received [], the integration of simulation intonursing curricula has been inconsistent. In /, theOntario Government provided each nursing program in theprovincewith approximately ,in funding to purchasesimulation equipment []. Prior to this time, the use ofmid- to high-delity simulation equipment as a teachingstrategy was uncommon in most programs of nursing. Mid-to high-delity equipment is dened as life-like equipmentthat can imitate real-life responses to medical conditions

[, ]. What followed was a time of dynamic change in

nursing curricula as nursing programs started the process ofincorporating simulation which provided an opportune timeto examine how organizational culture shapes the adoptionand incorporation of simulation.

aplay and colleagues [] discovered key organizationalelements that shape a common process of adoption andincorporation of simulation into nursing curricula. Institu-tions that were able to navigate this process and integratesimulation into all levels of curricula in which nursingcontent was taught were classied as high uptake. Te keyorganizational factor that was identied in high uptake siteswas the shared leadership among nursing leaders. Tis paperrepresents an effort to delve more deeply into the shared

Hindawi Publishing CorporationISRN NursingVolume 2014, Article ID 854785, 7 pageshttp://dx.doi.org/10.1155/2014/854785
http://dx.doi.org/10.1155/2014/854785http://dx.doi.org/10.1155/2014/854785


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leadership among nursing administrators and simulationleaders and to explain the three leadership strategies (negoti-ating, navigating, and networking) that played a key role inthe adoption and incorporation o simulation into nursingcurricula in Ontario, Canada. While the ocus o this studywas mid- to high-level delity equipment, the common term

simulation will be used throughout this paper.Leaders engage in processes that bring value to an orga-nization by inuencing change [] thereby shaping organiza-tional culture [,]. Now more than ever, academic nursingleaders are expected to be innovative and acilitate changebecause nursing education is undergoing a period o greatchange with the incorporation o new technologies, includingsimulation. Young and colleagues [] conducted a phe-nomenology study exploring the experiences o becoming anurse aculty leader among a group o nurse educators.Te participants in this study ofen reported that they eltunprepared to assume leadership roles and lacked the skillsor strategies needed to manage change. Horton-Deutschand colleagues [] identied three strategies used by nurseeducators when aced with leadership challenges: reecting,persevering through difficulties, and learning to relate toothers in new ways (page ). Pearsall and colleagues []suggest an additional strategy o doing your homework(page ) as a way to manage change. Te researchers oundthat learning about a subject and weighing the positives andnegatives beore making decisions lessened their concernsabout change when taking risks. Tey suggested that risktaking is a key actor in academic leadership since it involvestrying something different or innovative. Although theseresearchers identied general strategies used by nursingleaders when they were met with challenges, there remainsa gap in the literature related to strategies that academicnurse leaders use when trying to adopt and incorporatenew technology. Further insight is needed to understand theprocesses and strategies nurse leaders use to acilitate theintegration o simulation into nursing programs.

2. Method

.. Design. Te principles o grounded theory [] guidedall methodological decisions related to sampling, data col-lection, and analysis. Tis approach was used to guide thisresearch because it provided an opportunity to examinehow nursing leaders managed the complex process o adopt-

ing and incorporating simulation into nursing curricula. Areview o institutional mission and vision statements servedto provide organizationalcontext and insight intothe culturesin which this simulation initiative was occurring [,].

.. Sampling. Participants rom o provincial nursingprograms were included in this study. Participants includednursing administrators, simulation leaders, and nursing ac-ulty members. Maximum variation, a method o purposeulsampling, was used to capture the differences in nursingprograms by geography and structure o program []. Allgeographic regions o the province were represented as were

both college and university nursing programs and the col-laborations between them. In addition, maximum variationsampling was used to enhance the degree o representationamong the participants themselves.

Teoretical sampling, a hallmark o grounded theoryresearch, helps to explore, dene, and recognize attributes

o themes as they emerged. Tis type o sampling continueduntil no new properties emerged which indicated that theo-retical sufficiency was achieved [].

.. Data Collection. Data were collected using two roundso audio-recorded ace to ace or telephone semistructuredinterviews. Initial interviews ocused on the process o adop-tion and incorporation o simulation and were approximately minutes. Second interviews, ocused on emergingcategories, in particular the leadership roles which acilitatedthe process, were approximately minutes. NVivo sofware [] was used to organize and manage all data.

.. Data Analysis. All interviews were transcribed verbatimand then analyzed line-by-line and incident-by-incident bythe primary investigator (K). Te ensuing codes were devel-opedand denedthrough the useo the constant comparativemethod o analysis comparing data within and across sites[]. Te codes were then condensed into categories. Concur-rent data collection and analysis, a eature o grounded theoryresearch, was used to aid in the process o developing thecategories and in dening the properties and characteristicswhich led to the nascent structure o the developing theory.o stay true to the participants perspectives, in vivo codeswere used and will be highlighted in quotations throughoutthe paper.

.. Ethics. wo research ethics boards approved this study.Consent was obtained rom all participants who wereinormed that their participation was voluntary. Anonymityand condentiality were maintained by removing all identi-ers and numerically coding the data.

3. Results

.. Demographic Data. Participants included simulationleaders( = 9), nursing administrators( = 6), and nursingaculty( = 12). All participants were emale and registerednurses. All had a baccalaureate degree with the majority

having a masters degree (.%); .% had a PhD. Teyranged in age rom to years. Te majority (%) werebetween the ages o and years. Te primary place oemployment was almost evenly divided between universities(.%) and colleges (.%). Participants (.%) had anaverage o years (range plus years) o experienceusing mid- to high-delity simulators.

Among the sites in this study there was variability in theuptake o simulation ranging rom high to low. Te causecan be understood in part by considering the leadershipdifferences which presented in this study. Te most apparentdifference between the high uptake sites and the mid andlow uptake sites was the consistent leadership shared between


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the nursing administrators and the simulation leaders. Tisshared leadership was the key element that shaped the adop-tion and incorporation of simulation into nursing curricula.

.. Nursing Leaders. Nursing administrators were identiedas a chair, dean, or director of nursing within their respective

nursing programs. In their administrative roles, they wereinstrumental in the development of thenew simulation leaderrole. Nursing administrators in the high uptake sites realizedthat the workload would needto be sharedand hadthe insightto create a new role to facilitate the integration of simulation.Tey also recognized that the simulation initiative requiredan individual who was willing to take the lead. Tis washighlighted by one simulation leader who stated:

Te Dean approached me to spearhead the (simu-lation) initiative and. . .plan for the acquisitionof equipment and facilities. It was considereda special project that I was asked to lead . . .my job description was altered to accommodate

additional responsibilities ().

Tis represented the signicant level of responsibilityand decision-making power bestowed upon the simulationleaders.

Tis change in work responsibilities also came with achange in title. Te people who took on the role of simu-lation leader were identied by such titles as simulationists,simulation champions, simulation specialists, or simulationcoordinators. Te simulation leader role differed consid-erably across organizations with respect to title, responsi-bility, and expectations. However, despite the differences,most identied having some if not all of the followingresponsibilities: developing and sharing expertise about allaspects of simulation; developing or designing simulations;supporting nursing faculty members and clinical instructorsin the development of the knowledge andskillsto enable theirunderstanding of the equipments capacity and utilization;providing technological support; managing the facilities;and organizing simulation experiences for students. Somesimulation leaders also had the responsibilities of managingsimulation committees, creating simulation templates, andmotivating people to incorporate simulation into the curricu-lum.

Te diversity of role expectations and responsibilitiesamong the simulation leaders was institutionally driven andbased on what worked best at the time for the institution

and the nursing program, that is, what was the most feasibleand what was the most expeditious to implement. Tis washighlighted by two simulation leaders describing their role.Te rst stated: what I do is design and write out thescenarios and facilitate every simulation that happens inthe lab and . . . get more faculty and staff trained to feelcomfortable doing (simulation) (). Te second statedthat her role consists of primarily overseeing the simulationactivities, the physical space, and the logistics of it. Not somuch creating the actual simulation or the learning planobjectives, but taking the facultys vision and bringing itto life (). Te diversity within this role was furtheremphasized by organizational classication; some simulation

leaders were classied as nursing faculty while others wereclassied as staff. Te inconsistencies in title, responsibility,and work expectations among simulation leaders highlightthe challenges associated with a newly developing role.

In the high uptake sites where nursing administratorsand simulation leaders shared power, decision-making, and

responsibilities related to the integration of simulation, threekey strategies emerged that nursing leaders engaged in tofacilitate the adoption and incorporation of simulation intotheir nursing curricula. Tese included negotiating, navi-gating, and networking that both nursing administratorsand simulation leaders employed either jointly or indepen-dently.

.. Negotiating. Te negotiations that leaders engaged inwhen developing goals and action plans included comingto an agreement regarding the resources and personnelneeded to incorporate simulation into the curriculum. While

the nursing administrators and simulation leaders wereboth required to negotiate with individuals, the processstarted with the administrators. Nursing administrators wereinvolved in negotiations with upper level administrationwithin the institution where they emphasized the importanceof the simulation initiative and created awareness of whatwould be needed to be in place to support this initiative. Tiswas an essential rst step, since resources, space, and supportfrom the institution were required to develop the simulationlabs, particularly because the funding received from theprovince was earmarked for the purchase of simulationequipment only. Te second step was to convey the need for alead simulation person. Nursing administrators, particularlythose from the high uptake sites, used three strategies duringthese initial negotiations: education to heighten awarenessabout the needs of the nursing department, followed by per-sistence and persuasion. One nursing administrator providedan example of how she had articulated the needs of thenursing program by stating that she had to educate the Deanabout what a nursing lab is, and introduce (simulation) intoa culture where theres absolutely no knowledge of it ().Another administrator discussed the persistence she used tosecure resources by stating it took a lot of dialogue withsenior administration, negotiations around space and theproposals for a simulation coordinator . . . we were kind ofpersistent in making the argument (). She stated that sheapproached these negotiations with the philosophy that you

cannot get what you require unless you communicate yourneeds ().

Te nal negotiating strategy used was persuasion. Per-suasion in this context involved emphasizing the institutionalbenets that could result from the nursing program adoptingand incorporating simulation into the curricula. Nursingadministrators typically highlighted three institutional ben-ets when negotiating with upper level administration. First,integrating simulation was a way to become, or stay, competi-tive with other nursing programs. Second, having simulationintegrated into the curricula could aid in the recruitmentof potential students. Tird, the accomplishments related tosimulation (e.g., securing grants, conducting research, or the


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lab itsel) could be used to publicly promote the nursingprogram and, in turn, promote the institution as a whole.Tese strategies used by nursing administrators helped toacquire the necessary resources and personnel or simulation.

Once resources were allocated or space and a new posi-tion was created, the nursing administrators were then able

to share the negotiating responsibilities with the simulationleaders. Te ocus turned to increasing buy-in and the use osimulation among nursing aculty members which requireddifferent negotiating tactics by the nursing administrator andsimulation leader. Nursing administrators created opportu-nities or aculty to learn about the potential or simulationand encouraged them to consider where simulation ts intocourses or curricula. Tis was done by sharing inormation atmeetings or by supporting the aculty membersattendance atconerences, whereas simulation leaders provided opportuni-ties or nursing aculty members to gain hands-on experiencewith the equipment thereby enhancing their comort leveland providing opportunities to offer suggestions on howsimulation could be incorporated into their specic courses.Te institutions took a tandem approach to negotiations.Both types o leaders interacted with aculty members butused different negotiating strategies to implement simulationinto the nursing curriculum.

.. Navigating. Navigating requires nding a way, creating apath, or setting a specic course o action through unchartedterritory. It ofen involves using specic instruments ormeans. It requires direction or a plan and can be challenging[, ]. Participants in this study identied two strategiesused to direct the pathway or simulation to be integratedinto the curriculum. Te rst was the leadership style(s) usedby the nursing administrators during the adoption and initialincorporation o simulation into the curriculum. Te secondwas the development o the simulation leaders role.

Participants discussed three unique leadership stylesemployed by nursing administrators when navigatingthrough the adoption and incorporation o simulation intothe curriculum: (a) participatory, (b) delegative, and (c)laissez-aire. Te rst two leadership styles were ound inthe high uptake sites and were accompanied by a vision oran idea o how an innovation could t within the currentcurriculum consistent with charting a path or a course oaction when navigating. Participatory leadership encouragedinput rom all members o the nursing department about the

uses or simulation. Leaders who used this strategy presentedsimulation as a solution that could address challenges withgaps in the curriculum or augment clinical experiencesoffered to students. Tis type o leadership encouragedshared decision-making within the nursing departmentand provided the opportunity or all to have a voice andcontribute to the initial and ongoing vision. Sites that usedthis shared or team approach initially continued to do so assimulation was urther integrated into the curriculum.

Delegative leadership primarily involved unilateraldecision-making by nursing administrators at the onseto the initiative. Simulation was presented to simulationleaders and nursing aculty members as an expectation by

these leaders. Leaders who used a delegative style did notinclude much i any input rom the simulation leader oraculty members into the overall development o a vision.However, once the expectations o the nursing administratorswere made clear, the simulation leaders were given power,permission, and domain over how to incorporate simulation.

One example o this was stated by a simulation leader:Our Deanwould tell us . . . simulation is a priority.Here are my expectations, we need to do this toenhance our curriculum and the way that we

get there is totally up to you but here are myexpectations ().

Nursing administrators who used both participatory anddelegative leadership styles were able to encourage bothsimulation leaders and nursing aculty members to worktogether which resulted in a higher level o uptake thaninstitutions where the participants reported that a laissez-aire leadership style was employed. Tese sites had difficulty

because they did not or could not establish or convey a planor simulation or a direction to ollow. One aculty memberhighlighted this by stating that the director at the time saidbasically. . .i you think there is a place or (simulation) to beintegrated, nd a place ().

Te second strategy articulated by participants thatserved to maintain the direction o integrating simulationinto the curriculum was the development o the simulationleaders role. In most high uptake sites, simulation leaderswere given a new title, power, and autonomy with their newrole. Tis helped nursing programs to navigate the unchartedpath o integrating simulation since many simulation leadersinvested considerable personal time and effort to develop

expertise in this area. o do this, many simulation leadersworked toward creating a new work identity and aligningsimulation with their career and educational goals. Tis wasnoted by a simulation leader who stated:

As far as the simulation piece, it just seemed to bea t. . . it fell in line with what my organizationneeded but it also fell into line because I could

focus my Masters on (simulation) in nursingeducation ().

While there was substantial personal sacrice noted, insome cases this resulted in proessional achievements suchas advancing rom part-time to ull-time employment status.

Gaining expertise provided simulation leaders a means omanaging challenges which arose during the integration osimulation such as resistance or indifference among acultymembers or troubleshooting equipment problems.Te devel-opment o the simulation leaders role served to acilitate anddirect the path o simulation into the curriculum.

.. Networking. Networking involves creating or seeking outa support system comprised o individuals or groups whohave the same or similar interests and objectives [, ].Participants in this study described networking as the cre-ation o relationships by both the nursing administrator andsimulation leader who served to move simulation orward in


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the nursing curriculum. Tese connections occurred withinthe institution, among different professions, outside of theinstitution, and across the nursing profession. Both nursingadministrators and simulation leaders created support sys-tems to gain information and share resources related to simu-lation. Nursing administrators primarily used networking as

a means of collaborating andsecuring necessary or additionalresources, whereas simulation leaders used it for the purposeof learning and gaining expertise.

Within the individual institutions, some nursing leadersconnected with other departments representing differentdisciplines that included physical or occupational therapy,medicine, pharmacology, and emergency response. Tisstrategy allowed the programs to share resources such as labspace, equipment, and, at times, personnel, which providedthe potential for institutional cost-savings. Networking withcolleagues from other professions within the same organi-zation who have experience or expertise with simulationenabled simulation leaders to learn about the equipment andgain expertise in managing and organizing a lab. Addition-ally, this networking provided the opportunity for facultymembers and simulation leaders from multiple programs towork together, conduct research, and plan and implementsimulations. In some instances, these connections also led tothe development of interprofessional simulations thatmet theneeds of students in different programs.

Networking also occurred with local health care agenciessuch as hospitals and community health care organizations.In some cases, the nursing program would reach out tothe health care agency to inform them of the educationalapproaches offered to nursing students through simulation.Other institutions presented simulation to local health careagencies as a means of generating potential revenue by havingagencies rent out the facilities andequipment forstaff trainingpurposes. Other programs initiated these partnerships asa way to enhance interprofessional education. One admin-istrator summed this up stating: I felt that (simulation)was an interprofessional initiative for the whole region, thatsimulation would be a way to bring everybody together andraise the prole of this school ().

Simulation leaders also connected with other nursingprofessionals. Tese connections typically developed throughsimulation conferences. At the onset of this initiative, mostnetworking was done outside the province, in the UnitedStates, since there were few nursing experts in Ontario withwhom to consult. Tese interactions provided an opportunity

to learn about nursing-specic content and for simulationleaders to develop their own expertise. Institutions that wereable to support simulation leaders attendance at conferencesand thus gain expertise had an easier time integratingsimulation into the curriculum.

Networking with the purpose of securing resources thatbeneted more than one program within the same institutionand connecting with health professionals in the communityboth served to move simulation forward to become a faculty-wide or community affiliated initiative rather than just anursing-specic initiative. Networking was a key strategyused by nursing leaders during the preliminary phases of thesimulation initiative, but it must continue in order to advance

simulation in nursing education. It needs to be activelypursued by both nursing administrators and simulationleaders.

4. Discussion

Te tandem leadership between the nursing administratorand the simulation leader is similar to the denition of sharedleadership that exists in the literature. Shared leadershipis considered a dynamic interaction between people thatfocuses on achieving specic group or organizational goals[]. While this type of leadership is discussed within thebroader eld of education [], there is no discussion ofhow it has been applied to simulation. Tis is a signicantnding from this study that adds to the literature on sim-ulation. o date, much of the literature about the uptakeof simulation into nursing curricula has focused on theattitudes and beliefs of faculty members [] and the aspectsthat nursing faculty consider when making decisions about

whether to incorporate simulation []. Tis study, on theother hand, suggests that faculty attitudes and beliefs aboutsimulation as a teaching strategy may not be the only con-sideration which can facilitate or impede the adoption andincorporation of simulation. Te shared leadership betweenthe nursing administrator and the simulation leader whoutilize negotiating, navigating, and networking strategies tomanage change contributed signicantly in the adoption andincorporation of simulation into nursing programs. Sites thathad leaders working in tandem to share the workload andthe responsibilities experienced a high level of uptake ofsimulation compared to sites that did not have these nursingleaders. Effective shared leadership involved utilization of

negotiating, navigating, and networking strategies to managechange.

Te role of simulation leader proved to be crucial inthe process of adopting and incorporating simulation intonursing programs. Te ndings from this study provideinsights into the complexity and diversity of this role by high-lighting the multiple responsibilities and extensive workloadexpectations. What was discovered during this study is thatthe development of the role of the simulation leader wasdriven by the needs, requirements, and feasibility of eachindividual institution. Tis was highlighted by the lack ofconsistency related to workload, level of responsibility, andtitle. As a result, the role may become indistinguishable from

the institution because it is so specically based on the needsand resources within that organization. Tis can potentiallylead to ambiguity about the role of simulation leaders as itrelates to the broader context of the nursing culture. Tis isan issue for future consideration as the role of the simulationleaders becomes embedded into the organizational structureof nursing programs.

5. Strengths and Limitations

Te strengths of this study included the triangulation ofdata sources and theoretical sampling. riangulation of datasources was achieved by including participants who held


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different roles in the same institution, thus offering variedperspectives []. Teoretical sampling was achieved byreturning to participants to clariy concepts and add urtherdetails in order to rene the emerging theoretical categories[, ]. Tis strategy was used until no new propertiesemerge[d] [, page ].

A limitation o this study was that the chair, dean, orthe director roles within the nursing programs were groupedtogether under the umbrella o nursing administrator. Teroles were not differentiated with respect to specic responsi-bilities or the permanence o the position. Inclusion o theseaspects may have elicited additional ndings related to theshared leadership among the nursing leaders.

6. Conclusion

Nursing leaders, specically nursing administrators and sim-ulation leaders who represented high uptake sites, worked intandem and utilized negotiating, navigating, and networking

strategies to impact the uptake o simulation into nursingcurricula. Nursing leaders who employed these strategieswere able to secure necessary resources, collaborate with keystakeholders, gain inormation, create a vision, and orgea course o action through uncharted territory. Insightsregarding the development o the role o the simulation leaderwere shared and concerns about the uture o this role asit relates to the broader context o the nursing proessionwere raised. Additionally, this study offered strategies thatmay be useul when planning and executing the adoptionand incorporation o an innovation, specically simulation,and offered practical approaches that may be helpul to nurseleaders when embarking upon an organizational change.

Conflict of Interests

Te authors declare that they have no conict o interestsregarding the publication o this paper.

Authors Contribution

All authors meet at least oneo the ollowing criteria:substan-tial contributions to conception and design or acquisition odata, analysis, andinterpretation o data; drafing o the paperor revising it critically or important intellectual content. Allhave agreed on the nal version [].

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Negotiating Nursing Leadership