Staff perceptions of leadership during implementation of task-shifting in three surgical units

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.


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



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.


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.



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.

References

AdamsA.,BondS.&ArberS. (1995)Developmentandvalidationof

scales to measure organisational features of acute hospital wards.

International Journal of Nursing Studies 32 (6), 612–627.

Anderson L. (2010) Nursing Scope of Practice. Available at:

http://www.nursetogether.com/tabid/102/itemid/707/Nursing-

Scope-of-Practice.aspx, accessed 13 November 2011.

Anthony M.K., Standing T.S. & Hertz J. (2001) Nurses� beliefs

about their abilities to delegate within changing models of care.

Journal of Continuing Education in Nursing 32 (5), 210–215.

Australian Nursing & Midwifery Council (2010) Nursing

Practice Decisions Summary Guide. Available at: http://

www.nursingmidwiferyboard.gov.au/codes-guidelines-statements.

aspx (DMF A4 Nursing Summary Guide Final) accessed 9

December 2011.

Buonocore D. (2004) LeÆadership in action – creating change in

practice. AACN Clinical Issues 15 (2), 170–181.

Carr-Hill R., Dixon P. & Gibbs I. et al. (1992) Skill Mix and the

Effectiveness of Nursing Care. Available at: http://www.york.ac.

uk/media/che/documents/papers/occasionalpapers/CHE%20

Occasional%20Paper%2015.pdf, accessed 8 March 2011.

Cook M.J. & Leathard H.L. (2004) Learning for clinical

leadership. Journal of Nursing Management 12, 436–444.

Cummings G., MacGregor T., Davey M. et al. (2010) leadership

styles and outcome patterns for the nursing workforce and

work environment: a systematic review, International Journal

of Nursing Studies47 (3), 363–385.

Davidson P., Halcomb E., Hickman L., Phillips J. & Graham B.

(2006) �Beyond the rhetoric: what do we mean by a �model of

care�?� Australian Journal of Advanced Nursing2 (3), 47–55.

Deshong D. & Henderson A. (2010) The trainee assistant in

nursing – a pilot exercise in building and retaining a workforce.

Australian Health Review 34, 41–43.

A. Henderson et al.


Duffield C., Roche M., O�Brien-Pallas L., Catling-Paull C. &

King M. (2009) Staff satisfaction and retention and the

role of the Nursing Unit Manager. Collegian 16 (1),

11–17.

Greenhalgh T., Robert G., MacFarlane F., Bate P. & Kyriakidou

O. (2004) Diffusion of innovations in service organizations:

systematic review and recommendations. Milbank Quarterly

82 (4), 581–629.

Kutney-Lee A. & Aiken L. (2008) Effect of nurse staffing

and education on the outcomes of surgical patients with

comorbid serious mental illness. Psychiatric Services 59,

1466–1469.

Lewin K. (1951) Field Theory in Social Science, Harper and Row,

New York, NY.

Malloy T. & Penprase B. (2010) Nursing leadership style and

psychosocial work environment. Journal of Nursing Manage-

ment 18, 715–725.

Ramanujam R. & Rousseau D.M. (2006) The challenges are

organizational not just clinical. Journal of Organisational

Behaviour 27 (7), 811–827.

Van den Heede K., Sermeus W., Diva L. et al. (2009) Nurse

staffing and patient outcomes in Belgian acute hospitals: cross-

sectional analysis of administrative data. International Journal

of Nursing Studies 46 (7), 928–939.

World Health Organization (2008) Task Shifting: Rational

Redistribution of Tasks Among Health Workforce Teams:

Global Recommendations and Guidelines. World Health

Organization, Geneva.



Documents

Staff perceptions of leadership during implementation of task-shifting in three surgical units