Safety-Specific Transformational Leadership: Behavioral Characteristics and Measurement.

Safety-specific transformational leadership (SSTFL) has been examined in high-risk industries for decades with solid evidence for its effectiveness and influence on safety climates and safety outcomes. The concept has recently been introduced to healthcare, with an operational definition developed through a concept derivation process and the development of a typology of factors that influence the relationship between leadership and safety climate. This article describes the evidence-based behavioral characteristics of leaders practicing SSTFL, which serve as a basis for the development and testing of an instrument to measure the latent variable of SSTFL in interprofessional healthcare leaders.

ALSN 2021 Conference: Nursing Science for Leadership in the New Decade.

The Association for Leadership Science in Nursing's 2021 conference provided an opportunity to further enhance professional understanding of the difficulties facing nurse leaders as the COVID-19 pandemic continues to create unimaginable challenges. Presentations provided evidence in support of courageous caring leadership interventions.

Nurse Leader Burnout, Satisfaction, and Work-Life Balance.

OBJECTIVE: To examine and report burnout, secondary trauma, and compassion satisfaction in acute care nurse leaders through a large mixed-methods research study. BACKGROUND: Although nurse leaders are removed from daily patient care activities, the pervasive challenges in the work environment create conditions for professional burnout. Nurse leaders must garner compassion satisfaction from different sources, including peer and staff interactions. METHODS: The Professional Quality of Life scale was given to nurse leaders at 29 hospitals in 1 health system. Sixteen leaders from 2 hospitals participated in qualitative interviews. RESULTS: Six hundred seventy-two nurse leaders from 29 hospitals reported similar levels of burnout across frontline, midlevel, and director-level leadership. Directors demonstrated higher levels of compassion satisfaction and lower levels of work-life balance. Four themes emerged representing areas of professional life that potentiate and alleviate compassion fatigue. CONCLUSIONS: All levels of nurse leaders must address the risk of burnout and can do so through individual and organizational resiliency strategies.

Collaborative Rural Nurse Peer Review: A Quality Improvement Project.

BACKGROUND: Peer review is an essential element of professional nursing practice. LOCAL PROBLEM: Implementing nursing practice peer review is a challenge in any organization; some characteristics of small and rural hospitals can make the task especially daunting. METHODS: A team of nursing leaders and staff nurses from rural and critical access hospitals within 1 health care system was formed to make recommendations about implementing nursing practice peer review in the small rural facilities. Barriers included limited numbers of nurse reviewers by nursing specialty and inherent bias of reviewers due to personal knowledge of cases and nurses involved. INTERVENTIONS: A collaborative rural nursing practice peer review council was created, with staff nurse and leader representation from 6 geographically distinct facilities. RESULTS: The rural collaborative council has developed processes for case referral, reviewer assignment, investigation, and scoring founded on Just Culture principles. Satisfaction among staff nurses, reviewers, and Chief Nursing Officers has been high. CONCLUSIONS: Barriers to implementation of nursing practice peer review in rural hospitals can be mitigated through a collaborative approach, resulting in efficient and effective processes for small, rural, and geographically distinct hospitals.

Consensus achievement of leadership, organisational and individual factors that influence safety climate: Implications for nursing management.

AIM: To validate a framework of factors that influence the relationship of transformational leadership and safety climate, and to enable testing of safety chain factors by generating hypotheses regarding their mediating and moderating effects. BACKGROUND: Understanding the patient safety chain and mechanisms by which leaders affect a strong climate of safety is essential to transformational leadership practice, education, and research. METHODS: A systematic review of leadership and safety literature was used to develop an organising framework of factors proposed to influence the climate of safety. A panel of 25 international experts in leadership and safety engaged a three-round modified Delphi study with Likert-scored surveys. RESULTS: Eighty per cent of participating experts from six countries were retained to the final survey round. Consensus (>66% agreement) was achieved on 40 factors believed to influence safety climate in the acute care setting. CONCLUSIONS: Consensus regarding specific factors that play important roles in an organisation's climate of safety can be reached. Generally, the demonstration of leadership commitment to safety is key to cultivating a culture of patient safety. IMPLICATIONS FOR NURSING MANAGEMENT: Transformational nurse leaders should consider and employ all three categories of factors in daily leadership activities and decision-making to drive a strong climate of patient safety.

Decisional Involvement: Differences Related to Nurse Characteristics, Role, and Shared Leadership Participation.

A sample of 1933 registered nurses working in 24 hospitals with shared leadership was surveyed to examine perceptions of nurse decisional involvement. Council participation was associated with higher decisional involvement scores (P = .03), and nurse experience was a statistically significant predictor of decisional involvement (P < .01). Nurse manager and staff registered nurse scores were significantly different (P < .01). Shared leadership may promote staff nurse perceptions of involvement in decision-making.

Transformational Leadership in Nursing Education: Making the Case.

Transformational leadership is a trending style and competency that has been embraced by many industries and nursing practice settings. Similar positive influence on follower engagement, teamwork, and solidarity might be experienced if transformational leadership is employed by administration and faculty as a guiding framework for nursing education. The impact of embedding a teamwork culture in basic nursing education could be significant on students and ultimately on the nursing profession. Further research is needed to develop and test application of the transformational leadership framework in nursing education.

Developing nurses' transformational leadership skills.

Healthcare is a complex area with significant potential for service improvement despite the effects of increasing economic and social pressures on the quality and safety of patient care. As the largest group of healthcare professionals in direct contact with patients, nurses are well positioned to contribute to improvements in healthcare services and to the development of new policies. To influence healthcare improvements and policies effectively, nurses require leadership skills. Historically, it was thought that only nurses in management roles required leadership skills; however, the ability to influence change is a requirement at all levels of clinical practice. Transformational leadership competencies provide nurses with the skills to contribute to improvements in the quality and safety of patient care, while enhancing their career satisfaction. This article examines how nurses can apply transformational leadership to their practice. It also informs nurses how to conduct an initial self-assessment of their leadership skills and to formulate a transformational leadership development plan.

Transformational leadership in nursing: a concept analysis.

AIM: To analyse the concept of transformational leadership in the nursing context. BACKGROUND: Tasked with improving patient outcomes while decreasing the cost of care provision, nurses need strategies for implementing reform in health care and one promising strategy is transformational leadership. Exploration and greater understanding of transformational leadership and the potential it holds is integral to performance improvement and patient safety. DESIGN: Concept analysis using Walker and Avant's (2005) concept analysis method. DATA SOURCES: PubMed, CINAHL and PsychINFO. METHODS: This report draws on extant literature on transformational leadership, management, and nursing to effectively analyze the concept of transformational leadership in the nursing context. IMPLICATIONS FOR NURSING: This report proposes a new operational definition for transformational leadership and identifies model cases and defining attributes that are specific to the nursing context. The influence of transformational leadership on organizational culture and patient outcomes is evident. Of particular interest is the finding that transformational leadership can be defined as a set of teachable competencies. However, the mechanism by which transformational leadership influences patient outcomes remains unclear. CONCLUSION: Transformational leadership in nursing has been associated with high-performing teams and improved patient care, but rarely has it been considered as a set of competencies that can be taught. Also, further research is warranted to strengthen empirical referents; this can be done by improving the operational definition, reducing ambiguity in key constructs and exploring the specific mechanisms by which transformational leadership influences healthcare outcomes to validate subscale measures.

Factors Associated With Delayed Healing in a Study of the PrePex Device for Adult Male Circumcision in Kenya.

OBJECTIVES: To explore factors associated with healing requiring more than 6 weeks after placement of the PrePex device for adult medical male circumcision. METHODS: We enrolled 427 men ages 18-49 years in an observational study of PrePex at 1 urban and 2 peripheral clinics in western Kenya. Participants were scheduled for device removal at day 7 and a follow-up visit at day 42 (allowable range, 40-44) at which the provider recorded wound status, with complete healing defined as a dry wound without any scab, later confirmed by site investigator review of digital penile photographs. We performed univariate and multivariate logistic regression to explore associations between selected demographic, surgical, and follow-up factors and delayed healing (not healed by day 42 visit). RESULTS: Of the 427 men, 341 completing a day 42 visit with physical examination and recorded healing status were included. Fifty-four percent of included men were healed by day 42 visit. Factors associated with delayed healing in univariate analysis and remaining significant in the multivariate analysis were as follows: age 25 years or older [odds ratio (OR): 1.8; 95% confidence interval (CI): 1.4 to 2.4], an adverse event by day 44 (OR: 1.4; 95% CI: 1.03 to 2.0), and severe pain during device removal (protective association: OR: 0.7; 95% CI: 0.5 to 0.99). CONCLUSIONS: Older age (25+ years), occurrence of an adverse event, and lesser self-reported pain at device removal were associated with delayed wound healing. If confirmed by larger surveillance studies, these results should be incorporated into the counseling given to male circumcision clients.

Evaluation of SMARTube to Detect HIV Infection Before Seroconversion Using Standard Methods.

The acute phase of HIV infection carries substantial risk of transmission; identification of acute-phase infections may offer opportunities to reduce that risk. SMARTube incubation of blood specimens is designed to stimulate in vivo-primed HIV-specific lymphocytes to produce HIV antibodies in vitro. The resulting supernatant (S-plasma) can be tested to identify acute infections with commercially available HIV assays. We assessed the performance of the SMARTube to identify acute HIV infections in studies at three developing country sites. We conducted HIV incidence studies in Ho Chi Minh City, Vietnam, and Bloemfontein and Rustenburg, South Africa. We estimated HIV incidence in cross-sectional samples and measured prospective incidence in uninfected women followed for up to 12 months. We incorporated SMARTube into the HIV testing algorithm at cross-sectional screening and monthly follow-up visits. We tested 1,384 persons in Vietnam, 1,145 women in Bloemfontein, and 538 persons in Rustenburg. Cross-sectional samples from 11 participants that tested positive with SMARTube after an initial unincubated negative test result (11 of 2,472; 0.4% of all specimens) were considered "potential acute" infections. Matching samples from 3 of the 11 (27.3%) were confirmed by polymerase chain reaction (PCR) testing. In follow-up of 355, 401, and 223 uninfected women in Vietnam, Bloemfontein, and Rustenburg, respectively, 11 seroconversions occurred in Bloemfontein and Rustenburg. In four of these incident infections (36.4%), SMARTube testing had resulted in earlier detection of HIV infection than the eventual seroconversion visits. In our field studies, pretreatment with SMARTube allowed the identification of acute HIV-1 infection in some new infections, but with a positive predictive value of 27%. Larger studies are needed to evaluate SMARTube as an alternative to technically challenging and costly enzyme immunoassay and PCR testing to detect acute HIV infection.

Unexpected Complications Following Adult Medical Male Circumcision Using the PrePex Device.

INTRODUCTION: In this study, we describe and depict unexpected sequelae of adult medical male circumcision (MMC) using the PrePex device. MATERIALS AND METHODS: The PrePex system is an elastic compression device for adult MMC. The device is well studied, has been pre-qualified by the World Health Organization (WHO), and its use is being scaled-up in African countries targeted by WHO. We conducted a PrePex implementation study in routine service delivery among 427 men in the age range of 18-49 in western Kenya. We captured penile photographs to create a record of adverse events (AEs) and to monitor healing. Several unexpected AEs ensued, including some that have not been reported in other PrePex studies. We describe and depict those unexpected complications and resulting treatments to alert circumcision providers in the relevant areas. RESULTS: We observed 5 device displacements (1.2%); 3 cases of early sloughing of foreskin tissue (0.7%) among men with long foreskins; 2 cases of a long foreskin obstructing urine flow, as it became dry and necrotic (0.5%); and 2 cases of insufficient foreskin removal caused by invagination for which surgical completion was necessary (0.5%). All of the participants healed completely by day 42 post-circumcision or shortly thereafter. CONCLUSION: The potential for these complications should be incorporated into PrePex training programs. Integration of devices into MMC programs in medically underserved areas requires the availability of prompt surgical intervention for some sequelae, particularly displacement events.

Safety, effectiveness and acceptability of the PrePex device for adult male circumcision in Kenya.

OBJECTIVE: To assess the safety, effectiveness and acceptability of the PrePex device for adult medical male circumcision (MMC) in routine service delivery in Kenya. METHODS: We enrolled 427 men ages 18-49 at one fixed and two outreach clinics. Procedures were performed by trained clinical officers and nurses. The first 50 enrollees were scheduled for six follow-up visits, and remaining men were followed at Days 7 and 42. We recorded adverse events (AEs) and time to complete healing, and interviewed men about acceptability and pain. RESULTS: Placement and removal procedures each averaged between 3 and 4 minutes. Self-reported pain was minimal during placement but was fleetingly intense during removal. The rate of moderate/severe AEs was 5.9% overall (95% confidence interval [CI] 3.8%-8.5%), all of which resolved without sequelae. AEs included 5 device displacements, 2 spontaneous foreskin detachments, and 9 cases of insufficient foreskin removal. Surgical completion of MMC was required for 9 men (2.1%). Among the closely monitored first 50 participants, the probability of complete healing by Day 42 was 0.44 (95% CI 0.30-0.58), and 0.90 by Day 56. A large majority of men was favorable about their MMC procedure and would recommend PrePex to friends and family. CONCLUSIONS: The PrePex device was effective for MMC in Kenya, and well-accepted. The AE rate was higher than reported for surgical procedures there, or in previous PrePex studies. Healing time is longer than following surgical circumcision. Provider experience and clearer counseling on post-placement and post-removal care should lead to lower AE rates. TRIAL REGISTRATION: ClinicalTrials.gov NCT01711411.

HIV incidence and prevalence among cohorts of women with higher risk behaviour in Bloemfontein and Rustenburg, South Africa: a prospective study.

OBJECTIVES: The primary objective was to measure HIV incidence in two prospective cohorts of HIV-negative women. Secondary objectives included measuring pregnancy rates and participant retention rates. DESIGN: Cross-sectional HIV screening of women selected for higher risk behaviours, with a subsequent prospective study of uninfected women, followed monthly for up to 6 months. SETTING: Clinics established for research purposes in Bloemfontein and Rustenburg, South Africa. PARTICIPANTS: The authors enrolled women 18-35 years old and presumed at higher risk of sexual acquisition of HIV as indicated by self-reported sexual behaviour or recent sexually transmitted infection symptoms. In Bloemfontein, 1364 women were screened, 1154 were eligible for HIV testing and 1145 agreed to be tested. The prospective study enrolled 401 HIV-negative women. In Rustenburg, 946 women were screened, 540 were eligible and underwent HIV testing and 223 HIV-negative women entered the prospective study. PRIMARY AND SECONDARY OUTCOMES: Baseline prevalences of HIV infection and HIV incidence rates in the prospective cohorts, according to a double rapid test algorithm with a third rapid test for discrepant or indeterminate results. Pregnancy prevalences and pregnancy incidence rate in Bloemfontein. Participant retention rates in the prospective cohort until the study end. RESULTS: In Bloemfontein, 1145 women were tested, 391 entered follow-up and 92.3% of participants completed six study visits. In Rustenburg, 540 women were tested, 194 entered follow-up and retention up to the point of early study termination was 88.6%. Overall HIV prevalence was 21.2% (95% CI 18.9% to 23.6%) in Bloemfontein and 23.5% (95% CI 19.9% to 27.1%) in Rustenburg. Overall HIV incidence was 5.5/100 person-years (95% CI 2.5 to 10.4) in Bloemfontein and 3.0/100 person-years (95% CI 0.4 to 10.8) in Rustenburg. Cross-sectional pregnancy prevalences were 6.5% in Bloemfontein and 8.6% in Rustenburg. CONCLUSIONS: The authors observed substantial HIV incidence rates in both cohorts. Vigorous prevention efforts are needed in these smaller cities.