Adaptive Leadership Among Nurses: A Qualitative Meta-Synthesis

Introduction

The practice of adaptive leadership has been introduced as a more hands-on approach in identifying personal and organizational practices related to mobilizing organizations around adaptive challenges [1, 2]. It is the activity of mobilizing people to tackle tough challenges and thrive. The concept of thriving in nursing was brought by the stressful environment the nurses are dealing with. From long hours of providing care to patients and collaborative effort exerted from a multidisciplinary and culturally- diverse setting, nurses in all specialty areas [3] are very much exposed to emotional, mental and physical exhaustion. Like any other healthcare professions, up to 60% of nurses often feel that they are burned out [4]. Burnout is linked to absenteeism and lower job performance [5], and it has also been shown to partially explain turnover intention among nurses [6].

Recent technological advances change the way nurses deliver patient care [7]. With this, nurses adapt to the process of change as it is manifested for both patient and the nurse [8] and also requires to promote a continuing process of change for the patients’ significant others [9]. With these advances and changes in nursing practice, nurses are often times faced with challenges. This notion of how nurses do their job amidst the challenges of advancement is clearly reflected on the unique function of a nurse [10]: “To assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he (sic) would perform unaided if he had the necessary strength, will or knowledge and to do this in such a way as to help him gain independence as rapidly as possible” [10].

Background of the study

The current situation and future trends in nursing practice require nurses to respond and be prepared to the challenges which may affect the provision of quality care for patients and establishment of professional relationships. It was foreseen that the employment landscape will be affected by disruptive changes to business models over the coming years [11]. The challenges in adaptive leadership are presented in two separate aspects. One is technical challenge, in which problems can be defined and an expert can be found to solve it. The second is adaptive challenge, in which the problem cannot be solved by expertise alone. With the continuous change and increasing intricacies of health care, nurses need a proactive approach to patient care management. Adaptive leadership is presented as significant in nursing in judiciously analyzing the multifaceted problem- solving required within a dynamic health context [1]. Adaptive leadership in nursing collaborate with other disciplines and levels of experience to solve on challenging problems of the organization. Adaptive leadership is a collaborative effort of stakeholders to find the best solution on the challenge of the organization.

The success of effective nursing practice does not rely solely among nurses. This requires collaboration and coordination among members of the health care team, patients themselves and their families or relatives. Mobilizing people to meet their adaptive challenges and allowing them to participate in finding solutions will build the organization’s adaptive capacity.

In what follows, the researcher synthesized the concept of adaptive leadership in hospital and community settings, suggest ways it applies to the practice of nursing, explore how nurses utilize in hospital and community settings, and discuss the implications for nursing profession.

Despite of the evidence about adaptive leadership, there is dearth in the body of literature that presents the concepts of adaptive leadership to the practice of nursing. The researcher proposes that viewing the practice of nursing as adaptive leadership, as first suggested by Heifetz, promises to empower nurses and make progress on the challenges of nursing practice.

Objectives

This systematic review aimed to identify, evaluate and integrate the evidences exploring concepts of adaptive leadership in nursing. More specifically: How staff nurses and nurse managers utilize adaptive leadership behaviors in hospital and community settings?

Methods

Design

This systematic review followed a priori protocol [12] based on Joanna Briggs Institute (JBI) Reviewers’ Manual [13]. A mnemonic for qualitative reviews was developed to judiciously direct the structure and determine important aspects of the search. The focus was primarily the investigation of how staff nurses and nurse managers utilize adaptive leadership behaviors in hospital and community settings, which was reflected on the research question (Table 1).

Data Sources

The literature search strategies using electronic databases were implemented to search for relevant literature on adaptive leadership [14]. Nine electronic databases were utilized, namely, i) CINAHL, (ii) Medline, (iii) ProQuest: Nursing and Allied Health, (iv) DOAJ, (v) Springer, (vi) Wolters Kluwer, (vii) Taylor and Francis, (viii) Web of Science, and (ix) Google Scholar. Keywords were identified using mesh terms. Keywords with truncation and Boolean logic used in all databases were listed in Table 2. Only those articles which explored the concept of adaptive leadership in nursing were included.

Inclusion and exclusion criteria

Inclusion criteria include (a) no year restriction (with such criteria, this review attempts to cover the historical perspective of adaptive leadership in nursing), (b) English language, and (c) peer-reviewed journal articles.

Exclusion criteria include articles in press, conference proceedings abstracts, irrelevant to research keywords, and unpublished manuscripts (abstracts or dissertations), non-English language, non-nurse participants, and editorial pieces.

Critical Appraisal

The researcher together with two other reviewers assessed the articles for methodological validity. A consensus of all reviewers was established on which articles should proceed to the next phase of review using the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI). It is a standardized critical appraisal instrument on which the reviewers need to answer 10 questions applying a four-point scale: yes, no, unclear, and not applicable [15]. The first two authors independently assessed the identified primary studies for validity prior to inclusion in the review using JBI-QARI. The disagreements that arose between the first and second author were resolved through discussion with the researcher.

Data Extraction and Synthesis

Abstracts of the articles were matched against the inclusion and exclusion criteria. A total of 486 articles were identified relevant. After retrieval of the full copies of these articles, sixteen articles met the inclusion criteria. Two of the sixteen articles were quantitative, and three were not congruent with the review aims. The reference lists of the sixteen articles were manually searched. The Saudi Digital Library was used for the manual search of relevant references from the sixteen articles. The search revealed two potential articles. After having read the abstracts and full texts, both articles fit the inclusion criteria, which resulted in thirteen articles. The flow diagram illustrating the search process of the identified relevant articles is presented in Figure 1. Guided by the Critical Appraisal, the researcher and two reviewers individually evaluated the thirteen articles using the JBI-QARI reviewer’s matrix. Quotations from the participants and paraphrases by the authors were extracted following the JBI procedure for meta-synthesis [13]. Moreover, the researcher used a meta-aggregative approach to come up with themes from the identified findings.

Results

After the articles were critically appraised, nine research articles were considered in the meta-synthesis due to relevance and appropriateness of method. Four articles were excluded because they pertain to curriculum development in the nursing graduate school and narratives of students on about their field experience in the community. Figure 1 shows the PRISMA flow diagram [16] in the selection of articles for inclusion in the review.

The nine included articles used case qualitative methodologies. Three were case studies [17-19], one used a qualitative descriptive approach [20], one used grounded theory approach [21], one used a framework model development [22], one used content analysis [23], one is a qualitative observational study [24], and one used a phenomenological approach [25]. The methods used in the nine studies were in-depth interviews; focus group discussions; intrinsic case study approach using journals, interviews, video-recorded team performance; and field notes observations. The participants involved were staff nurses, nurse managers and patients. The studies were conducted from 2013 to 2016 in five countries: USA, South Africa, Germany, Switzerland, and China. All articles were written and published in English language. A summary of studies included for the review was illustrated in Table 3.

Meta-synthesis

A concept of how staff nurses and nurse managers utilize adaptive leadership in hospital and community settings. The meta-synthesis is presented under the three main themes comprising (1) leadership qualities, (2) leadership challenges, and (3) leadership capacities. The three themes had nine synthesized categories which were revealed from relevant themes (Figure 2). Illustrated in Figure 3 is the grouping of the findings into synthesized categories. Commonalities of theme were noted despite variances in the quality of the research. There is a frequency effect size [26] of 100% each for all of the three themes (Table 4).

Leadership Qualities

This theme originated from 15 grouped study findings [17-25] and four synthesized categories: expert, adaptive, realistic, understanding others. The theme illustrated that staff nurses and nurse managers possess adaptive leadership qualities such as being expert, adaptive, realistic and shows empathy among others.

There is a notable contrast between nurses with and without field experience [20]. All nurses with previous field experience cited the importance of skills and developing a relationship. Those nurses without field experience focused exclusively on clinical competency and technical skills. The work environment requires that nurses convey organizational citizenship, and a clear understanding of the mission. In addition, nurses as adaptive leaders should possess the competency of delivering the clinical skills [18]. However, any team member including patient and family might assume the roles of being an adaptive leader by understanding and identifying adaptive work and promoting adaptive change [22]. Whenever adaptive nurses face with new roles, they must have focused on adjusting themselves in strengthening their clinical knowledge and skills. Next, they built their professional credibility and role-modeling abilities [25]. Another adaptive leadership quality of nurses is being able to present information to patient and family on a clear, honest and in lay terms.

Providing the family with such a clear prognostic information allow families to understand the actual condition of their patient and to prepare themselves in making decisions about treatment. This makes the family view the problem on a more holistic manner. On the other hand, an adaptive nurse leader is a clinical expert and is very much aware of the responsibilities that the team members perform on various task situations [21]. Adaptive nurse leader should be a patient-advocate by providing sufficient information to patients; likewise, supportive to his team members by communicating clear information especially during technically challenging phases [23].

An adaptive nurse leader should know empathy that is, he carefully understands the situation of others. On a study conducted [17], the community felt they were given greater status because they were acknowledged. Relationships were acknowledged in terms of the quality of the nurse-patient encounter [24]. In establishing relationships, an adaptive leader must learn how to empathize with them. Moreover, respect of individuality is essential to prevent conflicts.

Leadership Challenges

This theme derived from 11 grouped study findings [17-25] and three synthesized categories: barriers, problem-solving approach, and knowledge-based.

This cumulative source of evidences presents two separate aspects of challenges in adaptive leadership. One is technical challenge, in which problems can be defined and an expert can be found to solve it. The second is adaptive challenge, in which the problem cannot be solved by expertise alone. The person who own this challenges is the one who must do the adaptive work [22].

Poor quality relationships among nurses were seen as adaptive challenge, this barrier cannot be addressed by the expertise of the manager. Rather, staff nurses describe the need for responsibility for one’s peer.

Adaptive leadership addresses tensions of various perspectives. This is why organizations must consider to develop flexibility and resilience, including establishing crucial relationships with a wide variety of stakeholders [18]. On the other hand, adaptive nurses were able to sustain their leadership while performing either or both clinical and administrative roles. However, on a separate study, majority of senior officers felt that there should have 2 clearly defined developmental tracks for clinical and administrative [20]. Adaptive leadership was reflected among team members on various task situations such as when protocol is normal, task completed, change in status, and resources inadequate [21]; however, it always important the adaptive nurses promote a pleasant work atmosphere. Adaptive leadership behavior has an essential coordinative function because it is often focused on effective and efficient accomplishment [23].

On a study among family members in the ICU, some family members show avoidance when nurses engage them to do adaptive work because of their preoccupation of losing their ICU patients [19]. When this occur, adaptive nurses demonstrate support and hope through compassion, reframing hope, giving time to process information, and assurance of adequate symptom management to support decision making and strengthen therapeutic relationship [19].

Leadership Capacities

This theme derived from 10 grouped study findings [17-25] and two synthesized categories: relationship development, and effect on members.

One of the authors [20] mentioned on their study the importance of developing relationship with the operational officers because it enhances the clinical competence for senior leadership roles. In establishing relationship, adaptive leaders look at what is happening and invite everyone into the conversation about the possible solutions to the problems at hand [18, 21]. The members of the team realized that they were the experts of the field when dealing with people labelled as deprived.

Discussion

This review aims to explore the concept of how staff nurses and nurse managers utilize adaptive leadership behaviors in hospital and community settings. Three main themes and nine sub-themes are discussed in this section.

First, staff nurses and nurse managers practicing adaptive leaders were described to possessed distinctive leadership qualities. Nurses were experts who focuses on clinical competency and technical skills [20, 21]. They convey a high level of awareness to the organization’s mission and excellent clinical skills [18]. They have an intensive experience acquired through practice and education. Therefore, adaptive leadership among nurses is a continuous journey of nursing over time; it can be learned and developed through practice and education. An innovative management strategy can be developed to properly guide nursing students and novice nurses become adaptive leaders in the future. Whenever there’s a need arise to promote adaptive change, nurses must focus on adjusting themselves in strengthening their clinical knowledge and skills [25]. Organizations should provide appropriate avenue for learning to accommodate such adaptive work. For example, hospitals may develop a mentorship program for novice nurses to improve their clinical competencies in practicing collaborative work among healthcare team. In this way, the process of learning adaptive leadership will be sustained because novice nurses can easily adjust to changes. Furthermore, adaptive nurses were realistic. They were patient-advocates and provide sufficient information to patients [23]. Thus, adaptive nurses do not offer false hope to patients and family members but only provide realistic information about one’s clinical condition. In addition, an adaptive nurse carefully understands the situation of others. One of the authors mentioned [17], community members felt they were given greater status because they were acknowledged. Therefore, it is a very essential element in establishing nurse-client relationships. It is suggested that nursing students should thoroughly understand the meaning of empathy versus sympathy because this quality should be developed in the practice of professional nursing.

Second, this review supported that nurses may encounter barriers as they practice adaptive leadership. These barriers were presented in the literature in two aspects [22]. One is technical challenge, in which problems can be defined and an expert can be found to solve it. The second is adaptive challenge, in which the problem cannot be solved by the expert alone. The person who own this challenges is the one who must do the adaptive work. Carefully understanding the nature and aspect of the problem, nurses would know how to properly solve it. Organizations may provide training among nurses to address the need for this understanding. Furthermore, they may also utilize this knowledge during strategic planning and in managing workplace conflicts. Adaptive leadership addresses tensions of various perspectives and difficult situations [18]. Thus, adaptive nurses should involve stakeholders in finding appropriate solutions to various organizational issues. On the other hand, one of the major challenges adaptive nurses may encounter is on how they will be able to sustain their leadership while performing either of both clinical and administrative roles. Organizations should also consider nurses’ exhaustive tasks and responsibilities which may lead to burnout and low job satisfaction. On the other note, clinical and technical knowledge are essential in planning for solutions to adaptive challenges in the organization. That is why, adaptive nurse leaders should be experts because they obtained the appropriate knowledge in the field of nursing.

Third, leadership capacities were notably evident in the practice of adaptive leadership. Developing relationship is crucial because it enhances the clinical competence for senior leadership roles [20]. This review also supported that adaptive leadership enhances relationship among superiors, peers and staff members. For example, chief nurses would have a more effective leadership command toward staff in the implementation of a particular program or during conflict resolution. Moreover, staff members should always be invited to involve themselves in the discussion of issues and communicate their ideas and concerns within the organization [18, 21]. Continuous mentorship program could be an effective strategy to help both the mentor and mentee for adaptive leadership roles. Mentees will be trained to become experts and become more adaptive in their leadership practice. Working with mentees such as novice nurses, mentors will be identified as experts and will further enhance their leadership capacities to sustain their adaptive work.

Conclusion

A meta-synthesis was developed: nurses utilizing adaptive leadership possessed distinctive qualities that can be learned and acquired over time. It is a continuous exploration in nursing which is directed towards enhancing clinical skills and knowledge to become experts and improve professional traits of becoming more adaptive, realistic and empathic. Thus, establishing professional relationship among superiors, peers and staff members is essential to develop these adaptive leadership traits. Using one’s expertise and knowledge were not being used to dictate what the organization needs. In finding for the most appropriate solution, adaptive nurse leaders were not the mere source of information to solve the problem. Instead, they facilitate collaboration and involvement of other members to come up with more concrete and inclusive solution. Adaptive nurse leaders use their expertise to assist the organization to properly solve the issues. Although there were leadership challenges along the way, adaptive nurse leaders still learn how to manage these problems by looking into its aspects, whether it is a technical or an adaptive challenge, and addressing this problem accordingly.

Moreover, this literature review provided substantive information about adaptive leadership as a knowledge-based practice. Adaptive nurse leaders should always abreast themselves with continuous training and education to enhance and update their knowledge. Thus, organizations should maintain their training programs for nurses to promote and sustain the practice of adaptive leadership. Furthermore, trainings should not only aim to update information or enhance skill sets of nurses but also to promote professional traits directed to their co-workers and clients.

Although concepts of adaptive leadership were presented, this met-synthesis suggested the need to critically explore the pathway of becoming an adaptive nurse leader. Understanding this picture will also help future researchers and leaders to address issues and challenges of utilizing adaptive leadership roles in their respective organizations.

Implications for Nursing Education

Schools of nursing and clinical training institutions should pay attention to students’ understanding about the interrelation of continuous improvement of clinical competencies and professional traits to becoming an adaptive nurse leader. With the ever-changing innovations in the nursing practice, students should be taught to become more adaptive to these changes. Nursing education should also be directed towards developing of adaptive nurses who will acquire leadership qualities needed to employ capacities and sustain its beneficial effects on nurses and clients. When students valued the importance of adaptive leadership, they might maintain this trait as they transformed to become professional nurses. In this manner, there will be a continuous process and the pathway of becoming an adaptive leader will be sustained.

Furthermore, schools and institutes should ensure that their educational programs include this information about adaptive leadership and address the development of qualities necessary to become adaptive nurse leaders.

Implications for Practice Settings

An effective strategy to promote adaptive leadership in the practice setting is the mentorship program. Organizations benefit from this through training of staff nurses particularly novice nurses to improve their clinical competencies and leadership qualities. Working with mentees such as novice nurses, mentors will be identified as experts and will further enhance their leadership capacities to sustain their adaptive work.

This meta-synthesis supported the idea of employing a professional staff development program which will provide continuous training programs for staff nurses to update their knowledge and enhance their leadership qualities. Nurse leaders such as supervisors and managers might use this meta-synthesis to effectively deal with their staff and clients without causing any further conflicts in the organization. Adaptive nurse leaders use their expertise and knowledge to facilitate collaborative efforts among staff nurses and clients.

Implications for Research

This meta-synthesis suggested the need to critically explore the pathway of becoming an adaptive nurse leader. Despite of the evidence about adaptive leadership, there is dearth in the body of literature that explains an adaptive leadership model in the nursing practice. Future research may also support additional information about leadership challenges and problem-solving approaches.

Limitation of the study

Despite the availability of relevant research articles, this meta-synthesis was limited to number of included studies and participants’ practice settings. Although there is an extensive search strategy, some relevant studies may have been missed. However, the use of quality appraisal enhanced the assessment of available evidences. One of the strength is that the three reviewers reviewed each study independently.

Conflicts of interest statement

No conflicts of interest are declared on this systematic review.

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