Assessment of a Leadership Enhancement Program for Nursing Managers of An Acute General Hospital in Hong Kong

Background: With the aim to enhance the senior nursing managers to be caring leaders so that they can nurture their team members to be holistic care providers, a one year program has been developed with emphasis on self-reflection and self-cultivation. Purpose: It aims to evaluate the effectiveness of a one-year leadership enhancement program in an acute general hospital. Design & Methods: Both quantitative and qualitative approaches were adopted. A pre and post questionnaire survey and the content analysis of self-reflective essays were conducted. Results: The overall means of the servant leadership scale and the workplace wellness scale were significantly higher after the program. Both scales were also found to have a significantly medium level of positive correlation. Reflective essays showed positive feedbacks complementing the quantitative data that the program was well received and effective. Conclusion: A servant leadership approach may be one way for hospital management to enhance a caring environment and a more quality workforce.


INTRODUCTION
An acute general hospital with appropriate 1400 in-patient beds which is built on a strong heritage of Christian love with compassionate care has been established in Hong Kong since 1973. Hospital predecessors have already set up a good foundation in terms of structure, policy, educational activities and role models. However, compassionate care has to be cultivated by everyone in the hospital and passed from one generation to the next. The nursing administrative department believed that senior nursing managers are an important part of the staff who can uphold the caring heritage and influence their teammates. In return, junior staff will provide a high quality of care to clients and learn to be caring leaders in future. Furthermore, the nursing shortage is a common phenomenon in many advanced cities, Hong Kong is of no exception. To ensure a quality nursing workforce in a time of labor shortage, nursing managers in executing strong nursing leadership play an important role in supervising and supporting the frontline nurses [1].
With the aim to enhance the senior nursing managers to be caring leaders so that they can nurture their team members to be holistic care providers, a one year program has been developed with an emphasis on self-reflection and self-cultivation. With the belief that lives influencing lives, the program expects participants to share, to learn from one another and build up mutual support in the nursing team. The program was started in April 2016 and ended in March 2017. The contents of the program consisted of one seminar per month for 5 months. Each seminar was a 1.5-hour talk during lunch break. Then, it followed with five sessions of small group sharing with 1.5 hours during lunch break or in the afternoon. The last part of the program was a one day retreat. The total hours spent on the program were 21. This paper reports the outcomes after the implementation of this leadership enhancement program.

THE LEADERSHIP MODEL AND CONTENT OF THE PROGRAM
A number of studies show that the nurse managers and her engagement with her staff is a key factor in nurse job satisfaction despite working in a stressful environment. Satisfaction usually comes from managerial care, support and respect [2 -5]. There are different management models or theories which help managers better lead and support their followers. As a hospital with strong Christian background, Jesus Christ has long be a model of leadership. He demonstrated his leadership in both his words and deeds. He claimed to come to the world to serve but not to be served [6]. He humbly washed his disciples' feet [7]. In management, the theory "the servant as leader" proposed by Greenleaf [8] matched the leadership model shown in the bible. The servant leadership model gained a lot of evidences of its effectiveness not only in business sector, but also in the healthcare settings [9 -12]. The basic idea of servant leadership is that servant leader recognizes his or her moral responsibility not only to the success of the organization but also to his or her subordinates, the organization's customers, and other organizational stakeholders [8]. Hale and Fields [13] defined servant leadership as " an understanding and practice of leadership that places the good of those led over the self-interest of the leader, emphasizing leader behaviors that focus on follower development, and de-emphasizing glorification of the leader" (p. 397). Beyond leading with altruism, Spears [14] identified 10 characteristics common among servant leaders: listening, empathy, healing, awareness, persuasion, conceptualization, foresight, stewardship, growth, and building community. Though servant leadership overlaps with other theories such as transformational, ethical, authentic and spiritual leadership and exhibits some behaviors as role modeling, inspirational communication, and altruism [15], it is suggested by Walumbwa, Hartnell and Oke [12] that servant leadership is theoretically distinct in several important ways. First, it includes a moral component. Second, it is uniquely concerned with the success of all organizational stakeholders. Third, servant leader acts in the best interest of the followers. Fourth, servant leader engages in self-reflection to reduce leaders' arrogance.
The servant leadership model is adopted in this program to encourage participants to put subordinates first, to be humble and learn from one and other. On the other hand, it is also important to take care of oneself before taking care of others [16]. A personal wellness, a holistic view of a person including physical, psychosocial and spiritual aspects is also introduced. Participants help to understand oneself holistically and develop more in their potentials to be a servant leader at the same time a holistic person to care for oneself and others from a holistic perspective. Details of the program can be seen in (Table 1). Self-cultivation -personal wellness Content: -take self-assessment on personal wellness -share ways for maintaining personal wellness Self-cultivation -An exploration of Self relating to leadership qualities Content: -take self-assessment on personal personality -share how one's personality affecting the leadership style

Self-cultivation -A servant leadership model as a holistic approach
Content: -revisit the characteristics of servant leadership -take self-assessment on servant leadership Management case sharing -staff Content: -share different approaches in managing difficult staff -identify ways of integration of theory into practices Self-cultivation -Understanding Self leadership Content: -take self-assessment on self-leadership -sharing ways of enhancing self -leadership

Retreat Topics
Objectives: -consolidate previous learnt concepts into clinical application -enrich personal strength with holistic components Content: -Movie appreciation for life reflection -Spiritual guidance on professional enhancement (*p <.05, **p<.001)

METHOD
Both quantitative and qualitative approaches were adopted in the assessment of the effectiveness of the program. A pre and post questionnaires were sent to participants of the program. After the completion of the program, participants were also asked to return a self-reflective essay for content analysis. Invitations were sent to all senior nursing managers of the hospital including Department Operation Managers (DOM), Nursing Consultants (NC), Senior Nursing Officers (SNO), Ward Managers (WM) and Advanced Practice Nurses(APN) of all units. Totally 42 senior nursing managers joined the program. All participants joined the program voluntarily. They are free to fill in the pre and post tests of the survey and submit with the anonymity of questionnaire which was only marked by self-assigned code.

Instruments
The questionnaire consists of two sets of scales. The first one is a general measure of servant leadership (Appendix A1) which composes of 7 categories: forming relationships with subordinates, empowering subordinates, helping subordinates grow and succeed, behaving ethically, having conceptual skills, putting subordinates first, and creating value for those outside of the organization [17]. Each category contains 2 items with the complete set of 14 items. Participants rated each of the items on a 5-point scale from 1=to a very small extent to 5= to a great extent. The alpha reliability of the overall scale was 0.98. Participants were asked to rate themselves as servant leaders who lead their followers in their service units.
The second set is a measure of well-being in the workplace (Appendix A2) which composes of 4 domains: work satisfaction, organizational respect for the employee, employer care and intrusion of work into private life. This Workplace Well-being Questionnaire (WWQ) contains 31 items. The participants were asked to rate the items that best represented their current and most relevant work situation on a 5-point scale: 0, not at all; 1, slightly; 2, moderately; 3, very; and 4, extremely true. This questionnaire was found to have a high test-retest reliability, Pearson r=0.91 for the overall scale [18] and a good validity [19].

Pre and Post Questionnaire
Totally 42 senior managers have taken part in the program. Twenty-two were DOM/NC/SNO, 20 were WM/APN. Ten are male and 32 female. Age was within 35 to 55. The average attendances of the seminars of DOM group and WM group were 72% and 83%, respectively. The average attendances of the small groups of DOM group and WM group were 51% and 61%, respectively. The total average attendances of all participants were 67%.
Out of 42, 26 participants have returned their pre and post-test questionnaires, the returned rate was 62%. Regarding the scoring of the servant leadership scale, participants got scoring from 4 out of 7 categories and the overall mean significantly higher after the program. Details can be seen in (Table 2). Relating to the workplace wellness scale, participants got scoring from 3 out of 4 domains and the overall means significantly higher after the program. Details can be seen in Table 3. When using the Pearson correlation test for the outcomes of leadership scores and workplace wellness score, a medium level of positive correlation was found between these variables with statistically significant differences r=0.427, p=<0.05. Details can be seen in Table 4.

Reflective Essays
There were totally 7 essays received. Low submission rate may be due to managers' busy schedule and lack of the habit of writing essays. However, all returned essays provided rich data for content analysis. The content of their reflection was analyzed into 2 main areas: the content of the program and effects on Participants.

Content of the Program
Words relating to the content of the program such as well organized, inspiring, enjoyable, fruitful, and meaningful can be found. Participants also showed appreciation to the course organizer, speakers and group facilitator. Some of their sharing are shown as below.

Well Organized, Inspiring
This is a pretty good course with comprehensive content and thoughtful arrangement. The sharing from different lecturers and leaders gave me many brainstorming and stimulate me to have a deeper understanding of the key elements of being a leader. However, I gained much more from the sharing in the tutorial group. I felt grateful that this course just right in time to guide my direction and my way. I could not stay in the past, I was determined to have a breakthrough and make a change. (Essay 7)

Enjoyable, Enlightening
I really enjoy this program and appreciate the effort from the coordinators. In this program, I could realize the different aspects of myself. This program was full of touching, sharing and stories and gave me a chance in a tranquil environment to revisit the value, mission and my dream in nursing. The topics of this program were diversified and the expert speakers provided the substantial content to enlighten me. The program made me think my work, family and life in multi-dimensions. (Essay 1)

Fruitful
To me, the course is a bottle of spiritual nutrients throughout my year in 2016-17. Having worked in nursing for many years, there are times that I have lost direction, shifted/lost the meaning and value of nursing or even in life because of all the chaos. Nonetheless, all the sessions have energized my spirit, to refresh and keep going. Finally, I would like to thank the course coordinators for their dedication and effort for the future nursing leaders. (Essay 4)

Effects on Participants
Three themes emerged with more than half of them mentioned in their sharing: Reflecting and refreshing; gain more self-understanding and reviving. Some of their sharing are illustrated below.

Reflecting and Refreshing
I think I am lucky to be one of the members of the program that I could have opportunities and time to stop and think. In fact, I can do it while I am free, but usually, I will be distracted by other staff. Honestly, I seldom 'stop and think' in my day-by-day busy working life which drains all my energy at the end of the working day. I think it is good for me to have an 'official' time to think more about myself, my career and my future. (Essay 6) I was wrongly assumed that I have already mastered many techniques at my age getting to retired and thought that this was merely a day camp with nothing new and time could easily be passed. Unexpectedly, the first item "technique cards" already made me rethink that I turned out haven't made good use of many techniques.
In the afternoon session, Dr. Choi was invited to be a speaker and I gained a lot from his sharing. He made me think again how to maintain my holistic health. Every day is a busy day, it does not only make you feel tired physically but also spiritually. We really need to take care of our holistic health in order to take care of the people around us. (Essay 5)

Gain More Self-Understanding
Although I thought the tutorial group would not be as attractive as a lecture, however, it gave me a chance to explore myself. I came to understand more of my strengths and weaknesses, and the type of "leader" I belong to. It acts like a mirror to allow me clearly see how could I live my life and what could I contribute to nursing. After recovery from illness, each day is a bonus for me. I really did not want to waste my life. However, in the busy days, I am getting lost…. (Essay 7) The exercises in sharing sessions can enhance self-understanding and know others' strengths. The group with similar seniority from a different background can create non-political resonance. By sharing with one and other, we can know others' perspectives and find the way out. Greater exposure can cultivate support and networking with each other to be companions on the lonely road. (Essay 2)

Reviving
PPEP program is a booster on my way. It refreshes my energy to continue. Besides, to sustain the seeding on me, I shall try my best to nourish those I meet. I believe little thing can make differences. Life influences live. (Essay 2) The fire in my heart being rekindled. Nowadays, I would not focus on how much was given to me by others, but how much I can do for others. In the past, I was being nurtured by my seniors. Today, I hope to be a blessing for others, nurture the juniors and help them to grow. Hoping that my hospital has more and more blessings in the future. (Essay 7) The focus of this day camp was not on teaching techniques, but have reflections on life and work. We reflected and discussed our works through the movie "The Five People You Meet in Heaven". My conclusion is, I have to change my attitude, to regain my original intention in nursing, to rekindle my passion, and to love my work. (Essay 5)

DISCUSSION
The pre and post-tests showed that there was an overall improvement in servant leadership particularly in the areas of empowering subordinates, behaving ethically, having conceptual skills and creating values for those outside of the organization. There may be several possible reasons for this positive result. First, the nursing administration demonstrated the respect and care to senior managers in organizing this program with the aim to enhance their leadership knowledge and skill. This may exert a positive influence on them to act in the same way to their followers. Second, this program introduced the philosophy and practice of the servant leadership and encourage managers to act in the best interest of their followers. More leadership potentials are unleashed and participants may also influence one another. Third, during the whole year of implementation, a culture to serve and care is much more reinforced, which help participants in the program to put theory into practice.
The pre and post tests also showed that there was an improvement in the workplace wellbeing in all areas and overall mean except in the area of "intrusion of work in private life". It is understandable that participants will perceive more respect from the organization and employer care since the nursing administration has invited training experts in designing and facilitating the whole program for them. The program coordinator sat in the whole program for support. Regarding no improvement in the domain of "intrusion of work in private life", some possible reasons may be: first, in time of shortage of nursing workforce, overtime is not uncommon for nursing management in nearly all acute hospitals in Hong Kong. Furthermore, the studied hospital serves a densely populated region with more than 500,000 population. It is sometimes difficult not to bring paperwork back to home or staying late to finish work at hand. Finally, maintaining a work/life balance takes time for improvement.
The correlation test showing a medium level of the positive relation of servant leadership with workplace wellbeing provides a further support of the effectiveness of servant leadership which is also consistent with other studies overseas [9,20,21]. It is worth promoting this type of program to other hospitals so that senior nursing managers may have a better support and a healthier work life. In turn, nursing staff and patients are supported and cared for. This type of leadership is also supported by a leadership model which is more appropriate to healthcare setting and aligned with compassionate leadership. In a compassionate health care setting, patients and staff would feel listened to, supported, and cared for [22].
With regard to the reflective essays, though not many participants submit theirs, the feedbacks compliment the quantitative data that the program is well organized and effective. It provides time and opportunities for senior nursing managers for reflection and refreshing. The serving hearts are revived. They are re-motivated to serve and pass the compassionate care to their followers.

LIMITATIONS
Regarding the quantitative approach, it is only a pre and post test designs and the long-term effect of the servant leadership is not known. If assessment after six and 12 months can be taken, a better picture may be obtained. Furthermore, this study only provides one perspective from the senior managers, if views from their followers and patients can be considered, a more comprehensive picture can be seen. Relating to the qualitative approach, if focus group or individual interview is conducted, more in-depth data can be collected for content analysis.

Implications for Practice and Research
Moving towards the 21 st century, there will be a great demand for hospital services due to increasing the aging population in Hong Kong. A labor shortage with possible declining work satisfaction will be the challenges of hospital administrators. A servant leadership approach is shown to be one way for hospital management to enhance a caring environment and a more qualified workforce. This program based on a servant leadership model, on one hand, helps nurse managers to lead by follower-center than self-center and use of self-reflection and self-cultivation. On the other hand, it also reminds them that a leader is no more than a human who needs to take care of oneself while taking care of others. Since it is an initial project of the hospital for training of nurse managers, further research should be conducted to assess its effectiveness for training another batch of nurse managers on a more solid mixed research approach.

CONCLUSION
A leadership enhancement program based on a servant leadership model with emphasis on self-reflection and selfcultivation was found to be effective in promoting nurse leaders well-being in one acute general hospital. This program is worth to be considered as an in-service leadership training program in other acute hospitals. However, further research should be conducted at the same time to assess its effectiveness to build up more evidence.

APPENDIX 1
The statements listed below describe the leadership style of a leader. Please read each statement. Circle the number to the right of each statement that best describes you.

APPENDIX 2
Choose the option that best represents your current and most relevant work situation (i.e., the work role where you spend most of your time and with who you have most contact) by circling the appropriate number.