INTRODUCTION:

Leadership is important in every sphere of activity, it is likely to be particularly crucial issue for nursing and midwifery at the beginning of the 21st century as nurses and midwives, along with other health professionals, find themselves faced with a climate of ongoing change. In almost all countries, nurses and midwives are the largest group of health-care professionals. Yet, while they play a significant role as providers of health care, this is often not reflected in the extent of their influence on health care reforms, health policy and implementation. A nursing educational institution is one that is continually expanding its capacity in creating future leaders. New undergraduate nurses now comprise a major portion of a typical hospital nursing staff. The researcher has observed that one of the objectives of the undergraduate nursing course is to develop effective leadership quality in students.

The course provides various theoretical components from the first year onwards, but doesn’t provide any specific leadership development program except during the final year of study which is of just a month practical experience, where no specific method is adopted in training students for leadership competencies. Many students enter nursing colleges with unrealistic expectations of practice arena. During their education and after graduation, they often experience disillusionment and are distressed by the realities of the health care delivery system. As this age group can be molded into desired forms by appropriate measures, the packages like leadership development can have maximum impact on their leadership abilities. Personal observation as a practicing nurse and nurse educator has shown that nurses working at all levels of health care system were excluded from decision making by other health care professional, health care administrators and policy makers. Nurses who at times where involved felt inadequate to make significant contribution and were hesitant to participate in such activity. Thus the researcher felt that Leadership development is clearly one way of supporting nurses to make effective contributions within health service structures, and equipping them with the knowledge, skills and attributes necessary to lead a health care team which is vital for imparting quality nursing services.

STATEMENT OF THE PROBLEM:

Impact of leadership development package (LDP) on leadership competencies of undergraduate nursing students of selected institutions in Kerala.

OBJECTIVES:

The main objectives for carrying out this study were;

1. To prepare a leadership development package.

2. To assess and evaluate the Self-reports of undergraduate nursing students for each of the five leadership practices before and after the administration of LDP.

3. To assess and evaluate the Observer reports of undergraduate nursing students for each of the five leadership practices before and after the administration of LDP.

4. To find the difference in the self report and observer report of undergraduate nursing students regarding the five leadership practices before and after the administration of LDP.

Hypotheses:

H1- Mean Self-report scores for each of the five leadership practice will increase from pretest to posttests for undergraduate nursing students in the experimental group than those in the control group as measured by the LPI at 0.05 level of significance.

H2 - Mean Observer report scores for each of the five leadership practice will increase from the pretest to posttest for undergraduate nursing students in the experimental group, than those in the control group as measured by the LPI at 0.05 level of significance.

H3- There is a significant difference between the mean self LPI scores and mean observer LPI scores for the five leadership practices of undergraduate nursing students at 0.05 level of significance.

METHODOLOGY:

This part of the study involved a quantitative approach .As the main purpose of this study was to find the impact of leadership development package¹ on leadership competencies of undergraduate nursing students, a quasi experimental, pretest multiple posttest control group design was utilized for the study to collect the quantitative data. Two leading and prominent Colleges of Nursing in private sector at Ernakulam were selected as per the convenience. Thirty students of the fourth year B Sc Nursing who satisfied the inclusion criteria from Lisie College of Nursing and Medical Trust College of Nursing were the study participants in the control and experimental group respectively. All participants of Lisie College of Nursing acted as the control group in order to prevent the contamination to the intervention. Tools for collecting quantitative data included a demographic information tool, Leadership Practice Inventory (LPI-Kouzes and Posner’s) - self and observer rated.² Content validity was established by giving the tools to ten subject experts who suggested that the tools and intervention were adequate with respect to the content. Reliability of the tool for the study was also established by the researcher using test retest method and the coefficient of correlation was found to be 0.86 for LPI Self and 0.90 for LPI Observer.

The leadership development package was modeled on Kouzes and Posner five exemplary leadership practices¹ which were as follows: model the way (MTW), inspire a shared vision (ISV), challenge the process (CTP), enable others to act (EOA) and encourage the heart (ETH).The Leadership Development Package consisted of four parts with eight modules. It was administered for four days, one day per week for four weeks using various teaching/ training techniques; self assessment, structured learning activities, skill building learning activities, group activities, reflective thinking, and ongoing self learning. Ethical clearance was obtained from the institutional ethical committee, separate permission was obtained from each setting and informed consent from participants was also obtained prior to data collection after assuring the confidentiality and use of data for study purpose. The participants completed the demographic information tool, the Pretest self rated data collection instrument (LPI-Self) which were then handed over to the investigator. Three Pretest observer scales (LPI-Observer) were distributed to all the participants. Written instruction was provided to the participants regarding the method of collecting observer reported data (LPI-Observer).All participants were instructed to hand over the completed three LPI-Observer instruments within four days. This was followed by the administration of intervention (LDP) as per the protocol to subjects in the experimental group. Posttest O2, O3, and O4 was administered 30, 90 and 180 days after the last day of intervention to participants in the experimental and control group using both LPI self and observer scales.

The data gathered from the participants was entered into the Statistical Package for the Social Sciences (SPSS) version 17.0 for quantitative analysis. Descriptive statistics was used for describing the sample characteristics, and for ranking the leadership practices. The parametric statistics used in this study was independent sample paired ‘t’ test, to analyze the difference between means of two groups of values to determine whether they were different by chance or another factor. The significance for all statistical analysis was set at 0.05 level to minimize the significant results that were due to chance. Observer ratings were averaged for each leadership practice resulting in one observer score for each participant at each time-period.

RESULTS:

Sample description :

Table 1.1.Frequency and percentage distribution of undergraduate nursing students according to gender, age and formal leadership training attended.

Item

Exp. Group

(n-30) F%

Control Group (n-30) F%

Gender

Female

Male

83.3

16.7

Age

21 yrs

22yrs

23yrs

13.4

43.3

16.7

43.3

Formal leadership training attended

Yes

Nil

100

Nil

100

Table 1.1 shows that majority of undergraduate nursing students in both the experimental (83.3%) and control group (90 %) was female. Most of them in the experimental group were 22 and 23 year old (43.3 % each) whereas most of them were 22 yrs in the control group (43.3%). None of them had undergone any formal leadership training program in both the groups. This shows that formal leadership development program do not exists as a part of the course which the students had undergone; hence, the students have to learn this important quality on their own.

Rank order of the five leadership practices of undergraduate nursing students :

In the study the Leadership Practices Inventory was used to measure the five leadership practices both as self rated and observer rated. Each of the five practices was scored based on responses to behavioral statements measured on a 10-point Likert-scale. The mean score for each of the five leadership practices was on a 6- 60 point scale. A higher value represented more frequent use of the leadership behavior.

The data presented in Table 2.1, indicates that the self ratings of the leadership practices were almost similar among participants in the experimental and control group of undergraduate nursing students except for inspire a shared vision and challenge the process.

Three separate observer ratings were obtained and the mean of these three ratings was used to describe the ranking of the five leadership practices of undergraduate nursing students. In Table 2.2 the leadership practice enable others to act was ranked first and encourage the heart was ranked second based on the mean pretest scores as rated by observers for undergraduate nursing students in the experimental group but encourage the heart was ranked first and enable others to act was ranked second in order for the control group participants. In both the experimental and control group model the way was ranked as third. The other two leadership practices inspire a shared vision and challenge the process was ranked as fourth and fifth in experimental group and vice versa in the control group. Therefore it can be inferred that the ranking of leadership practice of both the groups were slightly different as reported by the observers for undergraduate nursing students.

Table 2.1 Mean pretest score, Standard deviation and Rank order of the five leadership practices as rated by self among undergraduate nursing students in the experimental and control group.

Leadership Practices	Experimental Group (n-30) Mean SD Rank Order			Control Group(n-30) Mean SD Rank Order
Model the way	40.90	4.92	III	37.40	5.98	III
Inspire a shared vision	38.53	6.19	V	33.06	6.90	IV
Challenge the process	38-70	5.38	IV	32.70	6.44	V
Enable others to act	42.80	2.85	I	39.70	6.43	I
Encourage the heart	42.10	4.08	II	38.86	6.27	II

Table 2.2 Mean Pretest score and Standard deviation and Rank order for the five leadership practices as rated by observers for undergraduate nursing students in the experimental and control group.

Leadership Practices	Experimental Group(n-30) Mean SD Rank Order			Control Group(n-30) Mean SD Rank Order
Model the way	38.24	5.14	III	35.36	7.93	III
Inspire a shared vision	37.01	3.44	IV	33.76	7.18	V
Challenge the process	36.41	4.19	V	34.37	6.66	IV
Enable others to act	43.96	2.98	I	38.08	6.29	II
Encourage the heart	42.99	3.60	II	38.28	6.27	I

Comparison of mean self rated leadership practice scores of undergraduate nursing students:

Independent sample t test was computed to compare the mean pretest and mean posttest scores of the five leadership practices for the experimental and control group in order to find the impact of LDP on the mean self rated leadership practice scores.

Table 3.1 Mean, paired SD and SEM difference, t value and level of significance of the pretest and posttest scores of undergraduate nursing students in the experimental group as rated by self. N- 30

Leadership Practices	Self rating	Mean Score	Paired difference SD SEM		Paired t value	Significance
Model the way	Pretest	40.90
	Posttest 1	43.03	1.71	.31	-6.80	.001*
	Posttest 2	43.93	2.35	.43	-7.05	.001*
	Posttest 3	44.53	2.72	.49	-7.30	.001*
Inspire a shared vision	Pretest	38.53
	Posttest 1	40.50	2.12	.38	-5.06	.001*
	Posttest 2	41.70	2.91	.53	-5.95	.001*
	Posttest 3	42.43	3.54	.64	-6.02	.001*
Challenge the process	Pretest	38.70
	Posttest 1	40.36	1.80	.32	-5.05	.001*
	Posttest 2	41.60	2.49	.45	-6.36	.001*
	Posttest 3	42.33	2.85	.52	-6.96	.001*
Enable others to act	Pretest	42.80
	Posttest 1	45.13	2.23	.40	-5.72	.001*
	Posttest 2	46.16	2.39	.43	-7.68	.001*
	Posttest 3	47.16	2.25	.41	-10.62	.001*
Encourage the heart	Pretest	42.10
	Posttest 1	45.06	3.4887	.63	-4.65	.001*
	Posttest 2	46.83	3.9123	.71	-6.62	.001*
	Posttest 3	47.60	4.0747	.74	-7.39	001*

df 29 *Significant at 0.05 level

Table 3.2 Mean, paired SD and SEM difference, t value and level of significance of the pretest and posttest scores of undergraduate nursing students in the control group as rated by self. N-30

Leadership Practices	Self rating	Mean score	Paired difference SD SEM		Paired t value	Sig.
Model the way	Pretest	37.40
	Post test 1	36.86	1.10	0.20	2.64	.013*
	Post test 2	36.13	1.28	0.23	5.40	.001*
	Post test 3	36.16	1.40	0.25	4.80	.001*
Inspire a shared vision	Pretest	33.06
	Post test 1	32.86	1.37	0.25	0.79	.432
	Post test 2	32.46	1.37	0.25	2.38	.024*
	Post test 3	32.30	1.54	0.28	2.71	.011*
Challenge the process	Pretest	32.70
	Post test 1	32.53	1.11	0.20	0.81	.420
	Post test 2	32.03	0.92	0.16	3.95	.001*
	Post test 3	32.03	1.86	0.34	1.96	.060
Enable others to act	Pretest	39.70
	Pos ttest 1	39.43	1.43	0.26	1.01	.318
	Post test 2	39.30	1.32	0.24	1.64	.110
	Post test 3	38.83	1.87	0.34	2.53	.017*
Encourage the heart	Pretest	38.86
	Post test 1	38.96	1.32	0.24	-0.41	.682
	Post test 2	38.36	1.07	0.19	2.54	.016*
	Posttest 3	38.46	1.71	0.31	1.27	.211

df-29 *Significant at 0.05 level

Comparison of mean observer rated leadership practice scores of undergraduate nursing students

Table 4.1 Mean, paired SD and SEM difference, t value and level of significance of the pretest and posttest scores of undergraduate nursing students in the experimental group as rated by observer. N-30

Leadership Practices	Observer Rated	Mean	Paired difference SD SEM		Paired t value	Sig.
Model the way	Pretest	38.24
	Posttest 1	38.86	1.63	0.29	-2.06	.048*
	Posttest 2	39.70	1.68	0.30	-4.72	.001*
	Posttest 3	40.34	1.85	0.33	-6.19	.001*
Inspire a shared vision	Pretest	37.01
	Posttest 1	37.80	0.76	0.13	-5.66	.001*
	Posttest 2	38.47	0.73	0.13	-10.95	.001*
	Posttest 3	38.92	0.82	0.14	-12.79	.001*
Challenge the process	Pretest	36.41
	Posttest 1	37.48	0.85	0.15	-6.85	.001*
	Posttest 2	38.20	0.82	0.14	-11.89	.001*
	Posttest 3	38.87	1.36	0.24	-9.88	.001*
Enable others to act	Pretest	43.96
	Posttest 1	45.72	1.04	0.19	-9.17	.001*
	Posttest 2	46.78	1.40	0.25	-11.00	.001*
	Posttest 3	47.80	1.65	0.30	-12.68	.001*
Encourage the heart	Pretest	42.99
	Posttest 1	45.41	2.21	0.40	-5.981	.001*
	Posttest 2	46.51	2.71	0.49	-7.103	.001*
	Posttest 3	47.57	2.84	0.51	-8.815	.001*

df-29 *Significant at 0.05 level

Table 4.2 Mean, paired SD and SEM difference, t value and level of significance of the mean pretest and mean posttest scores of undergraduate nursing students in the control group as rated by observer N-30

Leadership Practices	Self report Scores	Mean	Paired Difference SD SEM		Paired t value	Sig.
Model the way	Pretest	35.36
	Posttest 1	35.20	.63	.11	1.40	.172
	Posttest 2	35.31	.75	.13	.36	.718
	Posttest 3	35.36	.73	.13	.00	1.000
Inspire a shared vision	Pretest	33.76
	Posttest 1	33.39	2.02	.36	.99	.330
	Posttest 2	33.32	2.19	.40	1.09	.284
	Posttest 3	33.40	2.02	.37	.98	.335
Challenge the process	Pretest	34.37
	Posttest 1	33.92	1.78	.32	1.35	.185
	Posttest 2	33.97	1.77	.32	1.23	.226
	Posttest 3	33.98	1.76	.32	1.20	.239
Enable others to act	Pretest	38.08
	Posttest 1	38.15	.67	.12	-.54	.590
	Posttest 2	38.29	.97	.17	-1.19	.242
	Posttest 3	38.39	.80	.14	-2.09	.045*
Encourage the heart	Pretest	38.28
	Posttest 1	38.24	.61	.11	.32	.747
	Posttest 2	38.30	.73	.13	-.19	.844
	Posttest 3	38.35	.61	.11	-.68	.497

df-29 *Significant at 0.05 level

Table 5.1Mean self and observer pretest scores, paired difference of SD and SEM, t value for the leadership practices of undergraduate nursing students. N-60

Leadership practices	Mean self Pretest Score	Mean observer Pretest Score	Paired difference SD SEM		t-value	Level of Significance
Model the way	39.15	36.85	8.44	1.09	-2.15	.036*
Inspire a shared vision	35.80	35.38	8.11	1.04	-0.39	.695
Challenge the process	35.70	35.39	7.92	1.02	-0.30	.765
Enable others to act	41.25	41.02	6.60	0.85	0.26	.791
Encourage the heart	40.48	40.63	6.68	8.63	0.17	.860

df-59 * Significant at 0.05 level

Table 5.2. Mean self and observer posttest scores, paired difference of SD and SEM, t value for the leadership practices of undergraduate nursing students.N-60.

Leadership Practices	Mean self Posttest Score O4	Mean observer Posttest Score O4	Paired difference SD SEM		t-value	Level of Significance
Model the way	40.35	37.85	7.63	0.98	-2.53	.014*
Inspire a shared vision	37.36	36.16	7.20	0.93	-1.29	.201
Challenge the process	37.18	36.42	7.26	0.93	-0.80	.423
Enable others to act	43.00	43.09	5.51	0.71	0.13	.894
Encourage the heart	43.03	42.96	5.22	0.67	-0.10	.920

df-59 *Significant at 0.05 level

· Data presented in table 4.1, showed that the obtained t value for all of the five leadership practices was found to be significant at 0.05 level showing that there was a significant increase in the mean observer rated post test scores from the mean observer rated pretest scores for all the five leadership practices among the undergraduate nursing students in the experimental group. And in table 4.2 the obtained t value for all of the five leadership practices of the control group of undergraduate nursing students was not found to be significant at 0.05 level except for mean third observer rated posttest score of the leadership practice enable others to act which was found to be significant at 0.05 level. Thus it can be concluded that the mean observer rated posttest scores for all the five leadership practices has shown a significant increase among participants in the experimental group than those in the control group except for the third mean observer rated posttest score for the leadership practice enable others to act, suggesting that the intervention had brought a significant change in the mean LPI observer rated posttest scores. Hence the research hypothesis H2 was accepted for the leadership practices model the way, inspire a shared vision, challenge the process, and encourage the heart and it was partially rejected ( 3^rd mean posttest score) for the leadership practice enable others to act. It hereby suggests that as rated by observers also the LDP was to a great extent effective in enhancing the leadership practices of undergraduate nursing students.

Comparison of mean self rated scores and mean observer rated scores for the five leadership practices of undergraduate nursing students - As the leadership practices of undergraduate nursing students were rated by self and also by observers, it was worthwhile to compare the ratings to make sure whether there was any difference between the ratings done by self and observer. The comparison was made using the mean pretest scores and third mean posttest scores for all the five leadership practices as rated by self and observers for the undergraduate nursing students and is presented in table 5.1 and 5.2 respectively.

Data presented in table 5.2 shows that the‘t’ values computed for the mean self rated pretest scores and mean observer rated pretest scores of undergraduate nursing students was found to be statistically significant at 0.05 level for the leadership practice model the way. The t values for all other four leadership practices were not found to be statistically significant. This indicates that the self and the observers rating for all the leadership practices was at the same level except for the leadership practice model the way where the undergraduate nursing students rated themselves higher than the observers.

Data presented in table 5.2 shows the ‘t’ values computed between mean self rated third posttest scores and mean observer rated third posttest scores of undergraduate nursing students for the leadership practice model the way was found to be statistically significant at 0.05 level. For all other four leadership practices the t value was not found to be statistically significant. This indicates that the undergraduate nursing students and the observers rated all the leadership practices at the same level except for the leadership practice model the way where the undergraduate nursing students rated themselves higher than the observers.

· In table 5.1 a statistically significant difference was found between mean self rated pretest score and mean observer rated pretest score for the leadership practice model the way and a similar result was found for the mean self rated third posttest score and observer rated third posttest score as indicated in table 5.2. Hence, for the leadership practice model the way there was a significant difference between the mean self rated scores and mean observer rated scores for undergraduate nursing students. The research hypothesis H5 was accepted only for the leadership practice model the way and was rejected for all the other four leadership practices. This suggests that the undergraduate nursing students and their observers rated the leadership practices at the same level for inspire a shared vision, challenge the process, enable others to act and encourage the heart but they differed with respect to the leadership practice model the way where the self rating was higher than the observer rating.

DISCUSSION:

The study findings reveal that none of the participants had undergone any formal leadership training program in both the groups. Primary degrees may not sufficiently prepare nurses for the application of leadership in their professional practice, and consequent shortfall in leadership skills falls to health care organizations to make up through promoting and developing leadership programs.³ Sherman et.al points out the urgent need for preparing tomorrow’s nurse leader as 29% of current nurse executives were retiring in next five years, and knowing it takes at least 10 years to prepare future nurse leaders.⁴

The ranking of the five leadership practices revealed that the most commonly used practices are enable others to act, encourage the heart and model the way and the leadership practices inspire a shared vision and challenge the process where ranked lowest by both self and observers. The findings of the present study have been supported by similar findings in other studies. Abaan and Duygulu in a study of one hundred thirty staff nurses from 35 units in the largest Ministry of Health Hospital in Ankara, Turkey (64% response rate) reported that the most frequent leadership practice was Modeling, closely followed by Enabling and Encouraging, and then Challenging and Inspiring.⁵In reference to this study it would be interesting to know more about why the leadership practices of inspire a shared vision and challenge the process were ranked lower by the leaders and also observers. This could be because of the nature of their work responsibilities or could it be because these two leadership practices are the least culturally-specific of the set of leadership practices? The culture of nursing educational programs tends to generate cohorts of nurses who were docile, obedient, dedicated to the hospital, and willing to work cheaply.⁶

The study findings also indicated that the leadership development package made an impact by improving the five leadership practices of participants who had undergone the program as reported by self and observers. Cummings, et al.,⁷ reviewed 24 studies. Nine of the 24 studies were related to the effectiveness of educational interventions in developing leadership behaviors in nursing. All nine studies used some type of pre/post measurement of leadership skills and competencies. All of the studies reported an increase in skills and competencies when rated by self or by others. Two of the three studies reported long term effects 3 months following education and one demonstrated positive results at 6 and 12 months. Finally, leadership training programs were mostly found to be effective, not just in bringing about short-term change, but also in the long term.⁷

LIMITATIONS:

· A lack of a universal definition of ‘effective’ leadership impacts the robustness and generalisability of findings.

· Testing of the effectiveness of leadership development program was through a cross-sectional approach, and thus it remains unclear as to how this learning subsequently proved beneficial in practice.

· Research related to the evaluation of the relationship between leadership education and competency level is limited. Measuring leadership skills is problematic due to the difficulty in demonstrating a cause and effect relationship between the education and the competency level. Leadership development is complex and affected by many variables. The educational program may not be the only variable affecting a change. Other variables might have included outside readings, other formal education, type of leadership position held, the organizational climate, or the ongoing nurses strike.

· Another limitation is the small sample size which may not be representative of the target population. The groups were only from two selected settings and may not be a true representative of graduate nursing students in other geographical locations. Hence generalization of the findings needs to be done with caution.

The most obvious caution when it comes to interpreting these findings is that it is impossible to be certain about how respondents actually behave versus how they say they behave, even though the use of observations from observers in this study goes a long ways toward reducing that potential gap, and minimizing self-report bias; the fact remains.

RECOMMENDATIONS:

A number of noteworthy recommendations for future research emerge from this study and these are as follows:

· Continued studies should be undertaken involving participants from other settings to increase the generalizability of these findings.

· The development of a national nursing leadership framework which should take cognizance of the clinical leadership development needs of nurses with best evidence from the literature.

· To develop evidence based leadership development strategies to assist nurses to articulate their contribution to care in the practice setting.

· The field of leadership education needs to develop standardized leadership curriculum.

· To evaluate different clinical leadership strategies which will be required for different clinical grades that have varying contextual needs.

· Financial costing need to be undertaken so as to ascertain a full cost benefit analyses of leadership development program

CONCLUSION:

The findings confirmed that the leadership development package was instrumental in bringing significant changes in all the five leadership practices of participants. Leadership is not a quality that is emphasized in nurse’s training, nor is it an ability that comes naturally to most nurses.^8&9 Nurses often takes on leadership positions with enthusiasm when they are provided with tools, training and the active support and encouragement of their superiors. More specifically, increasing general leadership opportunities for all levels and positions, including frontline nurses, would encourage more nurses to consider leadership positions.

LIST OF ABBREVIATIONS:

LDP- Leadership Development Package

LPI- Leadership Practice Inventory

MTW- Model the Way

ISV- Inspire a Shared Vision

CTP- Challenge the Process

EOA- Enable Others to Act

ETH- Encourage the Heart

SD- Standard Deviation

SEM- Standard Error of Mean

REFERENCE:

1. Kouzes, J.M., & Posner, B. Z. The five practices of exemplary leadership. San Francisco, CA: Pfeiffer. 2003.

2. Kouzes and Posner LPI self and observer. Pfeiffer, An Imprint of Wiley, San Francisco, CA. 2008.

3. Curtis E, Sheerin F & De Vries J. Developing leadership in nursing: the impact of education and training. British Journal ofNursing. 201 lb; 20: 344-352.

4. Sherman R O, Bishop M, Eggenberger T & Karden R. Development of a leadership competency model. The Journal ofNursing Administration. 2007; 37(2): 85- 94.

5. Duygulu, S., Hicdurmaz, D. & Akyar, L Nursing students' leadership and emotional intelligence in Turkey. The Joumal of Nursing Education 2011; 50: 281-285.

6. Andrist, L.The history of the relationship between feminism and nursing. In L. A. Andrist, ed., P. K. Nicholas, ed., & K.A. Wolf (Eds.), A history of nursing ideas. Boston: Jones & Bartlett. 2006.

7. Cummings G, Lee H, Macgregor T et al. Factors contributing to nursing leadership: a systematic review. Journal of Health Service Research Policy.2008; 13(4):240–248.

8. Connelly, L. M., Nabarrete, S. R., & Smith, K. K. A charge nurse workshop based on Research. Journal for Nurses in Staff Development 2003a; 19(4): 203-208.

9. Connelly, L. M., Yoder, L. H., & Miner-Williams, D. A qualitative study of charge nurse competencies. Medsurg Nursing 2003b; 12(5): 298-308.

Received on 24.11.2014 Modified on 07.01.2015

Asian J. Nur. Edu. and Research 5(2): April-June 2015; Page221-228

DOI: 10.5958/2349-2996.2015.00044.0