Leadership Behaviors of Frontline Staff Nurses
Christine Fardellone, DNP, RN; Carol M. Musil, PhD, RN, FAAN, FGSA;
Elaine Smith, EdD, MBA, RN, NEA-BC, ANEF; and Elizabeth R. Click, ND, RN, CWP
abstract
Background: A recommendation in the Institute
of Medicines report, The Future of Nursing: Leading
Change, Advancing Health, challenges the nursing pro-
fession to enhance nursings leadership role in health
care redesign.
Method: This descriptive, correlational, cross-sectional
study examined the self-perceived leadership behaviors
of RNs enrolled in a clinical ladder career pathway. A self-
report survey was conducted using the Leadership Prac-
tice Inventory and a demographic questionnaire.
Results: Significant associations between continuous
and categorical demographic factors and ladder levels
were reported. Nurses with more experience showed
fewer leadership behaviors.
Conclusion: Leadership development is necessary
for nurses in all areas of practice. The findings from this
study provide evidence of the strengths and weaknesses
in leadership behaviors of staff clinical RNs who often
make frontline decisions for patients.
J Contin Educ Nurs. 2014;45(11):506-513.
L eaders are described as individuals who are com-
mitted and capable of making appropriate de-
cisions, and who identify common goals and values
with others. Leaders provide hope, guidance, vision,
and direction to move forward and succeed, which is
important for both leaders and followers (Bormann
& Abrahamson, 2014; Burns, 1978; Maxwell, 1999).
The Institute of Medicines (IOM, 2010) report, The
Future of Nursing: Leading Change, Advancing Health,
emphasizes that strong nursing leadership is neces-
sary to improve patient safety outcomes and that the
506
nursing profession must enhance its leadership role in
health care redesign.
Although a number of studies have been conducted
to examine leadership behaviors of nurse managers and
executives (Cummings et al., 2010; New 2009; Oliver,
Gallo, Griffin, White, & Fitzpatrick, 2014; Wong, Spence
Laschinger, & Cummings, 2010), far less attention has
been directed to the leadership behaviors of clinical
nurses who provide day-to-day direction on the front-
lines of care. These nurses possess many of the skills nec-
essary to build healthy work environments that support
professional practice, quality patient care, and outcomes.
Therefore, this study examined the leadership behaviors
of clinical staff nurses who have firsthand experience of
the needs and desires of patients.
TRANSFORMATIONAL LEADERSHIP
Transformational leadership is described as highly
suited for the nursing profession since it is empowering,
caring, and ethical (Ross, Fitzpatrick, Click, Krouse, &
Clavelle, 2014; Trofino, 1995). Transformational leaders
Dr. Fardellone is Research Nurse, North Shore University Hospi-
tal, Center for Tobacco Control, Great Neck, and Dr. Smith is Vice
President, System Nursing Education, North Shore-Long Island Jewish
Health System, New Hyde Park, New York; and Dr. Musil is the Mar-
vin E. and Ruth Durr Denekas Professor of Nursing, and Dr. Click is
Medical Director and Assistant Professor, Frances Payne Bolton School
of Nursing, Case Western Reserve University, Cleveland, Ohio.
The authors have disclosed no potential conflicts of interest, finan-
cial or otherwise.
Address correspondence to Christine Fardellone, DNP, RN,
Research Nurse, North Shore University Hospital, Center for Tobacco
Control, 225 Community Drive, Great Neck, NY 11021; e-mail:
cfardell@nshs.edu.
Received: May 23, 2014; Accepted: August 26, 2014; Posted Online:
October 23, 2014
doi:10.3928/00220124-20141023-05
Copyright SLACK Incorporated
in nursing have expertise and strong nursing knowledge,
have a vision and can influence others, and can meet the
challenges necessary for quality patient care and patient
outcomes (Jooste, 2004). Transformational nursing lead-
ers build teams and share the decision making process
with the staff. The leaders change practice according to
the feedback of the team. In addition, transformational
nursing leaders effectively communicate to advocate for
both patients and the profession (Thyer, 2003).
Transformational leadership theory is particularly ap-
plicable to the clinical nursing arena, which encompasses
patient care demands, extended work hours, varied edu-
cational backgrounds, and the intense physical labor
required of nurses. The transformational leadership style
focuses on qualities that are necessary to meet current
changing organizational and health care needs. Leader-
ship behaviors must support high skill levels, align with
organizational goals and vision, and promote decision
making at the point of clinical care. Use of this leader-
ship style may benefit both organizations and patients
(New, 2009), and may improve nursing staff satisfaction.
STAFF NURSES AS CLINICAL LEADERS
Staff RNs are the clinical leaders at the bedside. Clini-
cal nurses collaborate with the health care team, patients,
and their families. They are the change agents who trans-
form the patient experience. There are few studies in the
literature related to the leadership behaviors of clinical
staff nurses who often make primary decisions related
to patient care and safety, even though proficient clini-
cal nurses are developing leadership qualities in nursing
practice (Valentine, 2002).
Recent research and evidence-based practice demon-
strate that nurses who participate in clinical leadership
can develop and practice transformational leadership
qualities (Habel & Sherman, 2012). A study by Abraham
(2011) evaluated the outcomes of a leadership program.
Clinical nurses who are aware of their own leadership
behaviors have the opportunity to transform through
leadership training and development. With additional
leadership development, clinical nurses may feel em-
powered, seek best nursing practices, and implement
new patient care strategies. These clinical nurses joined
committees, participated in scholarly projects and re-
search, published articles, and provided quality patient
care (Abraham, 2011). Clearly, staff nurses at the bedside
have the power to influence patient outcomes and pro-
fessional productivity.
Another study by George et al. (2002) examined
a leadership development program with staff clinical
nurses. The shared leadership program assisted clinical
nurses in acting autonomously, advocating for patients
The Journal of Continuing Education in Nursing Vol 45, No 11, 2014
by problem solving, and developing a shared vision to
accomplish organizational goals. The clinical staff nurses
developed leadership qualities necessary for technical
competence and interpersonal growth. Clinical nurses
noted improved confidence, feelings of empowerment
and assertiveness, increased problem solving ability,
and increased teamwork to improve patient outcomes
(George et al., 2002).
Research findings (Gossett & DeTata, 1992; Redman,
2006; Trofino, 1995; Watts, 2010) indicate that leader-
ship development programs may be necessary for clini-
cal nurses to transition from staff to leader to meet the
goals of the organization. Clinical nurses preparing to
be future nursing leaders will contribute to successful
quality patient care and will meet the needs of the health
care organization (Redman, 2006). The new Magnet
model supports clinical staff development in leadership
(Bormann & Abrahamson, 2014). Competence-based
programs provide personal and professional growth to
clinical nurses. By using new knowledge, the practice
environment becomes a rewarding and challenging ex-
perience for staff clinical nurses. Clinical nurses become
specialists in their new knowledge by planning to meet
the patients needs (Gossett & DeTata, 1992; Watts, 2010).
The challenges of health care reform have demon-
strated the importance of keeping expert nurses at the
bedside and promoting their professional development.
Expert nurses are essential to health care cost contain-
ment and providing quality care (Kramer, Schmalen-
berg, & Maguire, 2008; Shapiro, 1998; Watts, 2010).
These nurses are guided by immediacy, take measures
to understand situations, deal with complex situations,
manage multiple tasks, meet patient and family needs,
and negotiate and collaborate with the health care team.
Studies of expert clinical nurses have noted a positive
correlation between retention and improved patient out-
comes (Shapiro, 1998; Watts, 2010). Leadership develop-
ment and training may be a key component to the chang-
ing health care environment and the nursing profession
(Cook, 1999; Watts, 2010).
Leadership competencies including education, coach-
ing, and mentoring may be beneficial to clinical nurses to
develop experience in strategic decision making. Partici-
pation in clinically related work projects provide clinical
nurses the opportunities to develop leadership behaviors
with necessary guidance and support (Redman, 2006).
CLINICAL LADDER PROGRAMS
Clinical ladder programs provide a system within
hospital organizations to reward and recognize excel-
lence in practice. Experienced clinical ladder nurses
may have increased levels of competence and problem
507
solving tactics, and may have the opportunity to mentor
or be mentored. The knowledge that expert clinical lad-
der nurses possess may be useful in meeting the needs
of the changing health care environment (Kramer et al.,
2008; Watts, 2010). Clinical ladder programs for nurses
were once considered to be a retention tool. Currently,
clinical ladder programs provide nurses an opportunity
for advancement while remaining at the level of patient
care. Nurses participating in clinical ladder programs
at higher levels of such ladders demonstrate analyti-
cal assessment and problem solving skills that are not
always captured and passed on to others, even though
mentoring is a source of growth and stimulation (Krug-
man, Smith, & Goode, 2000). In addition, these training
programs also focus on being a role model and chal-
lenging and encouraging younger colleagues to partici-
pate in continuing professional education, certification,
organizational membership, leadership, community
service, committees, mentorships, coaching, and re-
search activities.
Given this training, one would expect that nurses
who are higher on the clinical ladder would demon-
strate more leadership behaviors. In addition, one
study evaluating career ladders for clinical staff nurses
in ambulatory care noted significantly more activity
in interdisciplinary and quality improvement proj-
ects (Nelson & Cook, 2008). Another study examined
nurses clinical expertise and professional character-
istics and found that clinical nurses develop expertise
as a result of experience. Frequent exposure to simi-
lar types of patients leads to outcomes that are familiar
to the caregiver (Bobay, Gentile, & Hagle, 2009). This
research would suggest that older and more experi-
enced clinical ladder nurses would show greater lead-
ership behaviors, although the literature on burnout
could argue that older and experienced nurses who do
not advance in organizations might demonstrate fewer
leadership behaviors and decreased feelings of personal
accomplishments (Kovacs, Kovacs, & Hegedus, 2010;
Robinson et al., 1991).
Therefore, identifying leadership behaviors present in
clinical nurses who are frontline caregivers and patient
advocates may clarify areas in which leadership changes
can be enhanced. This study examined:
Self-perceived leadership behaviors of RNs partici-
pating in a clinical ladder program.
Differences in self-perceived leadership behaviors
among nurses across levels of a clinical ladder pro-
gram.
Relationships between age and experience with lead-
ership behaviors of nurses in a clinical ladder pro-
gram.
508
METHOD
Design
A descriptive, correlational, cross-sectional study
design was used as the research method. The study sur-
veyed one group of clinical ladder nurses at one time.
Setting
The study setting was a large, tertiary care medical
center in the northeastern United States. A total of 1,674
staff RNs were employed at the institution, and the clini-
cal ladder program included 6.3% of the staff RNs.
Sample
A convenience sample of RNs was used. Inclu-
sion criterion focused on active membership in the
clinical ladder program. All clinical ladder nurses (N =
102), except the principal investigator (C.F.) who was
employed at the institution, were invited to partici-
pate. The clinical ladder program had 41 participants
in level 1, 27 participants in level 2, and 35 participants
in level 3.
Clinical Ladder Level
The clinical ladder is based on accrual of points
through active participation in the five focus areas of
research, quality, education, service excellence, and lead-
ership. The point requirement for RNs who apply for
clinical ladder level 1 is 150 points from three of the five
focus areas, 225 points from four of the five focus areas
for level 2, and 300 points from across all of the five
focus areas for clinical ladder level 3. Points for the clini-
cal ladder program can be accrued from the following
categories:
Attainment of advanced degree in nursing.
Specialty nursing certification.
Approved nonrelevant certifications.
Continuing education hours.
Oral presentations.
Poster presentations.
Publications.
Quality improvement projects.
Committee memberships.
Letters of commendation.
Service excellence.
Participation in community service.
Assigned as clinical coach or mentor.
Charge nurse fill in.
Attendance at leadership development course.
Professional awards.
Each category is assigned a point value and relevant
focus areas (North Shore-Long Island Jewish Health
System, 2010).
Copyright SLACK Incorporated

LEADERSHIP PRACTICE INVENTORY SUBSCALE SCORES (N = 73)
Subscale Mean Score
Model 46.78
Inspire 39.77
Challenge 41.12
Enable 50.3
Encourage 46.27
Instruments
All instruments used in this study were formatted for
self-report. Leadership behaviors were assessed with the
Leadership Practice Inventory (LPI) (Kouzes & Posner,
2003). The LPI is a 30-item assessment survey that pro-
vides a way for individuals to measure the frequency of
their own leadership behaviors on a 10-point Likert-type
scale. Higher scores exhibit behaviors used most often
and represent strengths. Lower scores represent op-
portunities for improvement (Kouzes & Posner, 2003).
Leadership behaviors are measured in five subscales:
Modeling the way.
Inspiring a shared vision.
Challenging the process.
Enabling others to act.
Encouraging the heart.
The scores can be calculated as percentages, means,
and standard deviations. Cronbachs alpha for the total
LPI of this study is reported as 0.95. Cronbachs alpha
for the LPI range from 0.69 to 0.85, with subscale alphas
of 0.91 (enabling others to act), 0.86 (encouraging the
heart), 0.91 (inspiring a shared vision), 0.86 (challenging
the process), and 0.84 (modeling the way) (Posner, 2010).
Test-retest reliability is reported as 0.93 (Houser, 2003;
Patrick, Laschinger, Wong, & Finegan, 2011).
The demographic questionnaire assessed the variables
of age, gender, ethnic background, marital status, edu-
cation, certification, employment status, total years of
RN experience, total years in current position, and total
years with current organization. The leadership attri-
butes assessed preceptor experience, previous leadership
training, charge nurse experience, participation in com-
mittees, quality improvement projects, and the five focus
areas of the clinical ladder program.
Procedure
After receiving institutional review board approval,
the study was introduced at the monthly clinical ladder
meeting. One week prior to sending the surveys, an intro-
The Journal of Continuing Education in Nursing Vol 45, No 11, 2014
TABLE 1
SD Median Minimum Maximum
8.04 49 25 60
12.33 42 8 60
10.63 42 12 59
5.92 51 31 60
8.96 48 18 60
ductory e-mail was distributed. All clinical ladder nurses
received a paper packet that included the demographic
questionnaire, the LPI self-report assessment survey,
consent for participation, and a stamped addressed enve-
lope for returning the questionnaire. A reminder e-mail
was sent 2 weeks after the survey distribution.
RESULTS
Of the 102 clinical ladder RNs, 74 (72%) completed
the demographic questionnaire and 73 (71%) completed
the LPI survey. A description of the sample group was
gathered from the completed surveys. The age range was
24 to 66 years (mean age = 42 years). Both female (n =
71, 96%) and male (n = 3, 4%) clinical ladder nurses en-
rolled in the research study. Eighty-six percent of the
participants were baccalaureate-prepared nurses with
nationally recognized certification in their specialty
area. Twenty-four percent were currently enrolled in
continuing formal education at the masters degree level.
More than 90% of nurses had preceptor, charge nurse,
and quality improvement experience. Sixty-four percent
of nurses had participated in leadership and interdisci-
plinary committees, 37% had previous leadership train-
ing, and 27% had previous management experience in
nursing or another field. The clinical ladder nurses also
participated in the focus areas of education (100%),
research (78%), quality (97%), service excellence (92%),
and leadership (88%; Fardellone & Click, 2013).
Mean LPI subscale scores are summarized in Table 1.
Actual subscale scores ranged from 8 to 60. At least one
nurse scored her own self-perceived leadership behavior
with a maximum score of 10 for the six questions related
to the subscale. The behaviors used in order of frequency
were enabling others to act, modeling the way, and en-
couraging the heart; challenging the process and inspir-
ing a shared vision were used somewhat less frequently,
but mean scores were two thirds of the maximum value.
Among all levels, enabling others to act was used most
frequently whereas inspiring a shared vision had the larg-
509
 TABLE 2

LEADERSHIP PRACTICE INVENTORY SUBSCALE SCORES AND LADDER LEVEL

Mean (SD)
Subscale Level 1 (N = 19) Level 2 (N = 19) Level 3 (N = 35) F Value p Value
Model 45.53 (7.7) 46.74 (9.06) 47.49 (7.78) 2.04 0.14
Inspire 40.47 (9.54) 40.95 (12.27) 38.74 (13.85) 0.70 0.50
Challenge 41.53 (8.68) 41.68 (11.87) 40.6 (11.16) 0.78 0.46
Enable 50.68 (4.52) 51.05 (6.03) 49.69 (6.57) 1.15 0.32
Encourage 46.79 (7.16) 46.05 (9.69) 46.11 (9.65) 0.30 0.74

DISCUSSION
TABLE 3
The IOM (2010) report recognizes the need for the
CORRELATION OF LEADERSHIP PRACTICE nursing profession to enhance its leadership role in
INVENTORY SUBSCALES BY AGE AND EXPERIENCE health care redesign. This study provides new evidence
Years in Years With evaluating leadership behaviors and provides insight into
Years as Current Current leadership behaviors that may affect patient outcomes.
Demographic RN Unit Organization
Clinical ladder nurses choose to remain at the front-
Age (n = 70) .92 .73 .74 line of care, advocate for patients, and become experts
Years as RN .79 .79 in clinical practice (Riley, Rolband, James, & Norton,
(n = 73) 2009). Clinical ladder programs motivate staff nurses to
Years in current .77 enhance professional development and provide an op-
unit (n = 73)
portunity for growth while remaining at the frontline of
Note. For all variables, p 0.001. patient care (Krugman et al., 2000).
Clinical ladder nurses possess leadership behaviors
noted in the LPI. Nurses highest average response was in
est standard deviation, suggesting the largest variation in the category enabling others to act. This behavior fos-
this response category (Fardellone & Click, 2013). ters collaboration and builds group strength by helping
The second research question compared mean LPI nurses to develop competence and self-determination.
subscale scores across clinical ladder groups. Analysis Modeling the way, which was the second highest
of variance (ANOVA) revealed no significant differ- average response, allows nurses to clarify values and set
ences in any of the mean subscale scores among levels examples with shared values. The third highest average
1, 2, and 3 of the clinical ladder nurse program. No response, encouraging the heart, is a behavior that
significant differences between ladder levels for any of recognizes contributions and creates a feeling of com-
the mean subscale scores were found, even after adjusting munity. The fourth response, challenging the process,
for years of experience as an RN. Unadjusted means looks for ways to improve and learn from experience.
and standard deviations are summarized in Table 2. The least commonly endorsed response was inspiring
The last research question examined the demographic a shared vision, which enlists others to imagine the
factors associated with ladder level and LPI subscales. future, share possibilities, and communicate the recom-
Age, years of experience as an RN, years with current mendations (Kouzes & Posner, 2003).
organization, and years in current unit were all corre- The findings from this study agree with Abrahams
lated with each other. Pearson correlation ranged from (2011) results. Findings of this study indicate a deficit
r = .73 to r = .92, p 0.0001 for all correlations (Table 3). in leadership behaviors for clinical ladder nurses with
Table 4 summarizes the correlation between LPI sub- greater experience, indicating a need for professional
scales and factors of age, years as an RN, years in cur- development to enhance leadership skills. By assisting
rent unit, and years with current organization. Nurses clinical nurses, health care institutions and patients may
with more experience showed fewer leadership behav- benefit from the quality care provided at the bedside.
iors. Pearson correlation ranged from r = .26 to r = .46, Clinical nurses need to be aware of their own leader-
p 0.05. ship behaviors and have the opportunity to transform

510 Copyright SLACK Incorporated


CORRELATION BETWEEN LEADERSHIP PRACTICE INVENTORY SUBSCALES AND DEMOGRAPHIC FACTORS
Subscale Age (n = 70)
Modeling the way .17
Inspiring a shared vision .29**
Challenging the process .28**
Enabling others to act .36***
Encouraging the heart .15
*p 0.10. **p 0.05. ***p 0.01. ****p 0.001.
through leadership training and development. Nurses
who participated in the educational leadership program
with theoretical knowledge, competencies, and opportu-
nities to practice leadership skills demonstrated changed
leadership skills and professional behavior following the
education (Abraham, 2011).
The transformational leadership practices of chief
nursing officers cannot be understated. In a study of
Magnet hospital chief nursing officers, findings indi-
cated that nurse executives influence quality clinical and
patient care by creating structures and processes that sup-
port nurse empowerment and evidence-based practice.
Study results noted greater transformational leadership
behaviors with years of nursing leadership experience
and advanced education, but the opposite was found in
the current study relative to clinical ladder nurses. En-
abling others to act and modeling the way were the
top two practices of the chief nursing officers (Clavelle,
Drenkard, Tullai-McGuinness, & Fitzpatrick, 2012).
Chief nursing officers with formal education and
years of leadership experience scored significantly higher
in challenging the process and inspiring a shared
vision compared with clinical ladder nurses who scored
lowest on these subscales. Whereas clinical ladder nurses
are experienced in disease management, they seem to
lack leadership behaviors. Health care organizations
must determine whether staff nurses lack leadership be-
haviors due to educational barriers or a lack of partici-
pation in leadership projects and activities that promote
transformational leadership qualities. Providing leader-
ship development opportunities to clinical ladder nurses
may introduce the qualities of transformational leader-
ship, which are teachable qualities (Clavelle et al., 2012;
Kouzes & Posner, 2003).
This study has provided baseline information to bet-
ter understand the leadership behaviors of RNs who are
frontline caregivers and patient advocates. Surprisingly,
The Journal of Continuing Education in Nursing Vol 45, No 11, 2014
TABLE 4
Years in Current Unit Years With Current
Years as RN (n = 73) (n = 73) Organization (n = 73)
.26** .17 .22*
.39*** .33*** .44****
.38*** .32*** .38***
.46**** .37*** .39***
.27** .25** .22*
the clinical ladder nurses with more years of RN expe-
rience reported fewer leadership behaviors. This is in
direct contrast to the findings of Clavelle et al. (2012).
There is a need to address the educational gap of leader-
ship training and to evaluate the obstacles that may be
preventing frontline staff nurses from leading their
patients to better health care outcomes.
In addition, this study validates the need to have
nurse managers prepared at the graduate level. A mas-
ters education prepares nurses to take critical action
to solve complex problems in the changing health care
environment (Scott & Yoder-Wise, 2013). Future nurse
leaders must participate in formal education and develop
appropriate attitudes and beliefs to be leaders in health
care reform (Bish, Kenny, & Nay, 2012).
STRENGTHS AND LIMITATIONS
Strengths of this study include a response rate of
71%, use of a valid and reliable tool, and a diverse sam-
ple of clinical ladder nurses. This study provides base-
line information for future research studies and may also
provide valuable information for health care systems to
plan for future leadership development to promote pro-
fessional nursing practice. Although the response rate
was adequate for questionnaire survey design (Dillman,
2000), the study may have been under-powered, with
insufficient numbers of nurses in each of the clinical lad-
der groups to detect leadership subscale differences even
though the mean scores suggest that the level 3 nurses
may have scored lower on several subscales, but higher
on role modeling behaviors.
Limitations of this study include the fact that the
LPI was self-administered in evaluating self-perceived
leadership behaviors. The LPI is also available as a 360
data collection method. Using that method may have en-
abled capture of strengths and weaknesses in leadership
qualities because it evaluates how three other cowork-
511

key points
Leadership Behaviors of Nurses
Fardellone, C., Musil, C.M., Smith, E., Click, E.R. (2014). Lead-
ership Behaviors of Frontline Staff Nurses. The Journal of
Continuing Education in Nursing, 45(11), 506-513.
1 Clinical ladder nurses with more years of RN experience
reported fewer leadership behaviors.
2 Enabling others to act was the most frequent leadership
behavior identified by clinical ladder nurses.
3 Professional development is necessary to enhance leadership
skills in all areas of nursing practice.
ers perceive the samples leadership qualities (Kouzes &
Posner, 2003). In addition, this research was based on
a convenience sample and lacked a comparison group.
The survey results did not represent the self-perceived
leadership behaviors of clinical ladder nurses from other
institutions. Clinical ladder nurses who declined to par-
ticipate in the study may possess valuable information
about self-perceived leadership behaviors, resulting in
more robust data.
RECOMMENDATIONS AND FUTURE RESEARCH
The goal of this study was to describe the self-
perceived leadership behaviors of RNs participat-
ing in a clinical ladder program. This study could be
expanded to compare clinical ladder programs at other
health care institutions. This study also could be used
to describe self-perceived leadership behaviors of RNs
functioning at the bedside, who chose not to participate
in the clinical ladder program. Because the goals of the
Affordable Care Act are to lead patients to better health
care outcomes, it is imperative for organizations to un-
derstand how nurses formulate decisions related to
patient care. Identifying leadership behaviors in other
disciplines may assist the nursing profession with lead-
ership competencies and education, which may benefit
the patient and the health care organization.
Repeating this study with a larger sample size may
provide evidence to enhance nursings leadership role in
health care redesign and meet the recommendations of
the IOMs (2010) report. A larger sample size also may
add to the evidence that leadership training is a neces-
sary component for the nursing profession in all areas of
practice. Leadership behaviors of staff RNs are lacking
in the literature, and a larger sample size may support
findings from this study. An additional recommendation
512
is to use this study to compare experienced RNs to new
graduate nurses. These data may provide evidence to
correlate leadership behaviors from professional experi-
ence and academic training, and may be beneficial in the
development of leadership education and competencies
(IOM, 2010).
Strengthening leadership capabilities within nursing
is important as health care continues to evolve and grow.
This study has added to the knowledge base on leader-
ship within clinical ladder nursing programs. Ensuring
that nurses develop their skills and leadership competen-
cies over time will impact patient outcomes and will be
a critical component of health care redesign going for-
ward. Nurses who choose to remain at the frontline of
patient care make extra efforts to improve the lives of
their patients every day.
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