Communication is vital for improving nursing leadership efficiency and advancing the mission of the organization. Creating a supportive environment and promoting quality and organizational success are crucial. Although nurse leaders can set a vision, goals, and boundaries for practice, they can't be present for each decision clinical nurses make. Therefore, nurse leader communication must be transformative; it should be informational, motivating, and forward-thinking.

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Effective communication has many nuances, such as subtle shifts in tone, gestures, word choice, and body language; consider all of these when communicating. Verbal and nonverbal communication work in tandem to deliver a message. In addition, the channel used to communicate influences the scope or reach of the information conveyed. High-impact (HI) communication maximizes these concepts (verbal, nonverbal, channels) to deliver a message that's effective and inspires the desired behavior. In healthcare, effective nursing leadership requires HI communication skills.

Background

Measurements of the effectiveness of spoken words vary. HI communication refers to a leader's use of interpersonal influence to produce a desired action.1 Kerns posited that leaders must focus on all communication components, including a speaker's behavioral skill set and oral communication skills, to become HI communicators.1 Verbal skills may include using a varied vocabulary, vivid words, and action verbs; removing repeated and empty word choices; and minimizing utterances, all with correct grammar and syntax.2 Nonverbal skills may include attention to body language, stance, and distance between the nurse leader and staff.2

Additionally, the channel used can convey importance and influence the message's reach or scope. In nursing, changes can occur rapidly, requiring the nurse leader to be clear and concise when communicating. Nurse leaders who communicate using HI strategies will apply deliberate techniques in verbal and nonverbal communication and channels of communicating to make the most impact with the nursing staff.

Verbal communication

Nurse leaders must communicate vital information to direct care nurses and others to deliver quality healthcare. Fuza postulated that the spoken word has a higher presence of subjectivism than the written word.3 A study found that informal conversations were less susceptible to subjective interpretation than formal conversations.3 However, those who achieve leader status don't always possess good communication skills. In researching leadership styles, Bush and colleagues found the lowest-scoring items when evaluating leaders were in the area of communication.4 In addition, a study of entry-level nurses found that their weakest communication skill was providing and receiving feedback.5

A study of leadership skills and relationships scored motivating language in praise and recognition as part of a nurse leader's impact on the practice environment and found that conflict management was mediated by higher nursing leadership abilities.6 Further, considering praise, recognition, feedback, and verbal encouragement, Cummings and colleagues found that nurse leader coaching conversations correlated with the job satisfaction of direct care nurses.7 It's often said that leaders can't overcommunicate, as repetition of messages conveys importance. For example, frequent and consistent feedback about errors leads staff to have higher perceptions of a culture of safety.4,8,9

Nonverbal communication

In social communication, nonverbal communication is considered more reliable than verbal communication.10 For nurse leaders, facial expressions can convey urgency, passion, and importance. A study conducted outside of the healthcare field on team processes reported that the use of body language when communicating was essential to the communication process.11

In addition, leaders displaying high-power body language are perceived as more confident.10 High-power body language includes poses such as standing with legs slightly apart, and hands on the hips. High-powered poses were perceived as more intelligent in research investigating patient perceptions of their healthcare provider.10 Conversely, body language such as standing or sitting with arms folded or arms lowered suggest less confidence.10 Nurse leaders should be cognizant of their body language to enhance perceptions of confidence when communicating.

Emotion evolves from the nonverbal realm but can quickly cross over to verbalization, if not suppressed. Nurse leaders who are successful in HI communication evaluate, monitor, and control body language that displays emotionality that may negatively impact the delivery of the message.2 Emotional intelligence is the ability to monitor one's emotions and strategically use them to guide one's thoughts and actions.12 No specific studies were found on HI communication and emotional intelligence. However, several studies have researched staff behaviors, attitudes, and turnover related to the nurse leader's emotional intelligence.12,13 One study found a correlation between emotional intelligence and intent to stay; the higher leaders' emotional intelligence scores, the more nurses intended to remain at their place of employment.13 In the realm of nonverbal communication, a high level of emotional intelligence is a positive trait for nurse leaders exhibiting HI communication competence.

Communication channels

Communication channels are evolving as technology matures and globalization occurs. A communication study found that formal written communication from leaders assisted employees in dealing with contextual demands and increased work quality.14 A study investigated readability in written communication and found that messages written in HI communication style take less time to read, are easier to comprehend, and are less likely to require a second reading.15Table 1 shows the characteristics of HI communication.

Table 1: Qualities of HI communication

The internet created an explosion in email communication. Starc and colleagues found that emails were the primary mode of communication among top nurse leaders, whereas midlevel leaders used face-to-face communication more often.16 Organizational health research on the mediating effect of communication found that frequent and higher levels of organizational communication increased employee engagement.17

Another form of communication is electronic text messaging. Staff in acute care settings frequently have devices for text messaging. Although text messaging is a quick, convenient communication method, it has some pitfalls, such as misdirected messages, associated costs, and being perceived as intrusive.16 Therefore, texting between nurse leaders and staff must have clearly defined boundaries and be used sparingly.

Theoretical/conceptual framework

Leadership studies have included many components with communication at the core. However, extant literature provides no explicit theory on HI communication among nurse leaders. Leader-member exchange (LMX) theory does have some applicability to HI communication. LMX theory is based on the communication relationship between employees and direct supervisors, emphasizing that a supervisor and an employee comprise a vertical dyad.18 Communication will occur between leaders and employees in three ways: in-group, mid-group, or out-of-group.18 The theory applies to the present study because HI communication skills are essential at all communication levels. In addition, interactions occur between the nurse leader and nurses, thus constituting a dyad where communication is interpreted and behaviors are modified.

Aim/significance

This study aims to distinguish specific constructs/groupings that constitute HI communication in nursing. In addition, it explores the associations between HI communication and leadership styles. The questions guiding the study are:

* How many dimensions are present in nurse leader HI communication?

* What's the association between nurse leader HI communication dimensions and leadership styles?

This study addresses a gap in the literature. In addition, there's no clear model of HI communication in nursing. Identifying the components of HI communication is a primary step in providing evidence for a model. This exploratory study on HI nurse leader communication may spur more extensive research.

Methods

Participants and procedure

This quantitative and investigational study collected data using a web-based survey (QuestionPro, Seattle, Wash.). Eligible participants were RNs currently practicing and were identified using a listing from the Texas Board of Nursing. Recruitment flyers were mailed to randomly chosen RNs with a link to the survey. A nominal ($10 Starbucks) gift card was offered for completing the survey. Over 3 months, 200 recruitment flyers were sent on seven separate occasions biweekly to different RNs, for a total of 1,400 flyers. The survey was open for 3 months (June, July, and August 2021).

Instruments

The survey comprised a biographical section, a HI communication scale, and the Multifactor Leadership Questionnaire 5X (MLQ 5X). Biographical information was collected on age, gender, years as an RN, work area, and work role. The MLQ 5X is used to measure effective leadership characteristics and has 45 questions: 36 measuring leadership styles and 9 measuring leadership outcomes.19 The questions measure respondents' perceptions of their direct leader/supervisor using a five-point Likert-type scale (5 = frequently, 4 = fairly often, 3 = sometimes, 2 = once in a while, 1 = not at all).

Questions related to leadership styles characterize transformational, transactional, and passive-avoidant leadership.19 The three leadership outcomes measured are extra effort (EE), effectiveness (EFF), and satisfaction (SAT). The MLQ 5X total scale and subscales have good internal reliability, with Cronbach alphas ranging from .74 to .94.19 The Cronbach alpha for the entire survey was .93.

The tool used to assess HI communication comprises 30 questions divided into three sections: verbal, nonverbal, and channels. This scale was developed using a multistage method. In the first stage, questions were developed based on a priori knowledge combined with a literature review. Key concepts evident in the literature were identified for construct validity. In the second stage, content experts appraised the scale. Four nurse leaders with 37 years of combined management experience reviewed the scale and assisted in making modifications and establishing face validity.

The third stage was scale validation using exploratory research, with the findings represented in this study. The questions measured respondents' perceptions of their direct leader/supervisor using a five-point Likert-type scale (4 = frequently, 3 = fairly often, 2 = sometimes, 1 = once in a while, 0 = not at all). Reliability testing (Cronbach alpha and exploratory graph analysis [EGA]) was conducted after the study to determine applicability and adjust groupings based on clusters. The Cronbach alpha for the HI communication scale was .82.

Statistical analysis

Data were analyzed using SPSS Version 27 software and the R/EGA package.20,21 Summed scores were used in correlations between MLQ 5X leadership styles and HI communication clusters. Skewness and kurtosis of the summed scores were in the range of normality, and Pearson correlations were used to evaluate the strength and direction of the summed scores. In addition, EGA provided information on constructs and relationships in the HI communication model.

EGA is considered network psychometrics focusing on the estimation of undirected models.22 This study focused on authentication of the model and constructs; thus, an exploratory perspective was applied. EGA is believed to have advantages over other exploratory methods (such as cluster analysis, exploratory factor analysis, and parallel analysis) in identifying empirical dimensions in multidimensional data with visual identification of single items and related clusters.23

Ethics

An Institutional Review Board approved this study. Participants provided informed consent prior to accessing the survey.

Results

In total, 78 surveys were received. Six incomplete surveys had insufficient data and were omitted from the analysis. Additionally, two surveys were duplicated, and the duplicate responses were removed, leaving 70 complete survey responses. This was deemed sufficient to establish the feasibility of progressing to robust, effective research.24 Biographical data collected from the participants are displayed in Table 2. Most participants were women (n = 59, 84.3%), and the average participant age was 41.34 years. None of the biographical data significantly correlated with dimensions of HI communication or leadership styles.

HI communication dimensions

Clusters and network structure were estimated using EGA. Confirmatory factor analysis was performed to support the five-dimensional structure, the results of which demonstrated possible fit for the five-cluster model: X2 661.048, df = 395.000, X2/df = 1.673, P = .000, CFI (comparative fit index) = 0.831, GFI (goodness of fit index) = 0.67, NFI (Bentler-Bonett Normed Fit Index) = 0.644, RMSE (root mean squared error) = 0.059. The study size impacts factor analysis, with large sample sizes representing more reliable analyses.25

Five clusters were also identified using EGA: inspirational, clear, influential, timely, and nonverbal communication. A negative relationship was found for some individual items that were negatively worded. The thickness of the edges in Figure 1 shows the homogeneity of the clusters. The edges between the items in different clusters are thinner; items in clusters 1, 2, and 4 have thicker edges. The implication is that those items, even in different clusters, have higher associations with each other.

Figure 1:. EGA model representation

Leadership characteristics and outcomes

The five clusters were used to conduct Pearson product-moment correlation analysis with leadership characteristics and outcomes. Table 3 shows the zero-order correlation results. Clusters 1 (inspirational communication), 2 (clear communication), 3 (influential communication), and 4 (timely communication) were positively correlated with transformational leadership, transactional leadership, EE, EFF, and SAT, and negatively correlated with passive-avoidant leadership. Cluster 5, nonverbal communication, was positively correlated with passive-avoidant leadership.

Table 3: Zero-order correlational results

Between-cluster analysis

Inspirational communication was positively correlated with clear, influential, and timely communication. Clear communication was positively correlated with influential, timely, and nonverbal communication. Influential communication was also positively correlated with timely communication. Nonverbal communication showed no correlations with the other four clusters.

Discussion

HI communication style has an impact on positive outcomes.8,9,26 Five dimensions of HI communication were identified in the study and correlated with leadership styles and attributes (see Table 4).

Table 4: Five dimensions of HI communication

HI communication dimensions

Regarding the first question addressed in this study (How many dimensions are present in nurse leader HI communication?) the results identified five separate dimensions: inspirational, clear, influential, timely, and nonverbal communication. These dimensions are discussed below.

Inspirational communication

Of the 30 HI communication questions, 12 were connected to inspirational communication. The highest-scoring question in this cluster was: "When my manager speaks, I understand what her/his intent is." This indicates a connection and alignment between a spoken message, body language, and motivational language. A 3-year study on motivating language used by leaders found consistent correlations between credibility and behavioral integrity as antecedents for motivating language.27 The present study indicates that a leader's alignment among talk, actions, and believability is woven into their ability to motivate through the spoken word. All questions linked to the cluster of inspirational communication through the EGA results positively correlated with the three positive leadership outcomes (EE, EFF, SAT) and transformational leadership style.

Clear communication

Five questions formed Cluster 2, clear communication. The highest-scoring question was: "In written communication, my manager uses words or abbreviations I don't always understand." This was somewhat surprising, as all participants in this study were RNs. Healthcare has often been accused of using confusing language, and as this study highlights, nurse leaders may continue to assume their language is universally understood. However, evidence in this study indicates this is a falsehood. These questions didn't correlate significantly with leadership outcomes or transformational leadership style, indicating that more evidence is needed in this area.

Influential communication

Cluster 3 was influential communication, which differs from inspirational communication. Inspirational communication is associated with motivation, inspiring change, and using intrinsic/extrinsic rewards.4,8,14 Influential communication, on the other hand, is concomitant with interpersonal relationships and the leader-staff dyad (LMX theory). This cluster comprised five questions, for which the means ranged between 2.13 and 2.79, indicating participants scored all questions fairly consistently. Questions in this cluster covered: the quantity of time spent speaking with staff; providing feedback on performance; sharing personal experiences; and conveying passion and excitement when communicating.

In their work on nurse leader communication, Starc and colleagues provided an example of how LMX theory can influence outcomes based on the leader-staff dyad relationship.16 They found a correlation between satisfaction with face-to-face communication and employee-organization relationships, such as trust, mutual control, commitment, and satisfaction. Additionally, Gutermann and colleagues found that high-quality LMX crosses over to staff engagement.28

Timely communication

Cluster 4, timely communication, included four questions based on obtaining quick responses from a nurse leader. Weberg and Davidson highlighted that early communication of a change in practice leads to sustained improvements and change.29 Change can be rapid in healthcare; therefore, timely communication is vital.

The highest-scoring question was: "If I need a quick response, I know which method (phone, email, text, etc.) is best to contact my manager." This question highlights technologic changes based on societal norms. Technology has created a global community and influenced how individuals communicate. As technology increases people's ability to communicate, the methods, context, and rhetoric add layers and dimensionality to communication.

Nonverbal communication

Cluster 5, nonverbal communication, included four questions linked through EGA results. Alignment of verbal and nonverbal communication is essential for a consistent message to be received. In cases of misalignment, the receiver will ultimately interpret the message based on nonverbal communication.29

The question in this cluster with the highest mean score was: "I can tell what mood my manager is in by his/her body language." The nurse leader should be skilled in maintaining a neutral tone in their body language when relaying an organizational message with which they don't necessarily agree. Research conducted on leader communication found that when staff perceived the nurse leader was authentic, employee work engagement improved, as did job satisfaction and the service climate.9

HI communication and leadership styles

The study's second guiding question was posed to explore the association between dimensions of nurse leader HI communication and known leadership styles. Three leadership styles (transformational, transactional, passive-avoidant) were used in a correlation analysis with the HI communication dimensions. Transformational leadership style had a significant positive relationship with the inspirational, clarity, influential, and timely HI communication dimensions. This implies that the more efficient a nurse leader is at providing clear, timely, inspirational, and influential communication, the higher the impact on perceptions of that leader as being transformational.

Communication wasn't explicitly identified in the measure of transformational leadership; however, effective communication is a vital component in the characteristics of transformational leadership (idealized influence, inspirational motivation, intellectual stimulation, individualized consideration).30-33 The question with the highest mean score was in the inspirational motivation subset and was: "My supervisor speaks optimistically about the future." The question with the lowest mean score was in the idealized behavior subset: "My supervisor talks about their most important values and beliefs."

Transactional leadership style was significantly positively correlated with inspirational, influential, and timely communication. No correlations were found between transactional characteristics and clear or nonverbal communication. Inspirational and influential communication demonstrated a strong relationship in transformational style and a moderate relationship for transactional style. The lowest-scoring question in this category was: "My supervisor directs my attention toward failures to meet standard." The mean was 1.68, indicating that this was perceived to occur once in a while or sometimes.

Transactional leadership uses staff's commodity needs to influence staff behaviors.34 The highest scoring mean (2.67) was the question: "My supervisor expresses satisfaction when I meet expectations." This indicates that nurse leaders may be more comfortable with rewarding staff for positive outcomes versus coaching staff when standards aren't met. In addition, timeliness of communication, which was positively correlated with transactional leadership, may be associated with the commodities offered to staff (extrinsic rewards) that can be time-dependent, such as rewards for covering an open shift or completing a necessary project.35

Passive-avoidant leadership style was negatively correlated with inspirational, clear, influential, and timely communication. This indicates that, as a leader demonstrates higher levels of HI communication, the perception of passive-avoidant characteristics in that leader diminishes. Passive-avoidant characteristics are less desirable and result in a lack of leadership trust, decreased leadership effectiveness, avoidance of leadership responsibility, limited information-sharing, limited staff support, and limited staff feedback.31,33,36 Behaviors associated with passive-avoidant were the lowest-scoring characteristics in the current study. Questions highlighting passive-avoidant characteristics were scored similarly by the study participants; the mean scores were 1.18 to 1.71. The question with the highest mean was: "My supervisor shows that they are a believer in 'if it ain't broke, don't fix it'." Appreciatively, the question with the lowest mean for the entire survey was in passive-avoidant category: "My supervisor is absent when needed."

Nonverbal communication was positively correlated with passive-avoidant leadership. Questions on nonverbal communication included: "I can tell what mood my manager is in by his/her body language," "When my manager does not support a decision, I can tell even without them speaking," and "Just by the manner in which my manager reacts, I can tell if he/she 'likes' someone or not." The questions on nonverbal communication were negatively worded; therefore, this correlation indicated that the more negative nonverbal communication nurse leaders use, the more they're perceived as using passive-avoidant leadership styles.

Limitations

The limitations of this study include the sample size, cross-sectional design, and use of self-report questionnaires. The identified dimensions of HI communication can be investigated in a more extensive study. Generalizations are limited, and correlations don't necessarily determine causation.

Implications for nursing leadership

HI communication isn't well studied in the nursing literature. Although previous studies have explored what's considered good communication, it's often mixed with other leader attributes. Ineffective communication in hospitals has been associated with ineffective time management, increased patient stay length, and adverse business and economic impacts.1

Oshodi and colleagues explored leader support and related effects on a culture of safety and found a high degree of importance (>=.8 factor load) for questions specific to communication.8 Other concepts associated with nurse leader communication include nurse satisfaction, turnover, and quality.3,6,7,13 Leadership support was determined to be vital when implementing evidence-based practice.24 Communication was again an essential component of leadership support.

Second, the groupings and clusters identified in this study aid in visualizing how constructs link together and are specific to HI communication. The study allows for scientific data and modifications before a more extensive study is conducted. The clusters determined through the investigational research serve as a basis for developing models related to HI communication.

Finally, meaningful associations can be the basis for evidence-based nurse leader education. Kuraoka found that experiential learning improved nurse leaders' motivating capacity.37 This is possibly because, through trial and error, leaders discover that motivational language works. Experiential learning is valuable; however, newer nurse leaders and those with less effective communication skills are still required to provide a supportive environment for direct care nurses.6,7,36 Kuraoka's findings indicate that nurse leader communication can be taught.37 By identifying HI communication concepts, organizations and leaders can develop succinct educational programs highlighting HI concepts to reduce the learning curve for effective nurse leader communication.

Summary

HI communication skills make communication effective in the rapidly changing healthcare environment. Identifying constructs is an initial step in forming a conceptual model for HI communication. This study identified five clusters (constructs) of communication and further highlighted that these constructs are associated with quality leadership. These constructs were influential, inspirational, timely, clear, and nonverbal communication. More research is needed to validate these constructs. Effective leader communication is a vital component for achieving the goals of an organization, patients, and nursing.

Research box

Purpose: The purpose of the study was to identify characteristics of high-impact (HI) communication in nursing leadership.

Participants/Method: This quantitative study was conducted in June to August 2021. Surveys were mailed to practicing RNs in Texas.

Results: A total of 78 surveys were returned. Exploratory graph analysis identified five components of HI communication.

Conclusion: HI communication components identified were inspirational, clear, influential, timely, and nonverbal communication. Transformational leadership style had a significant positive relationship with inspirational, clear, influential, and timely HI communication.

INSTRUCTIONS High-impact communication in nursing leadership: An exploratory study

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REFERENCES