1. Morse, Richard MSN, RN, NPD-BC
  2. Cline, Debbie DNP, RN, CNL, OCN, NEA-BC
  3. LaFrentz, Kelly MSN, RN, NPD-BC


Direct care/bedside nurses rarely view themselves as leaders, yet they have a powerful influence regarding patient outcomes and overall patient satisfaction. We will show that by assisting the direct care bedside nurse in recognizing they are leaders and offering them additional education and resources through the Rising Stars program, the participants will better understand the influence they have over their patients and impact related to organizational outcomes.


Article Content

Although it is common to have leadership programs that focus on transition of nurses into formal leadership roles, focusing on informal leaders such as the direct care clinical nurse (CN) is less common. "Nurses at all levels need strong leadership skills to contribute to patient safety and quality of care" (Institute of Medicine, 2010, p. 223). The importance of providing foundational nursing leadership education for CNs, along with the advanced knowledge development, was identified as a need.


According to the Institute of Medicine (2010), "What is needed is a style of leadership that involves working with others as full partners in a context of mutual respect and collaboration" (p. 223). CNs focus on providing and coordinating care in all clinical settings. Working with patients and their families, the CN must clearly articulate the plan of care while providing support to the most vulnerable. Each shift requires integration of knowledge, skills, and ability needed for electronic health records, clinical skills, and professional development. In addition, CNs are leaders of evidence-based practice, research, and quality improvement (QI).


The CN providing direct care can identify redundancies and improvements needed to enhance interactions with patients. To impact change, Abraham (2011) noted the need to develop the registered nurse (RN) not only in leadership skills but also in professionalism skills. There is an identified need to develop the CN to be an effective informal leader to lead change when identifying issues. This was different from education received for the role of the charge nurse as content focused on evidence-based practice, change management, QI, and self-reflection.


To fill this need, the Rising Stars (RS) program was developed and implemented in 2005 as a CN leadership development program at MD Anderson Cancer Center (MDA). The initial goal was to provide high-performing direct care CNs with additional skills and knowledge to support them as informal leaders. As the program matured, other levels of nursing have been included, and the goal has been revised to enhance the knowledge and skills of the experienced nurses so they may foster exceptional patient outcomes and experiences as well as be a role model.



Several forward-thinking nurse leaders identified a need to enhance knowledge of the bedside CN, which opened the first opportunity for participation in the RS program. The participants were nominated by their area leaders and selected by a review team. Nominations included evaluation of each nominee based on set criteria including, but not limited to, communication skills, leadership potential, and unit/organizational engagement.


To be successful in the RS program, support from leadership is essential. The identification of potential participants and active mentorship helps make the RS program successful. In addition, area leaders must recognize the importance of the participants attending each class and their role in assisting in the identification of an evidence-based QI project early in the program.


Content experts for the RS program originally consisted of internal and external nurses and staff trained in leadership topics. Faculty from an academic partner worked with the RS participants and provided valuable expertise and content to the program. Self-assessment debriefs were facilitated by instructors certified in the various tools utilized for the program. An RN facilitates the classes and assists in the translation of material to be meaningful to the CNs. Over time, the program transitioned to internal experts only. As content was modified, based on on-going evaluation to meet new program objectives and enhance the curriculum, a program coordinator was added to assist with the program. The coordinator organizes speakers, schedules rooms, and orders supplies, along with supporting the program in multiple other ways.



Curriculum development was created through the collaboration of many nurse leaders working together to identify the components to be taught. Table 1 displays the current curriculum. The program is 12 months and is completed through 8 hours of classroom/virtual content monthly, including development and implementation of a QI project. Utilization of a curriculum that takes the RS through QI implementation, presentation, and abstract development is used to assist in ensuring success in the program. Timing of offerings is considered for building knowledge and success.

Table 1 - Click to enlarge in new windowTABLE 1 Rising Star Curriculum, 2021

Needs Assessment

All participants completed a learning needs assessment (LNA) to identify topics of concern and interest that may be added to that cohorts' year-long curriculum. The LNA asks participants to identify the top five leadership skills they want to develop, such as delegation, teamwork, conflict management, QI, and managing up. Another section has the participant identify the top five areas that they struggle the most with at work, such as systems thinking, interdisciplinary services, relationships with peers, generational issues, and critical thinking. A free text section for additional comments is included. Because a mentorship program is very important to the growth and maturity of one's personal and professional development, the RS program also includes a mentorship class. Since 2019, all participants select a mentor and complete at least two mentoring sessions prior to program completion.


Over time, the most common concepts identified from the LNA have been conflict management, communication, managing up, power/influence, and QI. As a result, the curriculum for the RS program has evolved to more specific education focused on meeting those needs.



Outcomes Measured

Participants complete a self-assessment tool to evaluate their own leadership behaviors. According to the International Leadership Associates (2020), research has shown that the more frequent an individual is demonstrating particular leadership behaviors, the more often they will be identified as effective leaders. The RS participants complete class evaluations to measure if the objectives/goals were achieved. The final class evaluation includes two key questions: (a) Did the QI project have a positive impact on their unit/department/area? (b) Overall, was the RS program beneficial to them? The anonymous evaluation is given through an electronic platform and accessed by participants via a shared link or QR code.


In October 2019, a new evaluation to review the sustainability of the QI project and academic education was sent out to 112 previous RS participants. Evaluation questions included the following:


1. What happened to the evidence-based practice/QI project you worked on during the RS program?


2. Since graduating the RS program, have you worked on an abstract?


3. Since graduating the RS program, have you returned to school to further your education? If so, what was your degree plan?



The evaluation is now sent out annually to the RS postgraduates between 2 and 5 years in order to establish QI project status.


The results have assisted with enhancing the curriculum of the RS program as it has expanded. Expansion from a CN program to a more comprehensive professional nurse program has also provided opportunities for nurses from additional areas and departments to participate such as inpatient, ambulatory, research, case management, diagnostic imaging, interventional radiology, access, and utilization and from the regional HALs (Houston area locations).


Lessons Learned

At MDA, the year-long accredited CN residency program provides many similar class topics. To avoid redundancy, the RS content is provided at a higher level of complexity. Recent years have shown almost half of the RS class to be composed of previous residents, resulting in the need for different and more advanced leadership class topics. Therefore, additional classes and topics have been introduced into the curriculum that focuses on real-time learning needs.


With the transition from traditional to virtual classes, a flipped classroom approach that allows the RS participant time prior to virtual class to review and complete independent activities and classes is utilized. This format enables a richer discussion and sharing opportunity among the RS participants during the virtual classes. The RS program has evolved from a didactic classroom environment to a multimodal approach to meet the adult learner needs. This approach includes didactic, simulation, gaming, escape rooms, independent assignments, asynchronous learning, virtual classrooms, modules, reflection, and case studies. Because of the COVID-19 pandemic, class participation has been impacted through cancelled classes, content realignment, and extension of the program end date. With communication being a crucial factor as content was transitioned to a virtual classroom, the use of electronic communication within the class has increased.



An evaluation of the program is completed from an overall perspective and from each individual cohort as well. Every 3-5 years, the Review Committee meets to discuss curriculum changes, eligibility criteria (current is a minimum of 1 year and completion of the CN Residency Program if applicable, as well as being at the competent level of experience on the nursing career ladder), and number of participants per cohort (changed from 35 to 40 participants with current cohort), along with any other interests or concerns that could require modification to the program. The committee is composed of a team of stakeholders including current and previous RS participants and nurse leaders.


When the RS program first began, it concentrated on participants from the inpatient and ambulatory areas. As the program has advanced over the years, so have the nursing areas that are eligible for participation. The program remains focused on high-performing experienced nurses who wish to develop their knowledge and skills to foster exceptional patient outcomes and experiences as well as be leaders at the bedside. With the RS FY21 cohort, the program included its first advanced practice nurse participant.


The RS program curriculum has expanded to include classes developed through the institutional education and training departments and the leadership institute that provides classes that the RS participants participate in with other nonnurse students for a multidisciplinary learning experience. This enables the RS to have exposure to different perspectives, aside from nursing, regarding leadership-related topics.




The RS Selection/Review Committee is composed of stakeholders including nurse leaders and previous RS participants. The committee meets once a year to review eligible candidates for the next RS cohort. Forty nurses are selected from approximately 100 eligible candidates each year. The RS Selection/Review Committee also meets every few years to review program curriculum and design. Changes within the program are made at this time based on committee recommendations.


Several of the RS QI projects have been integrated at the department or institutional level. RS participants break up into small groups of three to four and work together on a QI project. The last three RS cohorts have averaged 11 QI teams each. Examples of QI projects implemented include the following:


* In oncology patients, what is the effect of aromatherapy as a first-line intervention compared to utilizing pharmacological interventions on decreasing the symptoms of nausea/vomiting and anxiety prior to patients' hospital discharge? This pilot study was put temporarily on hold because of COVID-19 restrictions. However, the Nursing Practice Congress has contacted the RS individuals responsible for this QI project to begin implementation.


* In ambulatory adult oncology patients receiving systemic therapy, how does a sleep assessment tool compared to patient self-reporting affect the capture of sleep disturbance within 3 months? The sleep assessment tool increased sleep disturbance assessments documented during medical oncological visits by 30% at 3 months posteducation.


* In hematology unit staff, how does the implementation of aromatherapy with the use of diffusers affect the level of workplace stress experienced over the span of 2 months? Of the 42 participants surveyed, 73% felt aromatherapy reduced workplace-related stress and 85% felt aromatherapy should continue to be used on the hematology units.



These are just a few examples of the many QI projects completed by the RS that look to enhance patient safety and quality of care delivered to their patient population.


After review of the last 5 years of evaluations and concentrating on the main two questions covered on the last class day of the program (Was the RS program beneficial? and Was the QI project beneficial?), the following outcomes were noted:


* The previous 5 years of the program yielded 144 graduates.


* Responses were received from 89 (62%) participants out of the 144 graduates.


* Of the 89, 79 (89%) strongly agreed that the program was beneficial to them.


* Of the 89, 69 (78%) strongly agreed that the QI project was beneficial to their area.



Additional participant comments included the following: "It is an excellent program," "The program helped to build confidence in interacting with people," "Enjoyed learning more about leadership and myself," and "I will bring the learned knowledge back to my clinical areas."


Lastly, the results of the postprogram survey that focused on the status of QI projects, progress on abstract submission, and return to school for advanced formal education were identified:


* All the QI projects were completed, and 19 have been integrated at the unit, department, or institutional level.


* Forty-one percent worked on an abstract, and eight have been submitted for a conference.


* Fifty-nine percent have completed advanced formal education; twelve have a master's in nursing degree.



Out of the 238 RS graduates from the previous 14 years, 75 (32%) have been promoted to leadership positions (see Table 2). This retention and promotion align with succession planning for the institution, although the goal of this program is to enhance leaders on the front line versus formal leadership roles.

Table 2 - Click to enlarge in new windowTABLE 2 Rising Stars Promotions

At this time, data have not been collected that would assess the influence of the RS program on patients, family members, or organizational leaders. Although this is under consideration for the future, antidotally, an increase in applications has been submitted by leaders in different areas, and informal discussions with nurse leaders are very positive about the program. The RS participants have engaged in mentoring, additional departmental responsibilities and committees, as well as participation in multidisciplinary institutional leadership training programs.


The RS program has been a very successful program as we have matured from the original goal of developing high-performing direct care CNs into informal leaders at the bedside. It has morphed into a goal of enhancing experienced nurses' knowledge and skills so they may foster exceptional patient outcomes and experiences as well as be the role model for newer staff. The program has moved from the inpatient arena to include other areas such as ambulatory, research, case management, and advance practice nursing.


Future Plans

As revisions have been made over the years to the curriculum, additional opportunities for improvement still exist. With the next RS Review Committee meeting, a topic of discussion will be enhanced eligibility criteria. MDA is a Magnet-recognized hospital and recently obtained its fifth consecutive designation. With this in mind and because of the increasing numbers of eligible candidates applying each year, review of the eligibility requirements is needed to ensure selection criteria continues to be current and relevant. MDA has many high-quality, tenured, and engaged nurses to select from. Another item for discussion is the application and supervisor feedback. The application, along with supervisor feedback, provides an effective way to review each candidate and make comparisons among all eligible candidates utilizing direct supervisor input. In addition, incorporating continuing education credit into the program is being evaluated.



Nursing Professional Development Practitioner Implications

The term nursing professional development (NPD) practitioner describes the RN who has a significant impact on the professional competence and growth of its learners in a variety of settings (Brunt & Russell, 2021). The RN facilitator of the RS program is an NPD specialist with responsibilities that include managing the application process, chairing the RS Selection/Review Committee, managing applicant notifications, informing executive leadership of program outcomes, and facilitating the program and classes. The RS program helps to increase and enhance the competence, confidence, and knowledge of its participants through interactive classes that focus on clinical leadership skills. The RS participants are expected to demonstrate comprehension through continual role modeling, mentoring, and dissemination of information at the unit/department level. These informal nurse leaders are on the frontline and collaborate with the NPD practitioner regarding orientees and competencies of new employees. The RS participants are typically utilized as preceptors and train-the-trainers who are often an extension of nursing education for implementing new or revised competencies and training.


Nurse Implications

"Strong nursing leadership helps encourage other nurses to function as team units" (Millburn, 2020). RS participants may leverage the positive influence they have with their team members to recognize just how important a resource and mentor they can be to their direct care bedside nurse peers. Nurses must recognize that their leadership skills are just as vital as their technical ability when delivering safe and effective care to the patient (Institute of Medicine, 2011).


Nurse Leader Implications

Per Mosier et al. (2019), nurses mention that frontline leaders had an amazing impact on their job satisfaction and ability to deliver high-quality care. Data from the American Nurses Association's National Data of Nursing Quality Indicators found, during a 2-year span, that a 25% increase in nurse job enjoyment was linked with an overall quality of care increase between 5% and 20% (Walker, 2018). When nurses are satisfied with their job, it legitimizes their worth and desire to do more. With RS participants as frontline informal leaders in the department, leaders can feel confident their nurses are provided with an immediate resource to depend on. A few of the comments from the leadership teams regarding the RS participants have been as follows: "They bring leadership, mentorship, and are leaders for different projects and future CN responsibilities"; "They bring their expertise, teach new graduates, big resource for the floor, back-up charge, and patience"; "They are first to volunteer; we rarely have to ask them to take on a new task"; and "The RS usually will take patients that are more difficult."


Organizational Implications

"Nurse turnover is a global concern that is both costly for health-care organisations and in the context of the work environment, affects quality and safety" (Heidari et al., 2017). Nurse job dissatisfaction can be linked directly to nurse turnover rates. Moreover, the national retention average for RNs in calendar year 2019 was 15.9% (NSI Nursing Solutions, Inc., 2020). Continual professional development helps to attract as well as retain an organizations' staff (Mlambo et al., 2021, p. 7). For nurses committed to quality patient care, career satisfaction is dependent on employers investing in professional development opportunities so they may continue to grow in their practice and strengthen their ability to administer quality patient care (Price & Reichert, 2017, p. 17). The RS program is one method of professional development that can assist in creating direct care leaders and that may improve retention and create an opportunity for succession planning. Evaluation of turnover data for the RS program graduates at 1 year was 0% in FY20 and 10.25% in FY21. In comparison, institutional nurse turnover data for the same two fiscal years was 6.88% in FY20 and 11.39% in FY21.



In the beginning, the RS program curriculum included education related to conflict management, performance improvement, evidence-based practice, giving and receiving feedback, and self-awareness in order to communicate more effectively within the unit and organization. In addition, skills such as abstract writing, creating a professional portfolio, and developing PowerPoint presentations were covered. Classes were originally didactic based and held in the traditional classroom setting.


Though the curriculum still includes education and practice in the aforementioned areas, it has evolved to include additional management classes, along with incorporating other instructional methods of content delivery. As part of the multimodal approach, participants are accountable for completing independent assignments throughout their year in the program. RS participants are assigned a QI project that is presented to peers and leadership at the end of the program. The assigned QI modules and project help prepare the RS to engage as a successful member or lead a QI team or project. Participants are encouraged to continue with the project and disseminate findings via a nursing peer-reviewed journal and/or conference beyond the conclusion of the RS program.


The RS program is a professional development program focused on the enhancement of the CN knowledge, skills, and abilities in the informal leadership role. Continuing professional development increases competence; introduces new skills; and protects the public by providing ethical, effective, and safe practice; this is a lifelong process by nurses for developing and maintaining their competence, professional practice, and achievement of career goals (King et al., 2021). The program prepares the participants to be a leader at the bedside to positively impact the work environment and patient care. Multiple research studies have shown that relationship-focused nursing leadership practices contribute to positive outcomes for the nursing profession such as job satisfaction, intention to stay in nursing, and health and well-being of nurses (Cummings et al., 2021). This program meets a desire for nurses to advance their knowledge, skills, and abilities for professional development in the area of clinical leadership without the requirement to return to school for an advanced degree. The units and departments are positively impacted by the education and resources the RS participants receive, which is then shared with other staff as they educate, precept, mentor, and role model for other nurses.




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