Predictors of new graduate nurses' health over the first 4 years of practice.

AIM: To examine predictors of Canadian new graduate nurses' health outcomes over 1 year. DESIGN: A time-lagged mail survey was conducted. METHOD: New graduate nurses across Canada (N = 406) responded to a mail survey at two time points: November 2012-March 2013 (Time 1) and May-July 2014 (Time 2). Multiple linear regression (mental and overall health) and logistic regression (post-traumatic stress disorder risk) analyses were conducted to assess the impact of Time 1 predictors on Time 2 health outcomes. RESULTS: Both situational and personal factors were significantly related to mental and overall health and post-traumatic stress disorder risk. Regression analysis identified that cynicism was a significant predictor of all three health outcomes, while occupational coping self-efficacy explained unique variance in mental health and work-life interference explained unique variance in post-traumatic stress disorder risk.

Starting Out: qualitative perspectives of new graduate nurses and nurse leaders on transition to practice.

AIM: To describe new graduate nurses' transition experiences in Canadian healthcare settings by exploring the perspectives of new graduate nurses and nurse leaders in unit level roles. BACKGROUND: Supporting successful transition to practice is key to retaining new graduate nurses in the workforce and meeting future demand for healthcare services. METHOD: A descriptive qualitative study using inductive content analysis of focus group and interview data from 42 new graduate nurses and 28 nurse leaders from seven Canadian provinces. RESULTS: New graduate nurses and nurse leaders identified similar factors that facilitate the transition to practice including formal orientation programmes, unit cultures that encourage constructive feedback and supportive mentors. Impediments including unanticipated changes to orientation length, inadequate staffing, uncivil unit cultures and heavy workloads. CONCLUSIONS: The results show that new graduate nurses need access to transition support and resources and that nurse leaders often face organisational constraints in being able to support new graduate nurses. IMPLICATIONS FOR NURSING MANAGEMENT: Organisations should ensure that nurse leaders have the resources they need to support the positive transition of new graduate nurses including adequate staffing and realistic workloads for both experienced and new nurses. Nurse leaders should work to create unit cultures that foster learning by encouraging new graduate nurses to ask questions and seek feedback without fear of criticism or incivility.

Upregulated WEE1 protects endothelial cells of colorectal cancer liver metastases.

Surgical resection of colorectal cancer liver metastases (CLM) can be curative, yet 80% of patients are unsuitable for this treatment. As angiogenesis is a determinant of CLM progression we isolated endothelial cells from CLM and sought a mechanism which is upregulated, essential for angiogenic properties of these cells and relevant to emerging therapeutic options. Matched CLM endothelial cells (CLMECs) and endothelial cells of normal adjacent liver (LiECs) were superficially similar but transcriptome sequencing revealed molecular differences, one of which was unexpected upregulation and functional significance of the checkpoint kinase WEE1. Western blotting confirmed that WEE1 protein was upregulated in CLMECs. Knockdown of WEE1 by targeted short interfering RNA or the WEE1 inhibitor AZD1775 suppressed proliferation and migration of CLMECs. Investigation of the underlying mechanism suggested induction of double-stranded DNA breaks due to nucleotide shortage which then led to caspase 3-dependent apoptosis. The implication for CLMEC tube formation was striking with AZD1775 inhibiting tube branch points by 83%. WEE1 inhibitors might therefore be a therapeutic option for CLM and could be considered more broadly as anti-angiogenic agents in cancer treatment.

Starting Out: A time-lagged study of new graduate nurses' transition to practice.

BACKGROUND: As the nursing profession ages, new graduate nurses are an invaluable health human resource. OBJECTIVES: The purpose of this study was to investigate factors influencing new graduate nurses' successful transition to their full professional role in Canadian hospital settings and to determine predictors of job and career satisfaction and turnover intentions over a one-year time period in their early employment. DESIGN: A national two-wave survey of new graduate nurses across Canada. PARTICIPANTS: A random sample of 3906 Registered Nurses with less than 3 years of experience currently working in direct patient care was obtained from the provincial registry databases across Canada. At Time 1, 1020 of 3743 eligible nurses returned completed questionnaires (usable response rate=27.3%). One year later, Time 1 respondents were mailed a follow-up survey; 406 returned a completed questionnaire (response rate=39.8%). METHODS: Surveys containing standardized questionnaires were mailed to participants' home address. Descriptive statistics, correlations, and hierarchical linear regression analyses were conducted using SPSS software. RESULTS: Overall, new graduate nurses were positive about their experiences and committed to nursing. However, over half of new nurses in the first year of practice reported high levels of emotional exhaustion and many witnessed or experienced incivility (24-42%) at work. Findings from hierarchical linear regression analyses revealed that situational and personal factors explained significant amounts of variance in new graduate nurses' job and career satisfaction and turnover intentions. Cynicism was a significant predictor of all four outcomes one year later, while Psycap predicted job and career satisfaction and career turnover intentions. CONCLUSIONS: Results provide a look into the worklife experiences of Canadian new graduate nurses over a one-year time period and identify factors that influence their job-related outcomes. These findings show that working conditions for new graduate nurses are generally positive and stable over time, although workplace mistreatment is an issue to be addressed.

Assessing the Nontechnical Skills of Surgical Trainees: Views of the Theater Team.

OBJECTIVE: This study aims to explore the views of members of theater teams regarding the proposed introduction of a workplace-based assessment of nontechnical skills of surgeons (NOTSS) into the Intercollegiate Surgical Curriculum Programme in the United Kingdom. In addition, the previous training and familiarity of the members of the surgical theater team with the concept and assessment of NOTSS would be evaluated. DESIGN: A regional survey of members of theater teams (consultant surgeons, anesthetists, scrub nurses, and trainees) was performed at 1 teaching and 2 district general hospitals in South Yorkshire. RESULTS: There were 160 respondents corresponding to a response rate of 81%. The majority (77%) were not aware of the NOTSS assessment tool with only 9% of respondents reporting to have previously used the NOTSS tool and just 3% having received training in NOTSS assessment. Overall, 81% stated that assessing NOTSS was as important as assessing technical skills. Trainees attributed less importance to nontechnical skills than the other groups (p ≤ 0.016). Although opinion appears divided as to whether the presence of a consultant surgeon in theater could potentially make it difficult to assess a trainee's leadership skills and decision-making capabilities, overall 60% agree that the routine use of NOTSS assessment would enhance safety in the operating theater and 80% agree that the NOTSS tool should be introduced to assess the nontechnical skills of trainees in theater. However, a significantly lower proportion of trainees (45%) agreed on the latter compared with the other groups (p = 0.001). CONCLUSIONS: Our survey demonstrates acceptability among the theater team for the introduction of the NOTSS tool into the surgical curriculum. However, lack of familiarity highlights the importance of faculty training for assessors before such an introduction.

A unit-level perspective on the long-term sustainability of a nursing best practice guidelines program: An embedded multiple case study.

BACKGROUND: Best practice guidelines are a tool for narrowing research-to-practice gaps and improving care outcomes. There is some empirical understanding of guideline implementation in nursing settings, yet there has been almost no consideration of the longer-term sustainability of guideline-based practice improvements. Many healthcare innovations are not sustained, underscoring the need for knowledge about how to promote their survival. PURPOSE: To understand how a nursing best practice guidelines program was sustained on acute healthcare center nursing units. METHODS: We undertook a qualitative descriptive case study of an organization-wide nursing best practice guidelines program with four embedded nursing unit subcases. The setting was a large, tertiary/quaternary urban health center in Canada. The nursing department initiated a program to enhance patient safety through the implementation of three guidelines: falls prevention, pressure ulcer prevention, and pain management. We selected four inpatient unit subcases that had differing levels of program sustainability at an average of almost seven years post initial program implementation. Data sources included 39 key informant interviews with nursing leaders/administrators and frontline nurses; site visits; and program-related documents. Data collection and content analysis were guided by a framework for the sustainability of healthcare innovations. RESULTS: Program sustainability was characterized by three elements: benefits, routinization, and development. Seven key factors most accounted for the differences in the level of program sustainability between subcases. These factors were: perceptions of advantages, collaboration, accountability, staffing, linked levels of leadership, attributes of formal unit leadership, and leaders' use of sustainability activities. Some prominent relationships between characteristics and factors explained long-term program sustainability. Of primary importance was the extent to which unit leaders used sustainability-oriented activities in both regular and responsive ways to attend to the relationships between sustainability characteristics and factors. CONCLUSIONS: Continued efforts are required to ensure long-term program sustainability on nursing units. Persistent and adaptive orchestration of sustainability-oriented activities by formal unit leadership teams is necessary for maintaining best practice guidelines over the long term. Leaders should consider a broad conceptualization of sustainability, beyond guideline-based benefits and routinization, because the development of unit capacity in response to changing circumstances appears essential.

Nursing unit leaders' influence on the long-term sustainability of evidence-based practice improvements.

AIM: To describe how actions of nursing unit leaders influenced the long-term sustainability of a best practice guidelines (BPG) program on inpatient units. BACKGROUND: Several factors influence the initial implementation of evidence-based practice improvements in nursing, with leadership recognized as essential. However, there is limited knowledge about enduring change, including how frontline nursing leaders influence the sustainability of practice improvements over the long term. METHODS: A qualitative descriptive case study included 39 in-depth interviews, observations, and document reviews. Four embedded nursing unit subcases had differing levels of program sustainability at 7 years (average) following implementation. RESULTS: Higher levels of BPG sustainability occurred on units where formal leadership teams used an integrated set of strategies and activities. Two key strategies were maintaining priorities and reinforcing expectations. The coordinated use of six activities (e.g., discussing, evaluating, integrating) promoted the continuation of BPG practices among staff. These leadership processes, fostering exchange and learning, contributed to sustainability-promoting environments characterized by teamwork and accountability. CONCLUSIONS: Unit leaders are required to strategically orchestrate several overlapping and synergistic efforts to achieve long-term sustainability of BPG-based practice improvements. IMPLICATIONS: As part of managing overall unit performance, unit leaders may influence practice improvement sustainability by aligning vision, strategies, and activities.

An organizational perspective on the long-term sustainability of a nursing best practice guidelines program: a case study.

BACKGROUND: Many healthcare innovations are not sustained over the long term, wasting costly implementation efforts and often desperately-needed initial improvements. Although there have been advances in knowledge about innovation implementation, there has been considerably less attention focused on understanding what happens following the early stages of change. Research is needed to determine how to improve the 'staying power' of healthcare innovations. As almost no empirical knowledge exists about innovation sustainability in nursing, the purpose of our study was to understand how a nursing best practice guidelines (BPG) program was sustained over a long-term period in an acute healthcare centre. METHODS: We conducted a qualitative descriptive case study to examine the program's sustainability at the nursing department level of the organization. The organization was a large, urban, multi-site acute care centre in Canada. The patient safety-oriented BPG program, initiated in 2004, consisted of an organization-wide implementation of three BPGs: falls prevention, pressure ulcer prevention, and pain management. Data were collected eight years following program initiation through 14 key informant interviews, document reviews, and observations. We developed a framework for the sustainability of healthcare innovations to guide data collection and content analysis. RESULTS: Program sustainability entailed a combination of three essential characteristics: benefits, institutionalization, and development. A constellation of 11 factors most influenced the long-term sustainability of the program. These factors were innovation-, context-, leadership-, and process-related. Three key interactions between factors influencing program sustainability and characteristics of program sustainability accounted for how the program had been sustained. These interactions were between: leadership commitment and benefits; complementarity of leadership actions and both institutionalization and development; and a reflection-and-course-correction strategy and development. CONCLUSIONS: Study findings indicate that the successful initial implementation of an organizational program does not automatically lead to longer-term program sustainability. The persistent, complementary, and aligned actions of committed leaders, in a variety of roles across a health centre department, seem necessary. Organizational leaders should consider a broad conceptualization of sustainability that extends beyond program institutionalization and/or program benefits. The development of an organizational program may be necessary for its long-term survival.

Orai3 Surface Accumulation and Calcium Entry Evoked by Vascular Endothelial Growth Factor.

OBJECTIVE: Vascular endothelial growth factor (VEGF) acts, in part, by triggering calcium ion (Ca(2+)) entry. Here, we sought understanding of a Synta66-resistant Ca(2+) entry pathway activated by VEGF. APPROACH AND RESULTS: Measurement of intracellular Ca(2+) in human umbilical vein endothelial cells detected a Synta66-resistant component of VEGF-activated Ca(2+) entry that occurred within 2 minutes after VEGF exposure. Knockdown of the channel-forming protein Orai3 suppressed this Ca(2+) entry. Similar effects occurred in 3 further types of human endothelial cell. Orai3 knockdown was inhibitory for VEGF-dependent endothelial tube formation in Matrigel in vitro and in vivo in the mouse. Unexpectedly, immunofluorescence and biotinylation experiments showed that Orai3 was not at the surface membrane unless VEGF was applied, after which it accumulated in the membrane within 2 minutes. The signaling pathway coupling VEGF to the effect on Orai3 involved activation of phospholipase Cγ1, Ca(2+) release, cytosolic group IV phospholipase A2α, arachidonic acid production, and, in part, microsomal glutathione S-transferase 2, an enzyme which catalyses the formation of leukotriene C4 from arachidonic acid. Shear stress reduced microsomal glutathione S-transferase 2 expression while inducing expression of leukotriene C4 synthase, suggesting reciprocal regulation of leukotriene C4-synthesizing enzymes and greater role of microsomal glutathione S-transferase 2 in low shear stress. CONCLUSIONS: VEGF signaling via arachidonic acid and arachidonic acid metabolism causes Orai3 to accumulate at the cell surface to mediate Ca(2+) entry and downstream endothelial cell remodeling.

The sustainability of healthcare innovations: a concept analysis.

AIM: To report on an analysis of the concept of the sustainability of healthcare innovations. BACKGROUND: While there have been significant empirical, theoretical and practical contributions made towards the development and implementation of healthcare innovations, there has been less attention paid to their sustainability. Yet many desired healthcare innovations are not sustained over the long term. There is a need to increase clarity around the concept of innovation sustainability to guide the advancement of knowledge on this topic. DESIGN: Concept analysis. DATA SOURCES: We included literature reviews, theoretical and empirical articles, books and grey literature obtained through database searching (ABI/INFORM, Academic Search Complete, Business Source Complete, CINAHL, Embase, MEDLINE and Web of Science) from 1996-May 2014, reference harvesting and citation searching. METHODS: We examined sources according to terms and definitions, characteristics, preconditions, outcomes and boundaries to evaluate the maturity of the concept. RESULTS: This concept is partially mature. Healthcare innovation sustainability remains a multi-dimensional, multi-factorial notion that is used inconsistently or ambiguously and takes on different meanings at different times in different contexts. We propose a broad conceptualization that consists of three characteristics: benefits, routinization or institutionalization, and development. We also suggest that sustained innovations are influenced by a variety of preconditions or factors, which are innovation-, context-, leadership- and process-related. CONCLUSION: Further conceptual development is essential to continue advancing our understanding of the sustainability of healthcare innovations, especially in nursing where this topic remains largely unexplored.

Advanced practice nursing, health care teams, and perceptions of team effectiveness.

This article summarizes the results of an extensive review of the organizational and health care literature of advanced practice nursing (APN) roles, health care teams, and perceptions of team effectiveness. Teams have a long history in health care. Managers play an important role in mobilizing resources, guiding expectations of APN roles in teams and within organizations, and facilitating team process. Researchers have identified a number of advantages to the addition of APN roles in health care teams. The process within health care teams are dynamic and responsive to their surrounding environment. It appears that teams and perceptions of team effectiveness need to be understood in the broader context in which the teams are situated. Key team process are identified for team members to perceive their team as effective. The concepts of teamwork, perceptions of team effectiveness, and the introduction of APN roles in teams have been studied disparately. An exploration of the links between these concepts may further our understanding the health care team's perceptions of team effectiveness when APN roles are introduced. Such knowledge could contribute to the effective deployment of APN roles in health care teams and improve the delivery of health care services to patients and families.

Leadership for evidence-based practice: strategic and functional behaviors for institutionalizing EBP.

BACKGROUND: Making evidence-based practice (EBP) a reality throughout an organization is a challenging goal in healthcare services. Leadership has been recognized as a critical element in that process. However, little is known about the exact role and function of various levels of leadership in the successful institutionalization of EBP within an organization. AIMS: To uncover what leaders at different levels and in different roles actually do, and what actions they take to develop, enhance, and sustain EBP as the norm. METHODS: Qualitative data from a case study regarding institutionalization of EBP in two contrasting cases (Role Model and Beginner hospitals) were systematically analyzed. Data were obtained from multiple interviews of leaders, both formal and informal, and from staff nurse focus groups. A deductive coding schema, based on concepts of functional leadership, was developed for this in-depth analysis. RESULTS: Participants' descriptions reflected a hierarchical array of strategic, functional, and cross-cutting behaviors. Within these macrolevel "themes," 10 behavioral midlevel themes were identified; for example, Intervening and Role modeling. Each theme is distinctive, yet various themes and their subthemes were interrelated and synergistic. These behaviors and their interrelationships were conceptualized in the framework "Leadership Behaviors Supportive of EBP Institutionalization" (L-EBP). Leaders at multiple levels in the Role Model case, both formal and informal, engaged in most of these behaviors. LINKING EVIDENCE TO ACTION: Supportive leadership behaviors required for organizational institutionalization of EBP reflect a complex set of interactive, multifaceted EBP-focused actions carried out by leaders from the chief nursing officer to staff nurses. A related framework such as L-EBP may provide concrete guidance needed to underpin the often-noted but abstract finding that leaders should "support" EBP.

CE: Original research: the perceptions of health care team members about engaging patients in care redesign.

OBJECTIVE: This study sought to explore the perceptions of health care workers about engaging patients as partners on care redesign teams under a program called Transforming Care at the Bedside (TCAB), and to examine the facilitating factors, barriers, and effects of such engagement. DESIGN: This descriptive, qualitative study collected data through focus groups and individual interviews. Participants included health care providers and managers from five units at three hospitals in a university-affiliated health care center in Canada. METHODS: A total of nine focus groups and 13 individual interviews were conducted in April 2012, 18 months after the TCAB program began in September 2010. Content analysis was used to analyze the qualitative data. FINDINGS: Health care providers and managers benefited from engaging patients in the decision-making process because the patients brought a new point of view. Involving the patients exposed team members to valuable information that they hadn't previously thought about during decision making. CONCLUSION: Health care teams stand to benefit from engaging patients in the change process. Patients contribute a different point of view, and this helps to ensure that the changes proposed and implemented address their needs.

Redefining self: patients' decision making about treatment for multiple sclerosis.

The treatment of multiple sclerosis (MS) has become possible with the advent of disease-modifying therapies, but little is known about patients' experiences when faced with a complex array of treatment options. The purpose of this phenomenological study was to explore the lived experience of making a first decision about treatment with disease-modifying therapies for relapsing-remitting MS. Nine participants shared their perspectives on negotiating the decision to accept, refuse, or delay treatment. All individuals described a core theme in which decision making about treatment was part of a process of coming to a "redefined self." This core theme included reflections about self-image, quality of life, goals, and being a person with MS. Six common themes supporting this core theme were (a) weighing and deciding what's important, (b) acknowledging the illness as part of oneself, (c) playing the mental game, (d) seeking credible resources, (e) evaluating symptoms and fit with quality of life, and (f) managing the roles and involvement of family. The findings of this study provide a greater understanding about the experience of making a therapeutic choice for those with MS and offer insights for nurses when supporting patients faced with options about treatment.

Clinical nurse specialists in Canada: why are some not working in the role?

Clinical nurse specialists (CNSs) are advanced practice nurses. They contribute to the quality and safety of patient care by providing an advanced level of clinical care to patients and families and by supporting healthcare team members to deliver evidence-based care. CNSs help to reduce healthcare costs when the roles are fully deployed and all the dimensions of the CNS role are implemented. The dimensions of the CNS role include clinical care, organizational leadership, research, education, professional development and consultation to provide patient care. There is a paucity of research on CNSs in Canada. We conducted the first Canada-wide survey of CNSs and asked each nursing regulatory body to identify the CNSs in their registration database. One-quarter (n=196/776) of the regulator-identified CNS respondents whom we contacted for the study were no longer or had never been a CNS. Currently, adequate mechanisms are lacking to identify and track CNSs in Canada, and little is known about the factors that influence CNSs' decisions to leave their role. The non-employed CNS respondents in our survey highlighted that the lack of role clarity, their inability to find employment as a CNS and the inability to implement all the dimensions of the CNS role were key factors in their decision not to work as a CNS. These findings have important implications, given that these factors are potentially modifiable and amenable to decisions made by nursing leaders in organizations and regulatory bodies. Mechanisms to identify and track CNSs in Canada are needed to develop an effective workforce plan and maximize the integration of CNSs in the workforce.

The effect of transforming care at the bedside initiative on healthcare teams' work environments.

BACKGROUND: Different initiatives have been implemented in healthcare organizations to improve efficiency, such as transforming care at the bedside (TCAB). However, there are important gaps in understanding the effect of TCAB on healthcare teams' work environments. AIM: The specific aim of the study is to describe findings regarding the TCAB initiative effects on healthcare teams' work environments. METHODS: A pretest and posttest study design was used for this study. The TCAB initiative was implemented in fall 2010 in a university health center in Montreal, Canada. The sample consisted of healthcare workers from four different care units. RESULTS: Statistically significant improvement was observed with the communicating specific information subscale from the measure of processes of care variable, and a significant difference was found between the support from colleagues variable, which was higher at baseline than postprogram. The differences for psychological demand, decisional latitude, and effort-reward were not significant. CONCLUSIONS: TCAB is an intervention that allows healthcare teams to implement change to improve patients' and families' outcomes. Ongoing energy should focus on how to improve communication among all members of the team and ensure their support.

Practice patterns and perceived impact of clinical nurse specialist roles in Canada: results of a national survey.

BACKGROUND: Clinical nurse specialists are recognized internationally for providing an advanced level of practice. They positively impact the delivery of healthcare services by using specialty-specific expert knowledge and skills, and integrating competencies as clinicians, educators, researchers, consultants and leaders. Graduate-level education is recommended for the role but many countries do not have formal credentialing mechanisms for clinical nurse specialists. Previous studies have found that clinical nurse specialist roles are poorly understood by stakeholders. Few national studies have examined the utilization of clinical nurse specialists. OBJECTIVE: To identify the practice patterns of clinical nurse specialists in Canada. DESIGN: A descriptive cross-sectional survey. PARTICIPANTS: Self-identified clinical nurse specialists in Canada. METHODS: A 50-item self-report questionnaire was developed, pilot-tested in English and French, and administered to self-identified clinical nurse specialists from April 2011 to August 2011. Data were analyzed using descriptive and inferential statistics and content analysis. RESULTS: The actual number of clinical nurse specialists in Canada remains unknown. The response rate using the number of registry-identified clinical nurse specialists was 33% (804/2431). Of this number, 608 reported working as a clinical nurse specialist. The response rate for graduate-prepared clinical nurse specialists was 60% (471/782). The practice patterns of clinical nurse specialists varied across clinical specialties. Graduate-level education influenced their practice patterns. Few administrative structures and resources were in place to support clinical nurse specialist role development. The lack of title protection resulted in confusion around who identifies themselves as a clinical nurse specialist and consequently made it difficult to determine the number of clinical nurse specialists in Canada. CONCLUSIONS: This is the first national survey of clinical nurse specialists in Canada. A clearer understanding of these roles provides stakeholders with much needed information about clinical nurse specialist practice patterns. Such information can inform decisions about policies, education and organizational supports to effectively utilize this role in healthcare systems. This study emphasizes the need to develop standardized educational requirements, consistent role titles and credentialing mechanisms to facilitate the identification and comparison of clinical nurse specialist roles and role outcomes internationally.

Part 2: Nurses' career aspirations to management roles: qualitative findings from a national study of Canadian nurses.

AIM: Our aim was to investigate direct-care nurses' interests in formal management roles and factors that facilitate their decision-making. BACKGROUND: Based on a projected shortage of nurses by 2022, the profession could be short of 4200 nurse managers in Canada within the next decade. However, no data are currently available that identify nurses' interests in assuming manager roles. METHODS: Using focus group methodology, we conducted 18 focus groups with 125 staff nurses and managers in four regions across Canada. RESULTS: Major themes and subthemes influencing nurses' decisions to pursue management roles included personal demographic (education, age, clinical experience and life circumstances), personal disposition (leadership skills, intrinsic rewards and professional commitment) and situation (leadership development opportunities, manager role perceptions and presence of mentors). Although nurses see management roles as positive opportunities, they did not perceive the rewards to be great enough to outweigh their concerns. CONCLUSIONS: Findings suggested that organizations need to provide support, leadership development and succession opportunities and to redesign manager roles for optimum success. IMPLICATIONS FOR NURSING MANAGEMENT: Leaders need to ensure that they convey positive images of manager roles and actively identify and support staff nurses with leadership potential.