How Formal and Informal Nurse Leaders Enact Shared Implementation Leadership in a Hospital Setting

ABSTRACT

Aim

To describe how implementation leadership manifests among formal and informal point of care nurse leaders during a successful evidence‐based practice implementation.

Design

A collective case study.

Methods

A conceptual framework on shared implementation leadership guided the study. Two units known for strong implementation were selected as instrumental cases from a healthcare network. Data were collected from multiple sources (2022–2023), including document review, site visits, focus group and individual interviews with formal managerial and non‐managerial nurse leaders, staff nurses, interdisciplinary clinical staff and departmental leaders. The Framework Method was used to thematically analyse within‐case findings, followed by cross‐case comparison.

Results

Nurse leaders in formal and informal roles engaged in collaborative processes to collectively enact leadership behaviours throughout the implementation phases. Change‐, relation‐ and task‐oriented behaviours aimed to foster staff readiness, ensure supportive presence, structure implementation activities and reinforce the use of evidence‐based practices on the units. Collaborative processes fostered leaders' engagement and kept one another informed to align and synchronise their collective actions.

Conclusion

This study extends our understanding of implementation leadership in nursing by highlighting a shared and relational approach among diverse point of care leaders. Strengthening team‐level processes is essential to enhance leadership capacity for implementation in nursing.

Implications for the Profession

Given the global push for innovative, high‐quality healthcare, strong leadership is needed to create conditions for implementation and practice change. This study makes visible how multiple and diverse leaders collectively support implementation.

Impact

With much focus on nurse manager roles, there is a gap in the research showing how multiple point of care leaders facilitate implementation, which this study addresses. This study can serve as a template to assist nurse leaders in their implementation efforts and to advocate for developing diverse nurse leadership roles.

Reporting Method

The report adheres to the COnsolidated criteria for REporting Quality research (COREQ) guidelines.

Patient or Public Contribution

This study did not include patient or public involvement in the design, conduct or reporting.

Trial Registration

International Registered Report Identifier (IRRID): DERRI‐10.2196/54681

Summary.

• What does this paper contribute to the wider global clinical community

  • ○
    This paper demonstrates how diverse nurse leaders at the point of care can collaboratively and collectively drive successful evidence‐based practice implementation prompting a need to develop and strengthen leadership roles in nursing worldwide.

1. Introduction

There is an abundance of research‐informed innovations, products and practice recommendations for healthcare and nursing practice that, when implemented, can successfully lead to more effective, efficient and safe patient care and improved patient outcomes (Connor et al. 2023). However, implementing evidence‐based practices (EBPs) in acute care settings is challenging and requires navigating a complex and dynamic context shaped by patients' multifaceted needs, limited resources, variability in nursing's availability and skill levels, and the critical role of effective teamwork in adopting new practices (Huber et al. 2021).

Implementation leadership (IL) refers to a strategic and effective leadership approach by point of care (POC) leaders for supporting implementation of EBPs, and is a contextual process that has gained significant attention in the last decade within healthcare literature for promoting implementation success (Aarons et al. 2024). To date, IL in healthcare has predominately been described in relation to individual managerial roles at the POC (Castiglione 2020), despite the reality that nursing leadership in hospital settings often involves multiple formal and informal leaders working together across unit‐level operations. This leadership dynamic remains underexplored in the literature but is essential to understand for effective IL development in nursing.

2. Background

IL encompasses effective macro and micro‐level behaviours of POC leaders that contribute to the successful implementation of EBPs (Castiglione 2020; Gifford et al. 2017). In a systematic review of 31 studies examining leadership in support of research use across multiple settings, managers engaged in behaviours that enforced and enabled change with the most frequent behaviours being supporting change, communicating with staff, building coalitions with interprofessional colleagues, supporting learning and participating in implementation planning (Gifford et al. 2018). These behaviours align with the notion of managers, including nurse managers (NM) roles as ‘gatekeepers for EBP’ (Harvey et al. 2020, 60) and support the importance of developing NMs to be knowledgeable of processes, determinants and strategies to lead implementation efforts.

In some western countries such as Canada, nursing leadership on inpatient units may also be characterised by distinct leader positions that include formal leaders in both managerial positions and non‐managerial positions, each with expectations for promoting EBPs and their implementation. For example, Advanced Practice Nurses, including roles such as Clinical Nurse Specialists (CNSs) and Nurse Practitioners (NPs), are required to demonstrate competence in knowledge translation, evaluation and quality improvement (Jokiniemi et al. 2023) and to participate in knowledge management processes including synthesis and dissemination of research evidence (Cave et al. 2023). Similarly, Nursing Professional Development Practitioners (Educators) are expected to develop innovative interdisciplinary and nursing staff training, support role and practice transitions, create learning‐centered environments and act as change agents (Brunt and Bogdan 2024). While studies on Assistant Nurse Manager (ANM) roles are lacking, these individuals are also known to closely support nursing practice and participate in the evaluation of care activities. In additional to formal leaders, informal leaders who are recognised for their clinical competence on the unit, may be referred to a champions and exert social influence through role modelling and advocacy, actively engaging in the implementation process (Morena et al. 2022).

Although multiple nursing leaders at the POC have responsibilities related to supporting implementation and leading change, the theoretical conceptualization of IL have predominantly centered on NMs (Castiglione 2020). Similarly, IL scales (e.g., the Implementation Leadership Scale) have been validated exclusively with NM populations (Castiglione et al. 2023), thereby overlooking the broader spectrum of formal nursing leaders roles at the POC. Consequently, empirical literature has largely focused on the impact of IL by NMs (Boehm et al. 2022; Hsu et al. 2024; Shuman et al. 2023), with minimal attention to formal non‐managerial and informal leaders in nursing. This narrow focus limits our understanding of how IL is enacted across diverse nursing roles. A notable exception is a study by Ronquillo et al. (2023), which examined the IL behaviours of POC leaders including NMs, Educators and charge nurses and their influence on both the intention and actual use of mHealth innovations by nursing staff. This work highlights the need to explicitly explore how multiple leaders contribute to IL processes on inpatient units, signalling an important gap in the current literature.

The interpersonal social processes among diverse nurse leaders may also influence how IL manifests on acute care units; however, research on this has been limited. In one study, mutual engagement and reciprocal support between managers and internal facilitators either enabled or hindered implementation progress (van der Zijpp et al. 2016). Other studies noted that interdependence among diverse nursing leaders in applying implementation strategies and leveraging specific knowledge and networks, with a sense of cohesion and collaboration may contribute to positive implementation outcomes and sustainment of EBPs (Duff et al. 2020; Fleiszer et al. 2016). In a study determining the feasibility of an IL development strategy in nursing, NMs expressed a preference for collaborating with others in their care area to develop implementation plans (Gifford et al. 2019). These studies suggests that relational processes among leaders in leading implementation are important for task sharing and successful implementation outcomes. Moreover, some authors recommend that effective leadership in nursing requires team‐based facilitation composed of managers, internal facilitators and staff to support implementation and to create environments conducive to EBP (Eldh et al. 2023). The development of an implementation support team is often cited as a critical strategy at the outset of implementation but even this remains understudied in literature (McGuier et al. 2023). Given that formal nurse leaders in inpatient units are known as ‘nursing leadership teams’, exploring the social processes among these leaders as they support implementation is an important starting point and essential to a contextual understanding of IL (Bartley et al. 2022).

To date, no study has provided a rich description of IL behaviours enacted by diverse formal and informal nurse leaders at the POC and how these leaders work together to support implementation. Therefore, a deeper understanding of how nurse leaders at the POC share IL behaviours is needed to evolve the concept of IL in nursing.

3. The Study

The aim of this study was to describe how IL manifests among diverse nurse POC leaders over the course of a successful EBP implementation project on two inpatient hospital units. More specifically, this study answered the following questions: (1) What specific IL behaviours are enacted and shared by multiple nurse leaders? and (2) What social processes enabled sharing of IL behaviours?

4. Methodology

4.1. Design

We adopted a qualitative collective case study approach (Stake 2006). This research is situated within a constructivist paradigm as it expands the view of leadership from a function of hierarchical leader roles to a process that emerges from social relationships and is influenced by context. This case study allowed us to learn about the nuanced and complex ‘happenings’ or manifestation of a new concept called ‘shared IL’ in nursing, as it was experienced across two unique cases: Two inpatient hospital units with diverse clinical missions, EBPs implemented and POC nurse leaders supporting implementation (Stake 2006). The study methods and conceptual framework are fully described elsewhere (Castiglione et al. 2024). The Consolidated Criteria for Reporting Qualitative Research guided the reporting (Appendix S1) (Tong et al. 2007).

4.2. Conceptual Framework

To explore IL as a process among multiple and diverse leaders, we developed a framework (Castiglione et al. 2024), which introduced a lens of shared leadership to build on the meta‐categories of effective behaviours described in the Ottawa Model of Implementation Leadership (OMILe) (Gifford et al. 2017). Derived from empirical research in nursing in long‐term care centres, this model provides a theoretical basis from which to measure and develop IL. The OMILe characterises the behaviours necessary for successful implementation as change‐oriented (promoting change), relation‐oriented (providing support) and task‐oriented (facilitating task completion). Enacting IL requires leaders to possess the requisite knowledge and skills in transformational and transactional leadership styles, and the ability to apply implementation science theory to actionable plans (Gifford et al. 2017). Shared leadership is ‘a dynamic, interactive influence process among individuals in groups for which the objective is to lead one another to the achievement of group or organisational goals or both’ (Conger and Pearce 2003, 1). It diverges from the 'strong man theory of leadership that attends to the personal attributes, achievements and hierarchical authority of an individual, to a process of mutual influence and collective action within a team (DeRue and Ashford 2010). Applying a shared leadership lens to IL, to be referred to hereafter as ‘shared IL’, responds to calls to expand views of leadership for change as a relational process rather than as designated from individuals in specific roles of authority (Ford et al. 2021).

4.3. Case Selection and Recruitment

The case was defined as an inpatient unit where multiple and diverse POC nurse leaders supported the successful implementation of an EBP. Cases were selected from a large university‐affiliated healthcare network in Montreal, Canada, and bounded spatially by physical location, purposefully by clinical mission and temporally by implementation phases including exploration (evaluate need for change and explore EBPs), preparation (planning for implementation) and implementation (use of EBP) (Moullin et al. 2019).

Case selection occurred between February and August 2022. We employed maximum variation purposive sampling to select cases that met the following inclusion criteria: An EBP successfully implemented in the past 18 months; POC leaders that minimally included a formal managerial and non‐managerial leader; and feasibility of access to key informants and documents on the unit (Stake 1995). The selection of the second case was informed by early findings from the initial case to ensure variation in context. We identified two cases (Cases A and B) by ranking potential units in consultation with nursing practice advisors at the organisation.

4.4. Data Sources and Generation

In each case, we employed diverse data sources and generation methods to enable triangulation of the data and to view shared IL from multiple perspectives (Stake 2006). Data saturation consisted of an ongoing process where data generation ended when we perceived that a sufficient breadth of perspectives and ‘depth of understanding has been achieved’ in relation to the emerging categories within each case (Saunders et al. 2018, 1901). The data generation phase took place from June 2022 to December 2023.

4.4.1. Key Informant Interviews

We conducted focus groups and individual interviews with key informants, starting with formal POC nursing leaders. Using a purposive snowball sampling technique from interviews and document reviews, we identified additional key informants who had observed or interacted with leaders during implementation or who had significant involvement in the implementation. Departmental‐level nursing leaders and POC leaders (with no supervisory authority) approached potential participants via email with study information. SAC met with interested participants to answer questions about the study, then arranged interviews and sent participants a link to complete the sociodemographic questionnaire. A total of 25 key informants participated in the study: 12 in Case A and 13 in Case B (with one participant involved in both cases). The key informants comprised 12 POC nurse leaders in diverse formal roles, six staff nurses (one considered an informal leader for implementation), three interdisciplinary professionals, and four departmental leaders. Key informant characteristics varied by case (Table 1).

TABLE 1.

Key informant characteristics.

Characteristics		Case A	Case B
Key informant type	POC formal nurse leader	4	8
	POC informal nurse leader	1	0
	Additional key informants a	7	6
Job title	Manager	4	4
	Advanced practice and clinical support	2	5
	Bedside nurse	3	3
	Departmental leader a	3	2
Range of years in job title		2.5–10	1.5–22
Profession	Registered nurse (RN) a	10	13
	Allied health professional	2	1

^a The same key informant participated in both cases.

SAC conducted all the semi‐structured interviews. For focus groups, SES was present as an observer. The interviews were held either virtually or in person on the unit (due to changing COVID‐19 protocols) and lasting between 40 and 61 min. SAC had previous experience conducting qualitative interviews over the course of 15 years. A semi‐structured interview guide was designed to address the research questions, incorporating prompts and flexibility to support an emic perspective. The guide was pilot tested with two nurses not involved in the case units: One currently employed within the healthcare network and the other recently retired from it. Prior to the first interview, we reviewed documents received to date and highlighted key activities, which enabled us to nuance questions and prompts according to the details of the case.

Focus groups were initially organised with all formal unit leaders together to develop an initial understanding of the case. The focus group also served to refresh leaders' recollections of the implementation project details. Emerging themes, issues requiring clarification and ideas for further inquiry were noted during the interviews and recorded in detailed descriptive fieldnotes immediately afterward. Subsequent individual interviews with key informants further explored these issues in greater depth, building on the focus group data (Lambert and Loiselle 2008).

A total of 26 individual interviews (12 for Case A and 14 for Case B) were conducted with all participants. Potential informants were unable to participate due to various reasons: Inability to comment on shared IL (2), time constraints (1), and on leave (2). An additional individual interview was conducted with one participant to explore a facet of their experience not sufficiently discussed in the first interview. Each unit had one additional focus group conducted with formal POC leaders to validate constructed themes. All interviews were audio‐recorded and transcribed. We offered participants to review their transcripts; three accepted and provided minor feedback.

4.4.2. Document Gathering and Review

SAC collected and summarised relevant documents from key informants, organisational databases, and site visits using an intake form. Out of 227 documents reviewed, 175 were retained (53 in Case A and 118 in Case B), including emails, meeting invitations and summaries, clinical practice tools, training materials, patient‐oriented documents, staff surveys, reports and attendance records. Follow‐ups with key informants were conducted to clarify or obtain missing information.

4.4.3. Site Visits

The visits, conducted by SAC, lasted approximately 120 min for Case A, and 30 min for Case B involved a tour of the unit, highlighting leader offices, storage locations for EBP‐related materials, and areas where implementation activities and leadership processes took place (e.g., patient rooms, meeting alcoves). SAC also observed specific activities reflective of events mentioned in interviews or documents (such as a nursing team quality huddle and discharge teaching) and engaged in numerous informal conversations with individuals at the sites during the visits and on other occasions. Observations were recorded through free form jottings, sketches and photographs, which were later used to develop detailed textual fieldnotes.

4.4.4. Fieldnotes

Sixty‐one descriptive fieldnotes entries were generated by SAC immediately following formal site visits, interviews, and other interactions with key informants or other individuals throughout the study.

4.5. Data Analysis

We conducted a within‐case thematic analysis for each case followed by a cross‐case analysis, where cross‐case themes of shared IL behaviours and social processes were developed (Stake 2006). We overlapped the data analysis of one case study with the data generation of the second case, while maintaining a holistic view of each case.

4.5.1. Within‐Case Analysis

Thick case descriptions were constructed for each case to narrate the chronological events and participant experiences of shared IL in context. Data were organised and analysed using the Framework Method (Klingberg et al. 2024). An initial thematic framework was developed from a priori elements of the conceptual framework for shared IL. For Case A, SAC and two senior researchers (MLT & SES) with qualitative research experience independently read the first focus group transcript, along with the fieldnotes and interview guide associated with this focus group, annotating impressions and recurrent ideas related to the research questions. In a second round, we individually assigned codes under the IL behaviours and social processes categories to the data. Coming together, we then refined the thematic framework based on a discussion of the strengths and challenges of applying the framework, noting any data not categorised but benefiting from a new category. IL behaviour codes were determined using a combined deductive and inductive approach based on the existing meta‐categories within the OMILe, whereas codes for social processes were mostly derived inductively. SAC created the initial coding framework in NVivo 14 for Mac, uploading all data (e.g., transcripts, documents and fieldnotes). The framework was iteratively refined as it was applied to additional data. SAC grouped codes into existing behaviour categories or new social processes, summarised sections of data and linked categories to original data in a matrix for discussion. Integration of different data sources was noted in analytic memos, highlighting patterns that contributed to supporting the existing and emerging themes, particularly regarding shared IL as a process and the evolution of behaviours and interactions across implementation phases. These patterns were compared to the original conceptual framework for shared IL, then refined and named in relation to the research questions through regular discussions with the research team. The resulting thematic framework was applied to the analysis for Case B, with flexibility to allow for new codes and categories to be added. Finally, in‐depth reports were generated to tell a story of how shared IL manifested in each case.

4.5.2. Cross‐Case Analysis

This analysis involved a recursive process with several outputs to maintain a balance between the richness of individual cases and understanding shared IL as a whole (Stake 2006): Analytic memos were created to track ideas from revisiting case reports; a thematic clustered matrix was developed, detailing themes across cases; and a high‐level visual representation of shared IL was also drawn and re‐drawn to highlight themes and subthemes. Through an iterative process of moving between the visual abstract, analytic memos and the matrix, SAC collapsed and summarised themes that were most prominent across cases and which supported a better understanding of shared IL. Key themes on IL behaviours and social processes were summarised narratively. Additionally, cross‐case behaviours described by leader type and implementation phases were tabulated to highlight similarities and differences between cases.

4.6. Ethical Considerations

Ethics approval was obtained on February 24, 2022. Throughout the study, we maintained both explicit and implicit consent processes for participant involvement (Klykken 2022), including written and oral information about the study and regular check‐ins with participants prior and during data generation activities. Participants were instructed to maintain confidentiality of focus group content. Data was anonymized by assigning numerical codes to participants and redacting any identifying information. Being cognizant of the potential for deductive disclosure in the reporting of case studies, we reviewed this manuscript to minimise identifying information.

4.7. Rigour and Reflexivity

Examples of strategies we employed to ensure trustworthiness (Guba 1981), and adherence to Stake's (1995) criteria for good case reporting are described in Table 2.

TABLE 2.

Strategies for study rigour.

Criterion	Strategy
Credibility	Included two cases Used multiple sources of data and in sufficient numbers Used multiple data generation methods Worked to foster a trusting researcher‐participant relationship Substantiated emerging themes and understanding of each case as a whole with participants Debriefed with research team
Dependability	Published research protocol and documented adaptations made to initial plan Created memos to capture dynamic analytical interpretations
Confirmability	Wrote reflexive memos and stated researcher positionality influence on research process Integrated feedback from senior qualified researchers on interview methods Included raw data (e.g., quotations, documents) in report
Transferability	Defined case and case boundaries Selected cases with contextual variations in POC leaders, unit mission, change source (top‐down/unit‐based) Provided detailed description of findings highlighting similarities and differences in cases

5. Findings

Cases represented adult inpatient units with care missions for internal medicine (A) and surgical (B) patients. Case characteristics are described in Table 3, while a chronological account of the main events during implementation are described in Appendix S2. The unit in Case A was located across two wings of a floor in the health network, while the unit in Case B spanned one wing. Both cases successfully implemented EBPs (A: High flow oxygen therapy‐aka ‘AirVo’; B: Discharge teaching process for patients with newly implanted Left Ventricular Assist Device (LVAD)).

TABLE 3.

Case characteristics.

Case	A	B
Mission	Internal Medicine	Cardiac Surgery
Location	Unit spanning two wings of a health network hospital Six care pods and nursing stations 57 inpatient beds	Unit spanning one wing of a health network hospital Three care pods and nursing stations 36 inpatient beds +2 overcapacity beds
EBP	High flow oxygen therapy for COVID‐19 patients	Discharge teaching process for patients with newly implanted LVAD
Aim	To implement the use of high flow oxygen therapy, ‘AirVo’, in a non‐critical care unit	To improve and streamline the discharge teaching process
Circumstances prompting implementation	Severe shortage of critical care beds Mitigation strategies to divert patients requiring advanced respiratory support to non‐critical care units Emerging evidence during pandemic that prolonged high flow oxygen therapy improved COVID‐19 patient outcomes and reduced need for more invasive therapy High flow oxygen was available in critical care units and administered by RRTs only	Patients living with LVAD have a challenging rehabilitation and discharge journey due to amount and complexity of information to monitor and maintain the device Unstructured discharge process which was overwhelming for staff and patients Need for an overhaul in the content and coordination of patient education from multidisciplinary healthcare professionals
Impetus for implementation	Emergency measures coordination committee Top‐down profile	NM Unit‐based profile
Target group	Unit staff nurses (~55)	Unit staff nurses (~65) who had LVAD training, Cardiac NPs, interdisciplinary staff including perfusionists, intensivists and cardiac surgeons
Expected practices	Determine indication for patient admissibility and therapy initiation Manage AirVo machine following initiation Conduct frequent and regular assessments of patient's respiratory status including early warning signs (deterioration) Maintain care activities for patient on AirVo Respond to early warning signs by contacting RRTs/physicians, adjusting the machine parameters and continuous monitoring	Support patient use of iPad to view educational videos Provide new educational content to patients; review and reinforce teaching already provided over the course of admission until discharge Complete interdisciplinary teaching checklist
Indicators of implementation success	Implementation process perceived as smooth and successful by unit and organisational leaders Majority of staff were trained Staff felt supported and prepared, minimal resistance Efficient use of leaders' time (perceived by organisational leaders)	Majority of staff were trained Perceived and measured improvement in patient and family readiness for discharge Positive staff perception on the new tools Increased staff perception that roles and responsibilities for the discharge process were clear and coordinated among interdisciplinary team members Increased perception of strong communication between team members
Project timeline	December 2020–March 2021	September 2021–January 2023
Formal POC leaders	Managerial leader (3) NM (1) ANM (2) Non‐managerial leader (1) Educator	Managerial leaders (3) NM (1) ANM (2) Non‐managerial leader (6) Educator (1) CNS (1) NP (4)

Abbreviations: ANM, Assistant Nurse Manager; CNS, Clinical Nurse Specialist; COVID‐19, Coronavirus Disease 2019; CP, Clinical Perfusionist; Educator, Nursing Professional Development Practitioner; LVAD, Left Ventricular Assist Device; NM, Nurse Manager; NP, Nurse Practitioner; RRT, Registered Respiratory Therapist.

The types of POC leaders involved in implementation (formal, informal, managerial, non‐managerial) varied across the two cases. In both Case A and Case B, the managerial leaders included one NM and two ANMs, all of whom were assigned exclusively to their respective units. The non‐managerial leaders had broader roles, with responsibilities extending beyond the case units, except for the Educator in Case B, who was assigned solely to that unit. For instance, in Case A, the Educator was normally assigned to the unit but had been temporarily redeployed to support another inpatient unit during the COVID‐19 pandemic. In Case B, the NPs specialised in cardiac care and followed patients across their care trajectory, including the inpatient unit. Similarly, the CNS held a transversal role within the department's surgical mission, with the surgical unit being one of several areas under their responsibility.

Two main themes and their subthemes emerged from the cross‐case analysis, addressing the research questions: Collective IL Behaviours and Collaborative Team Processes. The themes and subthemes are elaborated in the text below. (Note: ‘staff’ refers to nursing and interdisciplinary clinical staff).

5.1. Theme 1: Collective IL Behaviours

This theme describes the IL behaviours enacted and shared by POC leaders to support implementation and adoption of the EBPs, and includes three subthemes: Change‐oriented, relations‐oriented and task‐oriented behaviours (Table 4). Each subtheme included categories of macro‐level behaviours. These, as well as examples of micro‐level behaviours under each category are detailed in Table 5 and elaborated further in the subsequent text. Leaders engaged in behaviours within and across unit boundaries, through direct staff interactions and indirect actions that prepared the unit environment for change. Behaviours were enacted across exploration, preparation and implementation phases and enacted by more than one leader across all behavioural categories.

TABLE 4.

Cross‐Case Theme 1 description, subthemes and categories.

Theme 1
Collective implementation leadership behaviours
Change‐oriented behaviours	Relation‐oriented behaviours	Task‐oriented behaviours
Leaders fostered staff readiness	Leaders ensured supportive presence	Leaders structured implementation activities and reinforced the use of the EBP
Conveyed importance for change Reassured and assuaged staff concerns Engaged staff in change process	Mobilised support Checked‐in with staff Provided instrumental support	Adapted EBP tools Planned for implementation Organised and managed training Procured resources Reinforced the new practice Disseminated information about implementation beyond the unit

TABLE 5.

Detailed description of case‐based implementation leadership behaviours enacted by nurse leaders across implementation phases.

Implementation leadership behaviours	Leader type Case A				Leader type Case B					Implementation phase Case A			Implementation phase Case B
	NM	ANM (1,2)	Educator	Staff leader	NM	ANM (1,2)	Educator	CNS	NP	Exploration	Preparation	Implementation	Exploration	Preparation	Implementation
Change‐oriented behaviours
Conveyed importance for change
Presented change as a matter of urgency
Presented evidence indicating need for change
Set an example for staff
Encouraged staff to attend training
Attended meetings and training events about the change with staff
Reassured and assuaged Staff Concerns
Introduced change early and slowly
Addressed concerns right away
Empathised with staff
Reframed fears so staff view the change positively
Created safe patient assignments
Engaged staff in change process
Reached out to staff to hear their perceptions about the need for change
Sought staff feedback on tool development
Kept staff abreast of information, updates, and activities
Thanked staff for their participation
Relation‐oriented behaviours
Mobilised support
Arranged own schedules to be present on the unit
Negotiated support plan with interdisciplinary team
Brokered answers to staff questions
Advocated for staff when support needs were not met
Checked‐in with staff
Prompted staff for questions
Observed staff to provide feedback
Provided instrumental support
Assisted staff in preparing materials and equipment
Modulated support based on needs and unit circumstances
Problem solved issues
Task‐oriented behaviours
Adapted EBP Tools
Consulted research and standards for practice
Proposed changes to existing tools based on adopter feedback
Managed drafts and versions of EBP tools
Formatted documents to organisational standards
Planned for implementation
Assessed the need for the change
Considered current capacity and resources to implement
Modified barriers to implementation
Organised and managed training
Scheduled training dates
Created assignments to liberate staff for training
Integrated educational materials into resource and orientation binders
Provided training
Procured resources
Applied for funds for technology
Ordered printed materials, documentation and equipment to store on the unit
Requested creation of specific education materials for staff
Reinforced new practice
Prompted staff through verbal and visual reminders
Revisited EBP in ongoing training activities on the unit
Integrated EBP tools in clinical rounds and decision‐making for admission and discharge
Disseminated information beyond the unit
Signalled readiness for implementation to interdisciplinary team and organisational leadership
Provided details on implementation progress
Communicated location of stored materials for EBP

5.1.1. Change‐Oriented Behaviours

In the exploration and planning phases, all leaders in both cases enacted behaviours that fostered staff readiness to adopt the EBP. Leaders balanced conveying importance for change to staff, with creating conditions for staff's concerns to be reassured and assuaged, and engaging staff in the change process. They communicated the EBP priority through implicit and explicit messaging. For example, in Case A, the ANM for the side of the unit that was not going to receive patients on AirVo still attended the training, conveying a strong message: ‘She attended the teaching because it was important to show the nurses who may not themselves have these patients that this is really important, and you have to come to this. This matters now’ (102, FG). In Case B, the CNS and NM presented data to staff on the need for change.

Leaders created space to hear and attend to staff concerns, addressing fears about adopting the EBP. This was enacted primarily by NMs in both cases, and the Educator in Case A and CNS in Case B. Behaviours included introducing the change early to give staff time to adjust (Case A), empathising with their concerns, answering questions and addressing concerns on the spot. In both cases, staff were mostly apprehensive about the perception of added responsibilities to already high workloads. For example, in Case A, in response to staff worries about the high‐level of acuity of patients on AirVo, the ANM created safe patient assignments and leaders clarified that only patients with a certain level of acuity would be admitted to the unit with 24‐h support provided by a Registered Respiratory Therapist (RRT). In both cases, staff felt that leaders heard and acted on their concerns.

Leaders actively engaged staff throughout the change process, keeping them informed, regularly soliciting their experiences and feedback and thanking them for their participation in the process. This engagement was particularly evident in Case B where leaders had more control over the project timeline, allowing for greater staff involvement in the development of a new discharge tool and process. Staff reported feeling more committed to the EBP due to this engagement:

We were involved in creating it. I think that also helped with the uptake or the understanding. It's not just another piece of paper that we have to fill out. It was really coined as this multidisciplinary teaching sheet. So we're all on the same page. (209, Int)

5.1.2. Relation‐Oriented Behaviours

In the implementation phase, leaders ensured supportive presence by mobilising support so that it was visible and continuous to staff as they adopted the EBP. This was particularly vital in Case A, where the increase in patient volume and acuity heightened staff anxieties. Leaders arranged their schedules to be present on the unit and negotiated additional support with RRTs to ensure staff had access to resources on evenings and weekends. In both cases, leaders sought quick answers to questions that they could not respond to themselves and advocated for staff when support needs were not met, for example when staff reported that the RRT did not respond to requests for support. Leaders checked‐in with staff regularly, prompting them for any questions they may have about the EBP, observing staff while engaging in the EBP and offering feedback to improve their performance.

Leaders, in particular the ANM and Educator provided instrumental support during implementation based on immediate staff needs by assisting with the preparation of materials and equipment required for the EBP prior to a patient arrival on the unit and helping to problem‐solve issues. Leaders also modulated their level of support by engaging in behaviours ranging from providing direct assistance such as coaching staff at the bedside or taking over patient care in Case A, role modelling discharge education with patients in Case B, to empowering staff to take initiative, which in both cases, consisted of prompting, nudging, and encouraging staff to manage on their own. This ANM describes how leaders tried to promote staff autonomy with the EBP through these behaviours:

And we try to responsiblize [sic] [staff] as well. So if it's a question that they can also find out the answer we'll give them the cues to get the right answer, to lead them in the right direction, but not to do it for them type of thing. (203, Int)

5.1.3. Task‐Oriented Behaviours

Across all implementation phases, leaders (except for informal leaders in Case A), operationalised implementation by engaging in behaviours that structured implementation activities and integrated the EBP into routine care through the accomplishment of specific tasks. Structuring activities included planning for implementation, organising and managing training for staff, and procuring resources from within and external to the organisation such as materials (Case A: Specialised saline bags), technology (Case A: AirVo machine; Case B: iPads) and forms (Case A and B: Documentation tools). Integration activities included adapting EBP tools and reinforcing the new practice in unit routines for example by using verbal and visual reminders, and revisiting the EBP in ongoing training activities on the unit. Leaders, and in particular the NM, Educator and those in advanced practice roles disseminated information about implementation beyond the unit as a way to reinforce the relevance of the implementation and EBP within the broader organisational context.

5.2. Theme 2: Collaborative Team Processes

This theme describes the social processes that enabled the collective enactment of IL behaviours. Two subthemes emerged that describe the collaborative interactions among leaders: Fostering Leader Engagement and Keeping One Another Informed (Table 6). Leaders aligned and synchronised their efforts to collectively enact IL behaviours. Yet, their collaboration appeared to be largely intuitive, suggesting that they shared strong internalised and tacit understanding of their roles and how they collectively supported implementation. This tacit knowledge was particularly evident in Case A where accounts of their interactions were recalled primarily from collective memory and only infrequently captured in communication records or other documentation.

TABLE 6.

Cross‐Case Theme 2 description, subthemes and categories.

Theme 2
Collaborative team processes
Fostering leader engagement	Keeping each other informed
Leaders maximised their individual and collective influence	Leaders collectively stayed on top of implementation
Capitalised on each leader's unique contributions Coordinated behaviours Clarified and distributed tasks and responsibilities	Exchanged perspectives and information Made shared decisions Followed up

Leaders self‐identified as a ‘team’ when discussing their interactions during implementation, referring typically to the formal nurse leaders at the POC. However, it is important to note that when prompted, leaders described that team membership changed depending on the implementation activities. For example, ‘team’ expanded to include staff and interdisciplinary members, especially during the preparation phases when broad perspectives were sought to inform tool adaptations. ‘Team’ contracted in reference to times of providing staff support, especially during the active implementation.

5.2.1. Fostering Leader Engagement

Leaders capitalised on each other's experience, knowledge, connections and expertise to maximise their individual and collective leadership in support of implementation. This was viewed by participants as essential for resolving issues, attuning to the situation, navigating implementation and accessing key individuals both inside and outside the organisation who could provide resources and information. Capitalising was dependent on leaders' awareness of their own and each other's strengths, personalities and workstyles to solve problems. In Case A for example, the NM highly valued the ANM's critical care background and her perception of whether staff could develop the necessary capabilities to care for more acute patients. In addition, leaders sought out the perspectives of those with closer proximity to staff to be better attuned to the reality on the unit, such as informal leaders (Case A) or the ANM who worked closely with staff day‐to‐day. Leaders also recognised their own limitations and sought specific leaders to support their own work, such as the CNS in Case B consulting with the other leaders to identify key stakeholders for feedback on the tool: ‘[The NM] obviously and the others helped me identify in terms of the NP, perfusion, PT/OT, nutrition and pharmacists.’ (204, FG).

Leaders used coordination strategies to organise one another, align implementation efforts and catalyse leaders into enacting specific IL behaviours. For example, the Educator in Case A recounted the information given to her so that she could organise training and support for the nurse on the unit:

So, [ANM] would let me know [about] any patient who was going to need AirVo. That we would be getting them soon, where the patient would be assigned, who the nurse was that was going to be assigned to the patient and what kind of support that nurse needed. (102, Ind)

In Case B, the CNS sent leaders emails that included summaries of the implementation progress to date and reminders to complete specific tasks for set deadlines (e.g., providing feedback on the discharge teaching checklist). In other situations, the NMs instructed specific leaders to take action to enhance shared accountability for achieving implementation goals. This is illustrated by a quote from the ANM in Case B:

[NM] asked me from time to time ‘did you remind the nurses?’ because sometimes when she checks it's not signed, and the patient was there for a week or so. I do remind them, sometimes they don't do it. So, I just keep reminding them. And then I go back to them, you know, ‘[NM] wasn't happy with whatever you didn't do’ and then [NM] comes to me and ‘Oh whatever you did, it worked well.’ (202, Int)

Clarifying and distributing tasks and responsibilities was another way leaders engaged one another. In both cases, leaders assigned or delegated specific tasks to one another that included checking in on a nurse for support and contacting key stakeholders for feedback on the protocol (Case A) or checklist tool (Case B). In Case B, task distribution often involved the CNS itemising task assignments during the development of the teaching checklist. At other times task distribution was implicit, relying on each leader's understanding of their roles, as described by the NM in Case A:

So, [Educator] said the nurses need to learn how to change the bag for the humidity. OK. So, to do that, we had to have the bags. We didn't have those bags previously, right, cause we never had AirVo. The bags had to be present on the unit somewhere. And the teaching for the nurses that they were there and how accessible they were, and they could change it…that's [Educator]'s element. I don't have to tell her that, she didn't have to tell me that. (101, Ind)

Open discussion helped clear up any confusion regarding task assignments, as explained by the Educator in the focus group for Case A:

I think if there is a question of well, ‘what is this, should I be doing this? Should you be doing this?’ Then there's a question that follows: ‘Are you going to handle this or do I?’ [ANM vocalizes agreement]. I think [ANM] said it perfectly, if something is unclear as to whose role this is [ANM vocalizes agreement] there's a quick conversation and ‘Ok, you're going to take care of it? Great’ I'm off! [ANM laughs]. (102, FG)

Clarifying and distributing tasks and responsibilities to engage leaders on the unit was viewed in both cases as a survival tactic, navigating the complexities of EBP implementation: ‘You have to do that to survive. You can't all be doing the same thing then the other parts of the puzzle get neglected.’ (101, FG).

5.2.2. Keeping One Another Informed

Leaders exchanged information and perspectives to strengthen both individual and collective support for the implementation process. During the exploration phase, leaders proactively sought each other out to better understand the factors influencing implementation success within the unit. In both cases, the NMs consulted with the ANMs and Educators for their perspectives on the current state of practice and to identify any competing priorities that could potentially hinder the implementation process. This feedback was essential for the NMs to make informed decisions about whether to proceed with implementation, as explained by the NM in Case B:

For me, it was to see if my understanding of the fact that there's many people involved in, that it's not always clear where the patient is [in the discharge process], if they kind of agreed and saw it too, since they're more at the front line‐ I'm a bit more removed, but that was my observation. So I wanted to kind of confirm that my observation was accurate and that [implementing a new discharge process] was worth it to pursue. (201, FG)

Information sharing among leaders initiated shared decision‐making around planning for implementation and anticipating potential setbacks. Leaders engaged in brainstorming sessions, discussing their perspectives and experiences through open discussions, email exchanges or targeted requests, like for example, in Case B, when the CNS approached the NP to draw on their specialised medical knowledge and familiarity with the patient population. This dialogue facilitated leaders' ability to adapt implementation plans based on their collective understanding of the situation on the unit, ultimately benefiting the staff. As noted by a staff member in Case B, these types of conversation among the leaders on the unit were a fundamental aspect of the implementation process:

[NM] got the information. She didn't necessarily show up to the huddle and announce ‘Hey, we're doing AirVo’. So there's definitely a discussion in the leadership team about implementing something new, how we can do it, when you should start it, how can we do this to ease it into our nursing practice, so it doesn't feel like something impossible for the staff to do. (112, Int)

Throughout the active implementation phase, leaders regularly followed up to keep each other informed about the progress of implementation, unit‐based implementation activities and external decisions that could impact this process. This ongoing communication helped them collectively assess whether their strategies were achieving implementation goals. For example, leaders kept each other up to date about the number of staff reached in training, updates on the formalisation of the protocol and teaching checklist, the number of patients on the floor requiring the EBP, and any issues with EBP. Following up was a regular activity involving both formal and informal leaders:

I mean during the process, we always like have some other meetings to say how it's going, how the [nursing team] is responding well to the machine, are they like, OK with the info that got, are they OK to find out how to reach the RT when they have an issue, stuff like that. So we always have follow up meetings. (103, Ind)

6. Discussion

The aim of this study was to describe how IL manifests among diverse POC nurse leaders during a successful EBP implementation project on two inpatient hospital units in a large university‐affiliated healthcare network. Our findings identified that leaders collectively enacted distinct change‐, relation‐ and task‐oriented behaviours by engaging in collaborative team processes that enabled the sharing of IL work across different members of the nursing leadership team. Our research findings provide detailed, practice‐based examples of how IL is enacted at the POC, offering insight into its complexity in nursing as a dynamic and multifaceted process for implementing EBP into clinical practice (Gifford et al. 2018).

Our findings underscore that strong POC leadership is integral for local planning, resources acquisition and training management, but also for fostering frequent, direct interactions with nursing and interdisciplinary staff throughout the implementation process. POC leaders leverage their presence and existing relationships with staff on hospital units to proactively address concerns, remain attuned to staff's perspectives when adapting EBPs, and guide staff through successful implementation of new practices (Nordin et al. 2024). Such behaviours not only support adoption but may also counteract staff resistance, an issue often rooted in nurses feeling devalued or excluded in change initiatives (Arsenault Knudsen et al. 2021). POC leadership behaviours that actively seek and respond to staff may mitigate resistance, and create environments where staff perceive that the EBP change is expected and supported.

Our findings add new dimensions to the concept of IL as it was described in the OMILe, particularly by highlighting structural, dynamic and relational components. Additionally, our study provides further credence to shared leadership as a useful lens from which to understand IL in nursing. We demonstrated that IL behaviours are exhibited my multiple leaders in nursing leadership teams across inpatient units, offering a broader perspective that extends beyond leadership attributed to a single leader source. We detail how leader involvement can fluctuate throughout the implementation process, specifying which behaviours are enacted by whom, when and how these behaviours may overlap between formal and informal leaders. These findings debunk the often dominant assumptions implicit in determinant frameworks where leadership is assigned to individual managers, by highlighting the shared contributions of leaders in both lateral and vertical, formal and informal roles on hospital units (Nilsen and Bernhardsson 2019).

A key contribution of this study is the implication of nursing leadership teams in sharing IL on inpatient units, addressing a significant gap at the intersection of implementation science, shared leadership and nursing literature. Different team archetypes have been described for implementation initiatives such as implementation support and quality improvement teams. These may be time‐limited and created for specific projects with members who share responsibility for driving innovation (McGuier et al. 2023). In the shared leadership literature, a wide variety of organisational team types have been described and more recently within time‐limited teams such as project management teams (Zhou et al. 2024). In nursing, most studies of leadership have focused on shared interdisciplinary clinical leadership and shared governance, with limited exploration of intradisciplinary leadership collaboration on inpatient units (Lamont et al. 2015). Our study introduces nursing leadership teams as a unique, permanent leadership team archetype, distinct from existing models in implementation, with membership primarily consisting of formal nursing leadership roles who have interdependent functions in implementation. Unlike solely managerial or time‐limited project or implementation teams, nursing leadership teams can provide stable and sustained leadership, support multiple implementation efforts on their units and fulfil interdependent functions that support implementation. These characteristics may be beneficial in implementation efforts by circumventing the need to bring together diverse facilitators in the early exploration phase. Instead, they allow and leverage existing knowledge of unit routines, nursing staff and history of change, to tailor the leadership approach to the specific task at hand.

Our study proposes a dynamic element to IL by situating the behaviours of nursing leadership team members across the continuum of implementation phases, a dimension not previously described in the OMILe. While previous evidence that different leadership behaviours may be enacted in specific implementation phases, such as promoting readiness in pre‐implementation phases (Kujala et al. 2019), to our knowledge no studies to date have described the specific leaders involved at these different time points. Our results offer a more detailed account of shared IL in nursing by identifying the types of leaders and specific behaviours that evolve and shift in prominence over time across the implementation continuum, aligning with research that underscores the temporal dimension of leadership and implementation strategies (Vax et al. 2021). As implementation is a process whereby the timing and utilisation of planned strategies is important, a better understanding of how diverse nurse leaders at the POC are implicated and the specific behaviours they enact at different phases is essential for successful integration of evidence into nursing practice. For example, leaders who are more proximal to staff in day‐to‐day operations enact more leadership behaviours during the active implementation phases. These shifts in leader influence also align with conceptualizations and empirical research suggesting that shared leadership reflects a dynamic process during the life of a project cycle (Lorinkova and Bartol 2021).

Lastly, our study adds a relational element to the OMILe by illustrating how collective enactment of IL behaviours arises from the collaborative interactions between diverse leaders. This finding highlights how team‐level processes operate in shared IL and extends van den Zijpp et al.'s research on leader interactions within a dyadic leadership model to multiple leaders within a team (van der Zijpp et al. 2016). It also supports other research that highlights the importance of task division, clarifying leadership roles and harnessing different leaders' expertise and skills throughout the implementation process in nursing, which have been linked to positive examples including the sustainability of EBPs (Fleiszer et al. 2016; Renolen et al. 2020). While the OMILe suggests holding regular leadership meetings as a task‐oriented behaviour for planning implementation, our study unpacks processes within team planning and other IL behaviours throughout the entire implementation process. Specifically, it describes how nursing leadership team members mutually influence one another through engagement and communication to align implementation efforts and enhance both individual and collective action towards successful implementation.

6.1. Strengths and Limitations

This study has several strengths. First, we built on existing theory with a conceptual framework to guide data generation and analysis. The use of multiple data generation methods and multi‐level data sources provided a robust description of shared IL in nursing. We also promoted transferability by selecting cases with varying contexts, including top‐down and unit‐based projects, reflecting the diversity of change sources nurses face (Cadeddu et al. 2023). However, there are limitations. We only selected two cases within the same organisation, which may affect transferability. Additionally, we excluded the sustainability phase from case boundaries. The retrospective nature of the study limited real‐time observation of leader behaviours and social processes relying instead on proxy reports. Finally, while we detailed IL behaviours across different implementation phases, we did not include a similar level of detail for social processes.

6.2. Recommendations for Further Research

This study represents a starting point for exploring shared IL in nursing, extending the conceptualization of the OMILe to multiple nurse leaders at the POC. Since definitions and descriptions of leadership are highly situational (Yukl et al. 2019), we recommend exploring shared IL in other nursing settings and across institutions in various jurisdictions where the leader roles may not be so diverse or with different mixes of nurse leader positions. Similarly, our study explored positive cases of shared IL in units that were recognised for high levels of synchronicity and cohesion among the nursing leadership teams, resulting in congruence across both cases. This warrants further study in units that experience more challenges with successful implementation, to delineate differences in the behaviours and processes as key barriers to shared IL. We have focused on the leadership as exhibited by nursing professionals. Often though, leadership for change cuts across disciplinary lines and shared IL should be examined in this context. Finally, future research should consider how the nursing leadership team structures including their configuration and interdependency of nurse leader roles, the availability of these roles across units and jurisdictions, and the flexibility of team membership can better support the implementation of EBPs.

6.3. Implications for Education and Practice

In line with existing research that supports the need to develop IL in nursing, the findings of our study suggest that a greater emphasis should be placed on strengthening team‐level processes in addition to supporting individual‐level leadership. Current in‐house training for IL programs typically focus on managers (Chen et al. 2024), or on leaders in individual roles (Patton et al. 2024). These programs can be adapted to enrol nursing leadership teams with a focus on developing collaborative team processes of leadership engagement and communication, in addition to IL behaviours.

Hospital administrators may also consider promoting nursing leadership teams with diverse team membership. In jurisdictions where non‐managerial leaders such as advance practice nurses are not implemented, creating nursing leadership teams for implementation with informal leaders may be a starting point. The shared IL described here illuminated that all formal leaders on a unit are involved in implementation, although some more prominently at different phases of implementation, and that this unified leadership communicates that the EBP change was a priority. NMs and other leaders who are tasked with introducing EBP changes to the unit should consider defining individual leader behaviours that contribute to their collective action, when they may be most effectively involved in implementation efforts and reflect on how to foster positive working relationships in implementation. As exemplars of successful shared IL in nursing, unit and organisational leaders could use the cases presented in this study as a model, which may be helpful for units who struggle with implementation. In units with strong IL, leaders can pause and reflect on the specific processes that enable them to successfully support implementation, helping them recognise and adapt these behaviours to changing contexts and team dynamics. By articulating these behaviours, they can more effectively share their expertise as coaches and mentors with other units during EBP projects.

More broadly, the findings offer transferable insights into how leadership for implementation can be distributed across various roles, regardless of formal title or organisational structure. While the specific composition of nursing leadership teams may differ internationally, particularly based on the availability of specialised nursing roles, the underlying principles such as fostering collaboration and engaging individuals where leadership is more broadly defined, including in informal leaders, can be adapted to diverse healthcare systems. This flexibility enhances the relevance of our findings for nurse leaders and policymakers across a range of global contexts.

7. Conclusion

This study provided support for shared IL in nursing as a process where POC leaders collaborate to collectively enact behaviours to support the implementation of EBPs, contributing new insights to the fields of nursing, shared leadership and implementation science. To our knowledge, this is a first study to present a rich description of a positive example of IL in nursing that considers multiple and diverse leader types within nursing leadership teams. These findings may be of value as a template and concrete model for what specific behaviours need to be fostered and the relational processes that can be encouraged to strengthen POC leadership on inpatient units.

Ethics Statement

Ethics approval was obtained from the Research Ethics Board of the McGill University Health Centre [Ref number: 2022–8408] on February 24, 2022.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Appendix S1: Reporting guideline.

Appendix S2: Chronological account of case events and activities according to implementation phases.

Castiglione, S. A. , Lavoie‐Tremblay M., Kilpatrick K., Gifford W., and Semenic S. E.. 2026. “How Formal and Informal Nurse Leaders Enact Shared Implementation Leadership in a Hospital Setting.” Journal of Advanced Nursing 82, no. 8: 7987–8005. 10.1111/jan.70374.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.