Assessing Behavioral Styles Among Nurse Managers: Implications for Leading Effective Teams

Abstract

Nurse leaders must use behaviors that foster effective teams. The purpose of this study was to determine the behavioral style by 3,396 nurse leaders who attended leadership and communication continuing education courses. Sessions included identifying behavioral style preferences using the DiSC® Personal Profile Instrument. Of the four behavioral dimensions, Dominance, Influence, Steadiness, and Conscientiousness, 73% scored highest in Dominance and Conscientiousness. The remaining 27% scored highest in preferences for Influence and Steadiness. Nursing leaders may benefit from awareness of differences in behavioral style preferences to enhance communication and team effectiveness, as well as improve satisfaction among team members.

Introduction

Healthcare costs, patient acuity, and the demand for safe care continue to be concerns for healthcare leaders. Equally concerning is the looming projected shortage of registered nurses (RNs) that will be available to provide safe and effective care. By 2020 in spite of increases in graduating nurses, the projected shortage is expected to be about 193,000 (Carnevale, Smith, and Gulish 2015). Multiple short- and long-term solutions are needed. Among them are the ability to communicate and provide environments where nurses feel valued and supported. Nursing leaders and managers must have the interpersonal skills to foster happy, committed employees and promote a multi-disciplinary approach to patient care and resource utilization. Having the right persons in the right positions, especially in managerial roles, is recognized as essential (Furlow 2000). An integral dimension of nurse leadership in healthcare organizations is the ability to manage the nonclinical aspects of nursing teams: the front line, day-to-day working relationships of the team members and the staff members who need to provide cost-effective, safe care.

The Institute of Medicine (IOM) introduced a set of five core competencies necessary to meet the needs of the 21st century health system. Second on the list was Interdisciplinary Teamwork with emphasis on cooperation, collaboration, and communication (Institute of Medicine 2003). Related are the leadership skills needed to motivate effective teamwork to improve outcomes. Such skills and practices are essential for effective leaders and may foster satisfying work environments (Kouzes and Posner 2007). Outcomes are better in environments where healthcare professionals communicate effectively and work together as a team (Institute of Medicine 2004; Suchman 2006). This is supported by evidence on Magnet designated hospitals where nurses have an important part of decisions about nursing practice and delivery of care. In such institutions, nursing satisfaction is high and turn-over is lower with reduced vacancies (dit Dariel and Regnaux 2015; Wonder 2013).

Much of the leadership literature focuses on core competencies or leadership approaches while little has focused on the behavioral styles of leaders. However, central to effective interdisciplinary teamwork is managing teams by recognizing and building on the unique differences in behavioral styles of the team members, as well as their own style. “Leadership is not about personality; it’s about behavior” (Kouzes and Posner 2007, p. 15). Valuing and understanding these style differences helps to enhance self-esteem and satisfaction among nursing teams and identify and utilize the inherent skills of individuals (Feather, Ebright, and Bakas 2015).

Workshops, educational opportunities, and leadership training are often used to fill the gap between the clinical knowledge nurses bring from the bedside to their managerial roles and the skills they will need to manage groups and organizations in the complex healthcare environment (Medland and Stern 2009). Given that nurses comprise the largest group of professionals in the hospital setting and spend more time at the bedside, they collectively have the potential to have a greater impact on quality and cost containment than any other group. The purpose of this paper is to report the behavioral styles identified among nurses attending leadership workshops to provide insights into how each style may affect team building, effective leadership, and communication with nurses. This may provide insight into how hospital-based nurse leaders approach their daily work. To our knowledge, predominate style preferences of nurse managers have not been reported.

Methods

Information on behavioral style preference was collected over several years as part of continuing education workshops in nurse leadership skills throughout the United States. The sessions, in part, presented information on developing working relationships with the diverse style preferences found among workers in hospitals and other healthcare organizations. Participants were RNs in management and leadership roles. Because the programs were designed as continuing education and not as a systematic research study, data on demographics were not obtained. Prior to analyzing data, the University of MS Medical Center IRB determined that this was not research involving human subjects using the US Health and Human Services Office from Human Research Protections criteria (http://www.hhs.gov/ohrp/regulations-and-policy/decision-trees/index.html#c1). Because data were not collected for research and are considered confidential, access to data files is not provided.

Each participant received a DiSC® behavioral style survey to complete during the session. The DiSC® Classic instrument was chosen for this study due to its stability and internal consistency, as well for the ease of comprehension of the four scales. We also found that the participants considered the DiSC® a useful tool in explaining how they reacted to different styles in the workplace and how they can adapt their personal style preference to forge a stronger working relationship with their colleagues.

The DiSC® is a self-scoring, forced choice instrument that requires the respondent to select words that are “most like me” or “least like me” from 28 sets of four words each. The instrument describes behavior along four dimensions: (1) Dominance, which indicates those who prefer to take action rather than discuss possible outcomes, thrive in settings where there is change, display direct eye contact in conversation, and use significant volume in speech; (2) Influence, or those who are easy to talk to, enjoy meeting people and discovering details about people, make a great deal of eye contact in conversation, and disclose personal information about themselves to others; (3) Steadiness, which describes individuals who avoid change and prefer a stable, consistent environment, speak softly, and appear to be low key; and (4) Conscientiousness, or those who use facts in conversation and seek correctness and even perfection in their speech and actions. In some cases, the behavioral characteristics of these four DiSC® patterns overlap, but the preference for one style is evident (Straw and Cerier 2002).

The DiSC® Instrument has been used in a wide variety applications from artificial intelligence to job selection for corporations (Bhardwaj, Mishra, and Hemalatha 2017). In healthcare, the instrument has been used in studying leadership success in hospitals (Fuqua and Bryan 2017) as well as identifying personal style differences for selecting applicants for surgical training (Bell et al. 2011). Bell and colleagues tested the use of adding a behavioral assessments to better screen for residency positions and concluded that it provides additional information of a candidate’s strengths and abilities. Nursing behavioral assessments using the DiSC® have been used less frequently although it has been advocated for determining the best candidates for nursing jobs (Furlow 2000). Because the DiSC® is relatively inexpensive and easy to administer in comparison to the organizational cost of turnover of either the leader or dissatisfied staff, selecting leaders with the right skills and leadership qualities is essential. The DiSC® can provide additional information to organizations when trying to assess the likelihood of success of a candidate for a leadership position that may not readily be gained through other methods like interviewing. Behavioral assessments such as DiSC® add another tool in evaluating the best candidates for leadership.

The DiSC® instrument is reliable and valid, with test–retest stability coefficients of 0.87–0.89 at 1week and 0.71–0.80 at 1year and Cronbach’s alpha from 0.85 to 0.92 in samples from the United States and United Kingdom (DiSC® Classic validation report 2008). The instrument has established validity including construct, multi-dimensional scaling, and factor analysis using both exploratory and confirmatory methods in large samples of 812 and 45,588, respectively. It significantly correlates with other well-known instruments in leadership and management such as the Myers–Briggs Type Indicator. Significant correlations were also obtained by comparing scores with the Adult Personality Inventory, Weschler Adult Intelligence Scale, Catell 16 Personality Factor Questionnaire, Minnesota Multiphasic Personality Inventory, and Strong Campbell Interest Inventory (DiSC® Classic validation report 2008).

Results

There were a total of 73 communication skills workshops conducted across the United States. Participant counts in the sessions averaged 46. Based on their scores, participants were initially identified as belonging to one of the four DiSC® dimensions, and then further identified as one of 15 subcategories of the four dimensions. In all, data were collected on 3,396 nurses. Table 1 shows the aggregate data for the 3,396 nurse responses.

Table 1.

Aggregate data for nurse responses (N = 3,396).

					Total	Percent
Dominance:	Developer	Result-oriented	Inspirational	Creative
	269	227	255	542	1293	38%
Influence:	Promoter	Persuader	Counselor	Appraiser
	171	118	187	99	575	17%
Steadiness:	Specialist	Achiever	Agent	Investigator
	110	71	84	89	354	10%
Conscientiousness:	Objective Thinker	Perfectionist	Practitioner
	249	727	198		$\frac{1174}{3396}$	$\frac{35\%}{100\%}$

The majority of the participants scored highest in preferences for Dominance and Conscientiousness. Thirty-eight percent of the nurses were identified in the Dominant dimension, and 35% were identified in the Conscientiousness dimension. The remaining 27% scored highest in preferences for Influence (17%) and Steadiness (10%). Figure 1 shows the distribution of nurses over the four dimensions.

Figure 1.

DiSC dimensions for nurses (N = 3,396).

When the four DiSC® dimensions were further subdivided into 15 Classical Patterns, 37% of the participants scored highest in only two of the 15 patterns, Perfectionist (21%), which is in the Conscientiousness dimension, and Creative (16%) which is in the Dominance dimension. All other Classical Patterns were less than 10% each. Figure 2 shows the distribution of nurses over the 15 Classical Patterns.

Figure 2.

Classical patterns for nurses (N = 3,396).

Discussion and Conclusion

Most people have a strong preference for their primary style and tend to use that style almost exclusively when interacting with others. As the majority of nurse managers scored highest in either Dominance or Conscientiousness, their strengths can be described as preferring to perform tasks over which they have control while focusing on quality to produce results. The strength of the Dominance dimension is the ability to make quick decisions, whereas the strength of the Conscientiousness dimension is paying attention to detail and accuracy. Both are important in fast-paced and rapidly changing environments such as hospital settings, where mistakes can have devastating outcomes. On the other hand, the characteristics of Influence and Steadiness, found in only 27% of the nurses, can be described as seeking an enthusiastic and optimistic work environment. Nurse leaders who use these styles may be particularly useful in units where interdisciplinary teams are important or when morale or staffing issues are leading to high staff turnover. Of note, Steadiness, which describes individuals who often avoid change and prefer stability was the least common dimension which may be an encouraging finding since today’s hospitals demand flexibility and change.

In Classical Pattern terms, over one-third of the nurses in this study were classified as either Creative or Perfectionist. Creative does not describe those who are artistic, but refers to a unique combination of strong preferences for acting quickly and, at the same time, for paying close attention to details. Individuals scoring in the Creative Pattern tend to be fast-paced and rise to meet challenges while simultaneously being careful to attend to details and check for accuracy. This pattern is unique among the 15 Classical Patterns since it is the only one that displays an equal preference for two different DiSC dimensions: Dominance and Conscientiousness. Individuals scoring in the Perfectionist pattern demonstrate a strong preference for restraint and caution, thus being careful in all they do. Although they do not have the Creative’s preference for taking action quickly, they do share the attention to high standards for quality (Martin and Keogh 2004).

The role of the nurse manager includes strategic resource allocation that directly impacts cost and quality. The nurse manager is also key to link frontline caregivers with the values and goals of the organization and facilitating staff relationships with other clinicians. However, the empathetic, social, and restraint behaviors that are useful in managing these relationships are the less preferred attributes of the Dominance and Conscientiousness dimensions. Among those surveyed in this study, Dominance and Conscientiousness were far more common than the other DiSC dimensions. Nurse managers with the Dominance and Conscientiousness characteristics strive to meet the demands of achieving results and maintaining accuracy (Slowikowski 2005), perhaps leaving less time for providing staff support and acknowledging contributions. However, this does not mean that they never use the behavioral styles associated with Influence and Steadiness. To be successful, nurse managers likely use other attributes associated with the domains of Influence or Steadiness in some situations. Building awareness of the options for utilizing other behavioral styles such as Influence or Steadiness in different situations was the goal of the communication sessions from which these data were collected.

Depending on the strength of the manager’s preference for a particular behavioral style, using other attributes may feel unnatural and require thought and energy. The energy requirement for employing different attributes decreases with practice and becomes more automatic over time. Being able to be flexible and incorporate a wider range of behaviors in different situations allows nurse managers to build on their natural strengths to become more effective leaders (Martin and Keogh 2004) and contributes to a leader’s ability to adapt to different issues, improve patient outcomes, and increase staff retention and satisfaction (Spence Laschinger, Wong, and Grau 2012; McFadden, Stock, and Gowen 2015; Merrill 2015). Change and unpredictability are the hallmarks of today’s healthcare environment (McDaniel, Lanham, and Anderson 2009) and successful leaders should be attentive to how the unpredictable circumstances can have large effects on outcomes. With effective “attribute-flexing” from leaders, the outcomes can be positive (Jordon et al. 2010). Hospital executives who support nurses and nurse leaders should be self-aware and aware of the natural behaviors of their nurse leaders.

At a time when costs must be contained and outcomes cannot be compromised, the nursing organization must be supported. This support must be for and from the nurse leaders. These leaders must be cognizant of whether or not their behaviors are effectively responding to their staff. With natural tendencies aligned more closely with Dominance and Conscientiousness, this may be effective when nurse leaders nurture their staff. However, when working in an inter-disciplinary environment, the interpersonal and engaging behaviors aligned with Influence may be more productive. Thus, hospital executives should provide targeted training opportunities to assure their nurse leaders can effectively flex to accommodate the needs of the organization.

A limitation of this study is that no demographic information, time as a nurse manager, or other training and education in leadership were obtained. This was because the sessions were primarily staff development continuing education workshops. Another limitation is that these data were cross-sectional. Since this analysis was exploratory in nature, there is no claim or inference that the results are generalizable to all nurse leaders. Furthermore, assessment using the DiSC® indicates a person’s comfort with a particular behavioral style and not necessarily the only leadership behavior one uses. It is not known if the nurses’ behavioral styles were stable over time. Behavioral style preference is likely a trait that is somewhat stable although with conscious effort and training it can be broadened to incorporate other attributes. Perhaps the Influence and Steadiness styles of nurse leaders, which were both dimensions that were low in this study, could be strengthened by incorporating training in flexing communication styles.

This study identified the predominant behavioral style preferences of over 3,000 nurse managers. It included the nurse leaders’ most natural strengths and where effort is needed to adapt to meet the various requirements of their day-to-day duties, as well as to transform care delivery. Future research is warranted to determine the associations between behavioral styles and leadership styles, as well exploring relationships between behavioral styles and emotional intelligence indicators. In addition, determining if nurse managers rely on limited behavioral styles or if they are flexible in employing multiple styles required by the situation would add to the knowledge about effective leadership characteristics. Many of today’s healthcare leadership development programs center on skills such as budgeting, hiring, or understanding systems and organizational structure. However, expanding leadership programs into areas such as how leader behaviors affect patients, staff, and organizational outcomes may prove more beneficial. Including personal development training in areas such as adaptability, flexibility, and “softer” skills, may prove more effective in the changing, complex environment of today’s hospitals and health systems.