Leadership behaviours play a significant role in implementing evidence‐based practice

To the Editors: We read with great interest the Cheng, Broome, Feng, and Hu (2017) article that explored factors that influence implementation of evidence-based practice (EBP) in nursing in China (Cheng et al., 2017). This study identified a variety of factors and provided a strong foundation for further studies. For example, the roles of project leaders were one of the factors; however, we believe that leadership behaviours are missing and must be considered in Chinese nursing. We wish to offer further insights in this commentary. It is well understood that leadership is an important factor that influences the implementation of EBP. However, leadership is much more than a role, position or status (Shaw, 2007). Based on contingency theory, leadership involves the person who is the leader, the setting in which they work and the people in which they lead or the followers (Fiedler, 1971). Behaviours are the “manner of conducting oneself in the external relations” (Oxford English dictionary 2018), and leadership behaviours are the interactions and activities that leaders take with their staff and people in their organisation to impact the workplace setting, culture and staff. Leadership role theory illustrates that behaviours are influenced by past experiences leaders have had and the subjective efforts they make to influence followers towards a vision or goals (Winkler, 2010). Thus, different leaders in the same role may interact differently with staff and use different activities and strategies in different settings to facilitate EBP. Even the same leader can use different behaviours over time as the context, staff and leaders themselves evolve, despite there being no change to a leader's formal role or position. As social learning theory has shown, leaders can improve or adapt their behaviours to be more effective after they learn, reflect and incorporate feedback from interactions in the classroom and workplace settings (Bandura, 1977). The leadership behaviours for facilitating implementation of EBP have been studied by a number of scholars. For example, Gifford, Graham, Ehrhart, Davies, and Aarons (2017) developed the Ottawa Model of Implementation Leadership (O-MILe) based on an integrative literature review and research. The fourth generation of the O-MILe includes three meta-categories of effective leadership behaviours for implementing EBP in healthcare settings: (i) relations-oriented (four activities), (ii) change-oriented (four activities) and (iii) task-oriented behaviours (six activities) (Gifford et al., 2017). Aarons, Ehrhart, and Farahnak (2014) developed the Implementation Leadership Scale (ILS) to measure leadership for implementing EBP, and the scale has been validated with good psychometric scores (Aarons et al., 2014). The ILS had four dimensions representing proactive, knowledgeable, supportive and perseverant leadership, which includes 12 specific leadership behaviours. A concept mapping study illustrated that the items of the ILS strongly aligned to the theoretical constructs of the O-MILe (Gifford et al., 2017). Although specific behaviours are essential to leading the implementation of EBP, universally effective behaviours have not been determined. What leaders do must be based on leaders’ evaluations of themselves, the settings and followers. Thus, interventions and programmes for developing implementation leadership need not only to include theory for understanding what leadership is and how it works, but must also include leadership coaching in real-world settings. The O-MILE has been used in different healthcare settings to guide leadership development programmes to implement EBP in nursing (Gifford et al., 2017). In these programmes, leaders received knowledge and skills to carry out effective leadership behaviours for implementing EBP through interactive worzx kshops and real-world coaching. This includes theory on leadership, EBP, implementation methods, engagement, goal setting for change and context-specific information on current practices and audit methods. Participants then built a plan of the specific leadership behaviours they would engage in, and were coached in their work setting to operationalise the plan for implementing EBP. In 2016, we started an international China/Canada collaborative research project to develop leadership behaviours for implementing evidence-based pain management practices in paediatric nursing in China. Our international research team includes two professors in Canada and two in USA, one chief nursing director and one head nurse in China, and an international Ph.D. student from China who is studying at the University of Ottawa, Canada. In this project, we have translated and validated the ILS into Chinese and assessed barriers and facilitators to implementing evidence-based pain management practices in paediatric nursing in China. Based on this very specific Chinese context, we have developed an implementation leadership strategy guided by the O-MILe that will be pilot tested and evaluated. Previous research has clearly told us that leadership is critical for implementing EBP in nursing. However, we suggest that what leaders do in their work setting to influence staff and the organisational environment is equally as important as the role or position they have. As few studies on implementation leadership exist in nursing, we strongly recommended that more intervention research is needed to understand how leadership improves implementation of EBP and open the “black box” on implementation leadership in China. Thanks are due to international research collaborators. The authors appreciate Hong Ruan, Denise Harrison, Gregory Aarons and Mark Ehrhart for their efforts and great contributions. None.

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