Response to Commentary on Cheng, Broome, Feng, and Hu (2017) Leadership behaviours play a significant role in implementing evidence‐based practice. Journal of Clinical Nursing, 2018;27:e1684–e1685

Thank you for the opportunity to respond to Hu and Gifford's comments (Hu & Gifford, 2018). We appreciated their acknowledgement of our findings about the factors influencing the successful implementation of evidence-based practice (EBP). The authors described leadership behaviours as having a significant role in implementing evidence-based practice. Although we did not specifically discuss leadership in the previous paper (Cheng, Broome, Feng, & Hu, 2017a), we agree and acknowledge the importance of leadership during evidence implementation. It was interesting to read about Hu and Gifford's work in progress related to the study of leadership behaviours in EBP. In subsequent papers, we have further explicated the role of leaders in EBP and therefore wish to offer further insights in this commentary. Hu and Gifford (2018) described two measures (i.e., O-MILe and ILS) that have been developed and validated to assess leadership in the EBP context based on the literature. These measures will be very important to scholars of EBP implementation. In our work, three questions arose related to leadership in this context and go beyond just the behaviours evidenced by leaders: (a) Who are the leaders for evidence implementation; (b) what is essential preparation for the leaders; and (c) how do the leaders manifest their roles during the implementation. By reviewing the 24 implementation projects, we found many formal leaders, for example, nurse managers, staff nurses and faculty members. Their leadership is exemplified and differentiated by the implementation approaches they take, for example, top-down, bottom-up and outsider-in (Cheng, Broome, Feng, & Hu, 2017b). Meanwhile, informal leader that might complement the formal project leaders’ role during evidence implementation was also evident. For instance, staff nurse champions emerged in some projects to assist the leaders in educating colleagues, auditing actual performance and solving problems. Some staff nurses who were informal leaders also expressed their wiliness to become a formal leader to fill a new “gap” which became evident during implementation. This pattern of formal and informal leadership intertwined together to make the evidence “take root” in nursing practice. Thus, there is a need to prepare evidence implementation leadership at all levels of the health system. Although there had not been any formal requirements, we did find some common characteristics among those “successful/effective” formal and informal leaders. First, the leaders had a passion about looking for the latest evidence to solve patient care problems in nursing practice. They were aware of the needs of clinical settings and knew exactly what the gaps were. Second, they shared and exchanged their views with stakeholders across disciplines, for example, administrators, medicine, nursing, pharmacy, physiotherapy, logistics and information systems. Sometimes, they took on the informal role of “knowledge broker” as part of the leadership role, by identifying key attributes of the evidence that might be used and analysed the context and achieve the census among the stakeholders on implementation plans. Third, during the implementation, the leaders wisely allocated resources and struck a common ground where each stakeholder would be able to understand and achieve their own goal. In order to move the projects forward, they had to keep alert constantly to align the overlapping goals between person and system. Finally, leaders were able to foresee the proximal and long-term outcomes, as well as tangible and intangible impacts from evidence implementation. This vision lay behind their every act (even sacrificing personal time) and kept them persisting on this evidence implementation leadership journey. We realise that some of these behaviours are measured in Ottawa Model of Implementation Leadership (Gifford, Graham, Ehrhart, Davies, & Aarons, 2017). However, the qualitative approach that we took enabled us to paint a better picture of the “process of leadership” versus just the isolated behaviours evidenced by leaders as measured by quantitative scales. We found that leaders were often formally appointed by the hospitals, while other times they naturally took the lead. However, in either situation, they engaged in a variety of behaviours designed to keep “the projects moving.” For example, they responded to a particular clinical context, worked in a collective manner, engaged in strategic planning and functional management, exhibiting multifaceted behaviours at multiple levels. Support from higher administration was critical for the leaders fully play out their roles, especially for the bottom-up and outsider leaders. In a more recently published paper in the Journal of Nursing Management (Cheng, Feng, Hu, & Broome, 2018), we further analysed data from the previous study and provided exemplars for a better understanding of the nurse managers’ leadership role during evidence implementation. We found it important to consider “hierarchy and obedience” as important concepts in the mainstream culture of the Chinese existing health care system, and suggest enhancing managerial support with recognition of their efforts and preparation of the leaders as facilitators to integration of the best available evidence into nurses’ workflow. As Hu and Gifford pointed out in their commentary, leadership is much more than a role, position or status. Their work, as well as ours and others, has begun to build a more comprehensive picture of leadership and provide a deeper and broader understanding of how evidence-based practice can be achieved. However, the leadership for evidence implementation needs further exploration from the perspectives of staff nurse leaders, outsider leaders as well as the informal nursing leaders in various levels that assisted in compensating the formal leadership of nursing managers. None. None to declare.

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