Leadership in Nursing

Given the rapid and continual changes to the healthcare landscape, the integration of innovative technology, and an aging, complex patient population, the way in which care is delivered must be reimagined. In order to address these issues and improve the delivery of care, effective and efficient leadership is vital.

The current healthcare system requires visionary leaders to address the challenges of the current healthcare environment and to become an active player in healthcare reform. The landmark report by the Institute of Medicine (IOM, 2011), The Future of Nursing, Leading Change, Advancing Health focuses on transformation of nursing practice, nursing education, and nursing leadership. The Future of Nursing, Leading Change, Advancing Health can be found at the National Academies of Science website.

All nurses require leadership skills and competencies to in order to partner with physicians and other healthcare professionals, both within and outside of their institution. Nurses play a vital role in transforming healthcare, such as:

  • Provision of safe, high quality, patient-centered care
  • Primary care services
  • Care delivery in the community
  • Provision of seamless, coordinated care
  • Accessible, affordable healthcare
  • Engagement in health information technology (such as EMRs) (IOM, 2011)

In order for nurses to achieve these outcomes, nursing leadership must undergo a radical transformation. Health reform legislation signed by President Obama in 2010 includes a wide range of initiatives including the redesign of the healthcare delivery system. Many of the programs that have been created rely on interventions that inherent in registered nurses’ scope of practice, such as care coordination and transitional care.

Being a leader, or a full partner in healthcare reform, means taking responsibility for recognizing problems or needs in the healthcare setting. Nurses at all levels of care must serve as strong advocates for patients and take the initiative to become involved with decision-making and offering suggestions on how to improve the delivery healthcare.

The delivery of high-quality nursing care is at risk during an era of critical transitions. The aging nursing workforce, retirement of nurse leaders, and the current and future nursing shortage requires strong nursing leadership. In order to achieve the vision of transforming the healthcare system, the profession must produce leaders throughout all areas the healthcare system. Leaders must be present at every level of care and across all settings. Nurses must be accountable for their contribution to providing high-quality care, while working collaboratively with leaders throughout the healthcare system (IOM, 2011).

The nursing workforce struggles with overextended, fatigued staff who are often disenchanted with the current work environment (Van Bogaert & Clarke, 2018). The healthcare system requires nurse leaders who are capable of creating a healthy work environment that instills trust, empowerment, support and encouragement, and a leadership style sustains nurses’ health and well-being.

The IOM (2011) explains how an effective leadership style is essential in today’s healthcare landscape, adding, “What is needed is a style of leadership that involves working with others as full partners in a context of mutual respect and collaboration” (p. 233). Leadership styles with a focus on respect and collaboration have been associated with improved patient outcomes, reduced medical errors, increased nurse retention and job satisfaction, improved teamwork, reduced lengths of hospital stay, and cost savings (IOM, 2011). Through effective nursing leadership, the nursing profession will continue to grow and evolve, and provide exceptional nursing care to patients who desperately need it.

Scope and Standards of Practice

As discussed in week 1, the Scope and Standards of Practice, developed by the American Nurses Association (ANA, 2015c), serves as a template for professional nursing practice for all registered nurses. Standard 11, Leadership, states, “The registered nurse leads within the professional practice setting and the profession” (ANA, 2010, p. 75). The following is a summary of the competencies of the Leadership standard:

  • Contributes to the establishment of an environment that supports and maintains resect, trust, and dignity.
  • Encourages innovation in practice and role performance to attain personal and professional plans, goals, and vision.
  • Communicates to manage change and address conflict.
  • Mentors colleagues for the advancement of nursing practice and the profession to enhance safe, quality health care.
  • Retains accountability for delegated nursing care.
  • Contributes to the evolution of the profession through participation in professional organizations.
  • Influences policy to promote health (ANA, 2015, p. 75)

The goal of both formal and informal nursing leadership roles is to transform the healthcare system, where quality and safety are paramount.

Leadership Concepts and Definitions

Leadership: “a process whereby an individual influences a group of individuals to achieve a common goal” (Northouse, 2018, p. 5)

Note the following concepts within this definition:

  • Leadership as a process: leadership is not a characteristic or trait of an individual, but an event that occurs between a leader and follower or a leader and a group (Northouse, 2018)
  • Leadership occurs in groups: leadership occurs within groups, with people who have the same common goals or purpose as the leader (Northouse, 2018)
  • Leadership has common goals: leaders and followers have a common goal or purpose. Leaders work with followers to achieve selected goals (Northouse, 2018)
  • Leadership involves influence: leadership is focused on how the leader affects the followers, and the type of communication between the individuals (Ruben & Gigliotti, 2017)

Formal leaders: individuals who hold a formal leadership position, such as nurse manager.

Informal leaders: individuals who do not hold a position with formal authority, though are recognized as leaders, and have influence over their peers (Pielstick, 2000).

Informal leaders are higher performers with significant skill, they feel responsible for the functioning of their team, which they strengthen by exerting their influence by solving problems for colleagues who are in need (Downey, Parslow, & Smart, 2011).

Followers or subordinates: individuals who are being directed by a leader or manager.

Empowerment

Amundsen and Martinsen (2014) define empowerment as giving influence to others, rather than having influence over. The central characteristic of a leader who empowers others is one who supports and encourages autonomy. When a nurse manager gives influence to a staff nurse, the nurse has more power over decision-making, delegating, etc., which in turn leads to a more autonomous practice. Nurse leaders must use empowerment strategies in order for staff to have the freedom to make patient care decisions, especially in this challenging healthcare landscape (Spencer & McLaren, 2016).

Two types of empowerment:

  • Structural empowerment: employees work in environments that have structure. When employees have access to opportunities, information, support, and necessary resources, they are able to be effective and achieve goals (Kanter, 1993)
  • Psychological empowerment: fosters a proactive approach about achieving goals. Individuals learn how to cope within the workplace environment and have more control over their lives. In addition, individuals believe they are capable of influence and by understanding workplace/system processes they are able to engage in necessary behaviors to reach their goals (Zimmerman, 1995).

Empowerment is a way to encourage employees to work beyond the usual standards, supporting a flexible approach to completing tasks and reaching goals (Pearson & Moomaw, 2005). Working beyond usual standards has multiple meanings. For example, a nurse can take a more autonomous approach to practice, educating oneself on new evidence, making a suggestion about an outdated policy, or suggesting a team meeting. While these examples may be part of usual nursing practice, and expected of all nurses, nursing staff need the support of management to follow through with certain actions. Managers need to empower nurses in order for them to have a fully autonomous practice.

motivation

Chandler (1991) shares another viewpoint of empowerment as “enabling individuals to feel effective so that they can successfully execute their jobs” (p. 66). When managers empower their nursing staff, it helps improve their confidence in carrying out tasks as they see fit. A clinic nurse may decide to follow up with a patient who was recently hospitalized. The clinic manager or provider must provide a work environment where such decision-making, and freedom, can be made by the nurse. When nurses have tight oversight from their managers, making autonomous decisions about care will be impeded, possibly leading to negative health outcomes.

Rao (2012) explains nursing empowerment as a condition where nurses have control over their practice when they successfully accomplish their goals, fulfill their responsibilities. Having control over one’s practice is empowering, nurses have the authority, or influence, to complete their tasks as they see fit, which is akin to having an autonomous practice. When nurses are empowered by their managers, they have the resources, support, and encouragement to complete their tasks. When leaders empower their staff, they are also encouraging autonomous practice. See week 1 for a review on Nursing Autonomy.

Empowerment is foundational to interprofessional collaboration, and nursing practice as a whole, and it is associated with the following outcomes:

  • Increased job satisfaction
  • Increased trust within the organization
  • Improved effectiveness within the nursing unit
  • Positive coworker relationships (Read & Laschinger, 2015; Regan, Laschinger, & Wong, 2015)

Working in today’s healthcare environment has forced leaders to improvise, creating ways to prepare themselves, and their team, to cope with workplace stressors, such as workplace bullying. Leaders can focus their efforts on strengthening empowerment, both structural and psychological, within the workplace to meet create a positive and productive environment.

Nurses as leaders at all levels, across all settings

Strong nursing leadership is required in all settings, from the bedside, to the community nurse, nurse managers, director of nursing, members of nursing organizations, nurse researchers, school nurses, etc. Nurses must exercise their leadership competencies collaboratively in all settings, such as hospitals, communities, schools, businesses, boards, the political arena, and more. All nurses must take responsibility for their professional growth by developing leadership skills and competencies in their area of specialty (IOM, 2011). Below are some examples of effective leadership from bedside to boardroom:

  • Awareness of the need to advocate, mediate, collaborate
  • Link actions to quality care
  • Nurses’ technical ability to deliver care in a safe and effective manner
  • Improving work processes at the bedside/frontline
  • Creating or offering new evidence for practice
  • Collaborate with policy makers
  • Craft policy and legislation that allows nurses to work to their fullest capacity
  • Lead nursing education/curriculum changes to prepare the nursing workforce to meet the needs of a complex healthcare environment
  • Serve on institutional and policy-making boards where critical decisions affecting patients are made
  • Autonomous practice in community health settings
  • Assertiveness, to have a strong voice in advocating for patients and their families (IOM, 2011)
leader

Healthy Work Environments

Nurse leaders play a major role in creating and maintaining healthy work environments (HWE). HWEs foster excellence in patient care and are an essential component to reversing the current nursing shortage and providing safe, quality, compassionate nursing care. In addition, HWEs improve nurses’ well-being and their perception of feeling fulfilled at work (American Association of Critical Care Nurses [AACN], 2016).

Unhealthy work environments lead to:

  • Medical errors
  • Ineffective delivery of care
  • Conflict and stress among health care professionals (AACN, 2016)

Today’s work environments demand increased attention to these negative consequences. In order to improve practice environments and nursing practice itself, nurse leaders must be positioned within their organization to have the power to inform and influence decision-making (AACN, 2016). Nurse leaders, such as nurse managers, must have the following core competencies and skills to create HWE environments:

  • self-knowledge
  • strategic vision
  • risk-taking
  • creativity
  • interpersonal and communication effectiveness
  • inspiration (Wong & Giallonardo, 2013)
  • team builders
  • agents for positive change
  • role models for collaboration
  • committed to service (Shirey, 2009).

AACN’s (2016) Healthy Work Environment Model has developed six evidence-based standards that can improve or maintain a healthy work environment:

  1. Skilled communication
    • Nurses must be as proficient in communication skills as they are in clinical skills
  2. True collaboration
    • Nurses must be relentless in pursuing and fostering true collaboration
  3. Effective decision-making
    • Nurses must be valued and committed partners in making policy, directing and evaluating clinical care, and leading organizational operations
  4. Appropriate staffing
    • Staffing must ensure the effective match between patient needs and nurse competencies
  5. Meaningful recognition
    • Nurses must be recognized and must recognize others for the value each brings to the work of the organization
  6. Authentic leadership
    • Nurse leaders must fully embrace the imperative of a healthy work environment, authentically live it, and engage others in its achievement

The critical elements needed to transform and maintain HWE requires the authentic leader to perform as follows:

  • share an understanding of the requirements and dynamics for providing direct patient care
  • generate an enthusiasm for meeting goals (including a HWE)
  • role model all six HWE standards
  • nurse leaders and team members objectively evaluate the impact of the leadership processes and decision-making in relation to HWE goals

While formal leaders, such as nurse managers, are easily positioned to inform practice though collaboration with other executives and formal leaders in nursing administration, bedside or staff nurses also play a major role with incorporating all six standards into practice. Communication, collaboration, effective decision-making, and leadership skills are integrated into all nursing roles. Nurses owe it to their patients, the nursing profession, and society to advance quality care and improve the overall health of the population.

Mentoring

According to the ANA (2015c) and the IOM (2010), all nurses are leaders, and one of the expectations of being a formal or informal leader is to mentor one’s peers. Mentoring is critical for advancement of nursing practice and the nursing profession as a whole, because when nurses mentor, counsel, or support their peers, the quality of nursing care is improved. Some example of mentoring can include the following:

  • Educate how to perform a new skill
  • How to problem-solve a complex patient concern
  • Share advice on time management
  • Encourage a peer when overwhelmed
  • Reassurance about abilities or skills
  • Advise on career goals, share guidance/suggestions

See week 2 resource, Professional Development Plan, for more information about mentoring.

Partnerships

Participating in community partnerships is essential for advancing the profession and transforming healthcare. The IOM (2010) discusses the importance of nurses developing partnerships with agencies or stakeholders within the community. For example, a nurse could become a member of an ethics committee at a local nursing home or create a relationship with a local food bank or soup kitchen to assist with discharge planning. Sharing knowledge from one’s current role and setting with community stakeholders advances everyone’s knowledge about each other’s needs, available services, all leading to improving the ability to better serve patient needs.

When nurses are knowledgeable about their community, and the care and services available to their patients, they are taking important steps towards transforming healthcare. Partnerships are indispensable for reaching the overarching goal of quality healthcare for all.

Nurses as “full partners”

In order for nurses to be a full partner in transforming healthcare, all nurses must acquire leadership skills and competencies and collaborate with other healthcare professionals and organizations. Some examples of being a full partner in patient care settings includes the following activities:

  • taking responsibility for identifying problems and areas of waste
  • devising and implementing a plan for improvement
  • tracking improvement over time
  • maintain a focus on short- and long-term goals; making necessary adjustments to realize established goals (IOM, 2011)

Considering the amount of time nurses spend with patients, compared to other disciplines, nurses are in a strategic position to identify problem areas, whether it’s due to a patient need or concern, or a policy, procedure, or process that impedes care. Both formal and informal leaders need to share ideas for improvement and become vested in finding solutions.

Nurses can improve workflow, improve safety of the work environment or learning new ways of team communication by taking the imitative to seek out new knowledge from the literature (such as library databases). While formal leaders, such as a nurse manager or nurse executive, may have more power to follow through with policy changes, informal leaders are integral to the process of identifying problems and offering solutions.

Nurse leaders also need to have an active voice with health policy. Healthcare reform requires nurses to take an active role with implementation of political activism efforts. Nurses can serve on advisory committees, commissions, hospital committees, and boards where policies are created or amended to advance healthcare (IOM, 2011). Participation in a committee within one’s organization takes time and effort, though brings many rewards, both personally and professionally. Consider creating a goal in your professional development plan that can impact health policy. Some examples include advocating for safe staffing at hospitals or ethical treatment at end of life.

Sigma Theta Tau International

The need for excellent leadership is essential in today’s rapidly changing, complex healthcare environment. Sigma Theta Tau International (STTI) is a global professional nursing organization with the mission of advancing healthcare and celebrate nursing excellence in scholarship, leadership, and service. STTI advocates for strong, positive leadership throughout the nursing profession in order to advance health (Vlasich, 2017).

STTI’s role is to develop leadership knowledge, skills and abilities for nurses globally. STTI believes leadership develops throughout one’s career, it is a journey of lifelong learning, with mentoring as the cornerstone of one’s leadership philosophy (Vlasich, 2017).

STTI (2020b) offers membership to students who are working towards a baccalaureate degree where nurses are developing leadership knowledge, skills and abilities. In order to become a member of STTI, students must meet the following criteria:

  • Completed half of the nursing curriculum.
  • Achieve academic excellence:
    • For universities/institutions of higher education that use a 4.0 grade point average system to measure academic achievement, baccalaureate students must have a cumulative grade point average (GPA) of at least 3.0.
  • Students must rank in the top 35% of the graduating class
  • Meet the expectation of academic integrity (STTI, 2020b)

STTI also provides leadership grants to assist nurses with membership fees and travel to Sigma events (STTI, 2020a).

For more additional information about membership visit the STTI website.

Leadership Theory and Leadership Styles

Leadership theories and styles focus on a wide variety of ways to lead others, such as an emphasis on serving others, creating relationships, having power and control over others, or working together to reach goals. This section will review the major concepts of leadership styles and some of the most common leadership theories.

Leadership styles are categorized based on human relationships or task completion (Cummings et al., 2018). The following is a brief overview of current leadership styles:

Feminine leadership style emphasizes a power with approach (Burns, 1978). Sindell and Shamberger (2016) explain the following feminine expressions:

  • listen for the emotional context and connection
  • listens to others in order to sympathize with their emotions
  • consoles, supports
  • shares an emotional reaction
  • supportive in areas of employee progress and development

Masculine leadership style emphasizes a power over approach (Burns, 1978). Sindell and Shamberger (2016) explain the following masculine expressions:

  • listens for content and clarity
  • ignores other’s emotions
  • does not express one’s emotions

Leadership Theories and Styles

Goh, Ang, and Della (2018) discuss the importance of examining one’s professional leadership style and its impact on peers, employees, goal attainment, and outcomes. Self-reflection could motivate one to find a leadership theory or style that can bring about overall improved outcomes.

One leadership theory or style is not necessarily better than the other. Each theory or style has its strengths and weaknesses, and depending on one’s perspective, goals, work setting, task, and even gender*, some leadership styles may produce better patient outcomes or higher job satisfaction.

Table 1 below complies a brief list of the some of the most commonly used leadership theories and styles:

Table 1: Leadership Theories
 

Transformational leadership

Transformational leadership has a positive and direct association with the level of organization commitment and retention of staff. Leadership qualities include charisma or non-verbal influence, inspirational motivation, intellectual stimulation, and individualized consideration. These leaders are admired, trusted, and respected. Leadership qualities have a significant impact on patient outcomes due to how well leaders inspire and motivate staff. Followers of this leadership style are more involved in their organization and put more effort in their work (Al, Galdas, & Watson, 2018)

Transactional leadership

Transactional leaders use a task-focused approach, whereby managers will motivate employees using punishment and reward. These leaders have the potential to improve job satisfaction, though overall, this style is associated with reduced empowerment and poorer health and well-being of staff (Cummings et al., 2018)

Authentic leadership

Authentic leadership is a relational leadership style that inspires staff performance and organizational outcomes. These leaders promote healthy work environments. Authentic leadership results in trust in the manager, job satisfaction, structural empowerment, positive work engagement, and work group relationships (Alilyyani, Wong, & Cummings. 2018)

 

Servant leadership

Servant leadership focuses on benevolent service to others. The servant leader puts employees first and promotes their well-being and growth and considers the interests of customers and the community. Servant leaders are role models of considerate treatment of others and help others in their development and growth. Servant leadership is akin to how nurses provide patient care, as nurses main focus is on their patients’ overall well-being and satisfaction (Neubert, Hunter, & Tolentino, 2016)

 

Path-goal leadership

Path-goal leadership motivates team members to accomplish designated goals by emphasizing the relationship between the leader, the follower, and the tasks. Path-goal leaders reward employees for meeting goals, leading to improved job satisfaction. This leadership defines goals, clarifies the path, removes obstacles, and provides support for task completion. Path-goal leaders understand the needs of the employee and shift their leadership style as necessary to motivate their employees to complete the task (Bickle, 2017)

 

 

Situational leadership

Situational leaders judge the response by the follower based on their ability and willingness to complete the task. The leader responds with one of four quadrants:

  • Telling: high task/low relationship (leader in command, situation with one correct response)
  • Selling: high task/high relationship (leader has most controls, assists subordinates with confidence to complete task)
  • Participating: high relationship/low task (leader and subordinate share decision-making)
  • Delegating: low task/low relationship (leader trusts subordinate’s ability to take full responsibility for making decisions/completing task) (Hershey & Blanchard, 1977)

Communication tools can be applied to each of the four quadrants to create an environment where communication is open, concerns and thoughts are expressed freely, and mutual understanding can become the standard within the organization. The primary consideration for a situational leader is communication and ensuring communication is clear and in partnership with the follower. By adjusting the leadership style to meet the followers’ needs, the follower grows and becomes more capable of completing the required tasks (Wright, 2017)

 

Theory X

Theory X leaders assume that employees will avoid work if possible, and they are inherently lazy and dislike work. Theory X leaders closely supervise employees (micromanage) and rely heavily on threat and intimidation to stimulate productivity.  These leaders provide clear expectations of the work they expect to be done, how it should be done, and how long it should take (Hattangadi, 2015)

 

Theory Y

Theory Y leaders assume employees will practice self-direction in achieving the goals and objectives of the organization and they are committed to those objectives. These leaders offer guidance and promote autonomy to their followers. Theory Y leaders engage their employees in decision-making processes to inspire motivation and creativity (Hattangadi, 2015)

 

Authoritarian

Authoritarian leaders do not develop relationships with their employees. This type of leadership meets goals through making demands, instituting punishments, regulations, rules and orders. These leaders are in full charge of decision-and rule-making and problem-solving. Followers must adhere to all the leader’s instructions without input and cannot question an order. Authoritarian leaders make all the decisions without employee involvement (Greenfield, 2007)

Authoritarian leadership can be an asset in situations where an urgent task must be completed in a timely manner. The authoritarian leader’s discipline and structure is essential in these situations (Wiesenthal, Kalpna, McDowell, & Radin, 2015)

 

Democratic

Democratic leaders facilitate collective decision-making, encouraging freedom and autonomy among team members. These leaders empower, support, and encourage their followers to make independent choices, thus supporting independent autonomous decision-making. Some of the core leadership traits include cooperation, active participation, accountability, and delegation of responsibilities and tasks (Avolio, Walumbwa, & Weber, 2009)

Since democratic leaders encourage autonomous and collective decision-making, the risk for role ambiguity and longer task completion can occur (Rahbi, Khalid, & Khan, 2017)

 

Laissez-faire

Laissez-faire leadership is defined as “… the avoidance or absence of leadership and is, by definition, the most inactive and most ineffective according to almost all research on the style (Bass & Avolio, 1994)

Laissez-faire leadership has been found to be the root cause of workplace role stress, which has the potential to negatively impact job satisfaction and work effectiveness (especially for those subordinates who are in need of active leadership) (Skogstad, Hetland, Glasø, & Einarsen, 2014)

Management by Walking Around

also called

Leading by Walking Around

Benefits:

  • Observes team members interacting with patients and with each other
  • Shows the team members the leader is vested in the team and interested their work
  • Ability to evaluate unit processes
  • Opportunity to evaluate the quality of work
  • Demonstrates interest in daily operations
  • Leaders can ascertain how well a unit functions through purposeful listening (Frandsen, 2014)

Leadership Characteristics

Burke, Flanagan, Ditomassi, and Hickey (2018) discusses nurse retention as an essential part of patient care delivery system. Thus, all nurse leaders must concentrate on creating ways to attract and retain nurses. Leadership characteristics identified by Burke et al. (2018) reflect transformational leadership, known to enhance job satisfaction. Qualities of exemplary nurse leaders include the following:

  • Passion
  • Optimism
  • Personal connection
  • Role modeling
  • Leadership mentoring
  • Presence
  • Availability

Burke et al. (2018) found registered nurses found the following NM behaviors positively impacted their job satisfaction:

  • Empowerment and Reflective Practice: a focus on enhancing nurse autonomy
  • Passion and Vision: the quest for excellence
  • Visibility: promotes interpersonal connections leading to a safe and caring environment
  • High Expectations and Professional Behaviors: Appreciate and value the role modeled by NMs

Leading Four Generations of Nurses

Frandsen (2014) discusses the generational divide in today’s workplace, and how nurses from four generations are working together for the first time in history. Frandsen (2014) describes the characteristics of each generation:

Silent Generation or Veterans or Traditionalists (1925-1945)

  • Likely the most disciplined employee, loyal
  • Seek approval from their employers, a traditional work ethic
  • Often have a lifetime career with one employer or one field of work
  • Respect for authority

Baby Boomer (1946-1964)

  • Optimistic, competitive, focus on personal accomplishment.
  • Work hard, often stressed, focus on achievement, seek self-improvement,
  • Complain though accept problems
  • In conflict with younger generations who do not share their values
  • Primary focus is on work, resulting in a higher susceptibility to burnout and stress-related illness

Generation X (1965-1980)

  • Many were “latch-key” children, resulting in a sense of independence that causes resentment when peers supervise their work
  • Question authority
  • Expect immediate results
  • Committed to their team and manager
  • Loyalty resides more with their peers and supervisor than with the organization

Generation Y or Echo Boomers or Millennial (1981-2000)

  • Team-oriented
  • Works well in groups
  • Multitasks
  • Willingness to work hard
  • Expects structure in the workplace
  • Respects positions and titles, seeks a satisfying relationship with managers
  • Seeks out continuing education, professional development
  • Desire to establish a relationship with their manager may cause conflict with Gen Xers who choose a hands-off approach

In order to understand peers or followers, leaders must reflect on their own generational characteristics (André, 2018).