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Leadership in Nursing

Definitions, Theories, and Styles of Leadership

Developing future nurse leaders is one of the greatest challenges faced by the nursing profession (Mahoney, 2001).  Powerful leadership skills are needed by all nurses—those providing direct care to those in top management positions.  Anyone who is looked to as an authority (e.g., a nurse taking care of a patient) or who is responsible for giving assistance to others is considered a leader (Mahoney, 2001).

A clinical nursing leader is one who is involved in direct patient care and who continuously improves care by influencing others (Cook, 2001).  Leadership is not merely a series of skills or tasks; rather, it is an attitude that informs behavior (Cook, 2001).  In addition, good leadership is consistent superior performance with long term benefit to all involved.  Leaders are not merely those who control others, but they act as visionaries who help employees to plan, lead, control, and organize their activities (Jooste, 2004). 

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Leadership has been defined many ways in the literature.  However, several features are common to most definitions of leadership.  For example, leadership is a process, involves influence, usually occurs in a group setting, involves the attainment of a goal, and leadership exists at all levels (Faugier & Woolnough, 2002).  There are several recognized leadership styles.  Autocratic leaders set an end goal without allowing others to participate in the decision-making process (Faugier & Woolnough, 2002).  Bureaucratic leadership occurs when a leader rigidly adheres to rules, regulations, and policies.  Participative leaders allow staff to participate in decision-making and actively seek out the participation of those involved.  This type of leadership allows team members to feel more committed to the goals they were involved with formulating (Faugier & Woolnough, 2002).  Laissez faire leadership leaves employees to their own devices in meeting goals, and is a highly risky form of leadership.  A more effective form of leadership may be situational leadership.  This is where the leader switches between the above styles depending upon the situation at hand and upon the competence of the followers (Faugier & Woolnough, 2002). 

There is a difference between theory and style of leadership.  According to Moiden (2002), theory represents reality, while style of leadership is the various ways one can implement a theory of leadership—the way in which something is said or done.  Organizations should aim for a leadership style that allows for high levels of work performance, with few disruptions, in a wide variety of situational circumstances, in an efficient manner (Moiden, 2002).  Similarly, there is a difference between management and leadership.  Managers plan, organize and control, while leaders communicate vision, motivate, inspire and empower in order to create organizational change (Faugier & Woolnough, 2002). 

Transactional versus Translational Leadership

Outhwaite (2003) cites definitions of transactional and transformational leadership as posited by Bass in 1990.  Transactional leadership involves the skills required in the effective day to day running of a team.  However, transformational leadership involves how an integrated team works together and the innovativeness of their approach to the work (Outhwaite, 2003).  For example, a leader can empower team members by allowing individuals to lead certain aspects of a project based on their areas of expertise.  This will encourage the development of individual leadership skills.  In addition, leaders should explore barriers and identify conflicts when they arise, and then work collaboratively with the team to resolve these (Outhwaite, 2003).  Furthermore, the leader should remain a part of the team, sharing in the work, thus remaining close to operations and being able to understand the employee’s perspective (Outhwaite, 2003).

Transactional leadership focuses on providing day-to-day care, while transformational leadership is more focused on processes that motivate followers to perform to their full potential by influencing change and providing a sense of direction (Cook, 2001).  The ability of a leader to articulate a shared vision is an important aspect of transformational leadership (Faugier & Woolnough, 2002).  Transactional leadership is most concerned with managing predictability and order, while transformational leaders recognize the importance of challenging the status quo (Faugier & Woolnough, 2002). 

One group of authors described the use of transformational leadership by Magnet hospitals (De Geest, Claessens, Longerich, & Schubert, 2003).  This leadership style allows for instilling faith and respect, treating of employees as individuals, innovation in problem solving, transmission of values and ethical principles, and provision of challenging goals while communicating a vision for the future (De Geest, et al., 2003).  Transformational leadership is especially well-suited to today’s fast-changing health care environment where adaptation is extremely important.  The author cites findings that this leadership style is positively associated with higher employee satisfaction and better performance.  These, in turn, correlate positively with higher patient satisfaction (De Geest, et al., 2003).  One way to facilitate change using transformational leadership involves the use of action learning (De Geest, et al., 2003).  Leaders use directive, supportive, democratic, and enabling methods to implement and sustain change.  The effects of such leadership will radiate to better outcomes for both nurses and patients.
Transformational leadership focuses on the interpersonal processes between leaders and followers and is encouraged by empowerment (Hyett, 2003).  Empowered nurses are able to believe in their own ability to create and adapt to change.  When using a team approach to leadership, it is important to set boundaries, goals, accountability, and supports for team members (Hyett, 2003).  Transformational leadership is seen as empowering, but the nurse manager must balance the use of power in a democratic fashion to avoid the appearance of abuse of power (Welford, 2002).  Respect and trust of staff by the leader is essential.

Clinical or Shared Governance

Clinical governance is a new way of working in which National Health Service (NHS) organizations are accountable for continuous quality improvement, safeguarding standards of care, and creating an environment for clinical excellence (Moiden, 2002).  Requirements of several recent UK government policies require that new forms of leadership better reflecting the diversity of the workforce and the community be developed (Scott & Caress, 2005).  Leadership needs to be strengthened and needs to involve all staff in clinical leadership.  Shared governance is one method of allowing for this.  This form of leadership empowers all staff for decision making processes, and allows staff to work together to develop multi-professional care (Scott & Caress, 2005).  Shared governance is a decentralized style of management in which all team members have responsibility and managers are facilitative, rather than using a hierarchical management style where managers are controlling and staff are not involved in decision-making (Scott & Caress, 2005).  Scott and Caress (2005) contend that this type of leadership will lead to increased morale and job satisfaction, increased motivation and staff contribution, encouragement of creativity, and increased sense of worth.

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Knowledge, Attitudes, and Skills of an Effective Nurse Leader

A clinical nursing leader is one who is involved in direct patient care and who continuously improves care by influencing others (Cook, 2001).  Leadership is not merely a series of skills or tasks; rather, it is an attitude that informs behavior (Cook, 2001).  Several important functions of a nurse leader are: acting as a role model, collaboration to provide optimum care, provision of information and support, providing care based on theory and research, and being an advocate for patients and the health care organization (Mahoney, 2001).  In addition, nurse leaders should have knowledge of management, communication, and teamwork skills, as well as some background in health economics, finance, and evidence-based outcomes (Mahoney, 2001).  Personal qualities desirable in a nurse leader include competence, confidence, courage, collaboration, and creativity.  Nurse leaders should be aware of the changing environment and make changes proactively.  Leaders who show concern for the needs and objectives of staff members and are cognizant of the conditions affecting the work environment will encourage productivity (Moiden, 2003).  In doing this, it is important that a philosophy of productivity is established.

According to Jooste (2004), three things that are essential to leadership are authority, power, and influence.  Effective leaders of today should use more influence and less authority and power.  It is more important to be able to motivate, persuade, appreciate, and negotiate than to merely wield power.  The author cites three categories of influence for nurse leaders to use in creating a supportive care environment.  These include modeling by example, building caring relationships, and mentoring by instruction (Jooste, 2004).  In addition, Jooste lists five practices fundamental to good leadership including inspiring a shared vision, enabling others to act, challenging processes, modeling, and encouraging.  For example, a leader may challenge others to act by recognizing contributions and by fostering collaboration.  Recognizing contributions also serves to encourage employees in their work.  Team leadership moves the focus away from the leader towards the team as a whole (Jooste, 2004). 

Applications to Practice Settings

Hyett described several barriers to health visitors taking on a leadership role (2003).  For example, health visitors usually work in a self-led environment, yet there may be no mechanism for self control or decision-making at the point of service—thus stifling innovation (Hyett, 2003).  Furthermore, if nurses who do try to initiate change are not supported, they lose confidence and assertiveness and may feel disempowered and unable to support one another (Hyett, 2003).  Management often focuses on the volume of services provided, leading to loss self-esteem and dependence—causing workers to become disruptive, or to leave the organization (Hyett, 2003). 

Focus group data from a study of implementing change in a nursing home suggests that nurses want a leader with drive, enthusiasm, and credibility—not mere superiority (Rycroft-Malone, et al., 2004).  Further, focus group members identified qualities desired in a leader facilitating change.  This person should have knowledge of the collaborative project, should have status with the team, should be able to manage others, take a positive approach to management, and possess good management skills (Rycroft-Malone, et al., 2004).

Applications to the Wider Health and Social Context

Nurse leaders function at all levels of nursing from the ward through top nursing management.  Over time, the function of leadership has changed from one of authority and power to one of being powerful without being overpowering (Jooste, 2004).  Boundaries between upper, middle, and lower level leaders are becoming blurred, and responsibilities are becoming less static and more flexible in nature.  In other words, there is a trend toward decentralization of responsibility and authority from upper to the lower levels of health care delivery (Jooste, 2004). 
An ongoing program of political leadership at the Royal College of Nursing describes a multi-step model for political influencing (Thomas, Billington & Getliffe, 2004).  Some steps include: identifying the issue to be changed, turning the issue into a proposal for change, find and speak with supporters and stakeholders to develop a collective voice, identification of desired policy change outcomes, and construction of messages to get the issue across (Thomas et al., 2004). 

Education for Leadership

In order for nursing practice to improve, an investment must be made in educating nurses to be effective leaders (Cook, 2001).  Cook contends that leadership should be introduced in initial nursing preparation curricula, and mentoring should be available for aspiring nurse leaders (2001).  For example, the use of evidence-based practice requires nurses to be able to evaluate evidence and formulate solutions based upon the best available evidence (Cook, 2001).  In order for these things to occur, it is important that nurses have educational preparation for leadership during training to prepare them to have greater understanding and control of events that may occur during work situations (Moiden, 2002).

The NHS has adopted the Leading an Empowered Organization (LEO) project in order to encourage the use of transformational leadership (Moiden, 2002).  By doing so, the goal is to enable professionals to empower themselves and others through responsibility, authority, and accountability.  The program also aims to help professionals develop autonomy, take risks, solve problems, and articulate responsibility (Moiden, 2002).  Strategies such as the Leading and Empowered Organization (LEO) programme and the RCN Clinical Leaders Programme are designed to produce leaders in nursing who are aware of the benefits of transformational leadership (Faugier & Woolnough, 2002).

Challenges and Opportunities to Stimulate Change 

The health care environment is constantly changing and producing new challenges that the nurse leader must work within (Jooste, 2004).  Leadership involves enabling people to produce extraordinary things while being faced with challenge and change (Jooste, 2004).  While management in the past took a direct, hierarchical approach to leadership, the time has come for a better leadership style that includes encouragement, listening, and facilitating (Hyett, 2003).  Hyett (2003, p. 231) cites Yoder-Wise (1999) as defining leadership as “the ability to create new systems and methods to accomplish a desired vision”.  Today, the belief is that anyone can be a leader—leadership is a learnable set of skills and practices (Hyett, 2003).  All nurses must display leadership skills such as adaptability, self-confidence, and judgment in the provision of health care (Hyett, 2003).  The expectation is that nurses lead care, and that they be able to move between leading and following frequently (Hyett, 2003).

Empowering Patients to Participate in the Decision-Making Process

Only when health care services are well-led will they be well-organized in meeting the needs of patients (Fradd, 2004).  Nurses have considerable influence on the patient’s experience as patient involvement in care is most often nurse-led (Fradd, 2004).  Today, patients are more aware of their own health care needs and better informed about treatments and practice.  This requires nurses to be better equipped with analytical and assertiveness skills (Welford, 2002).  Transformational leadership is ideal for today’s nursing practice as it seeks to satisfy needs, and involves both the leader and the follower in meeting needs (Welford, 2002).  It is also flexible—allowing the leader to adapt in varied situations.  The leader accepts that things will change often, and followers will enjoy this flexibility.  Thus both nurses and patients will benefit.  The avoidance of hierarchy and the ability to work in new ways helps organizations put resources together to create added value for both employees and consumers (Welford, 2002).  Further, use of transformational leadership allows team nurses to enhance their role as teacher or advocate (Welford, 2002). 

Cook, M. (2001).  The renaissance of clinical leadership.  International nursing review, 48: 38-46. 

De Geest, S., Claessens, P., Longerich, H. and Schubert, M. (2003).  Transformational leadership: Worthwhile the investment!  European Journal of Cardiovascular Nursing, 2: 3-5.

Faugier, J. and Woolnough, H. (2002).  National nursing leadership programme.  Mental Health Practice, 6 (3): 28-34.

Fradd, L. (2004).  Political leadership in action.  Journal of Nursing Management, 12: 242-245. 

Hyett, E. (2003).  What blocks health visitors from taking on a leadership role?  Journal of Nursing Management, 11: 229-33.

Jooste, K. (2004).  Leadership: A new perspective.  Journal of Nursing Management, 12: 217-223.

Mahoney, J. (2001).  Leadership skills for the 21st century.  Journal of Nursing Management, 9: 269-71.

Moiden, N. (2003).  A framework for leadership.  Nursing Management, 9: 19-23.

Moiden, M. (2002).  Evolution of leadership in nursing.  Nursing Management, 9: 20-25.

Outhwaite, S. (2003).  The importance of leadership in the development of an integrated team.  Journal of Nursing Management, 11: 371-76.

Rycroft-Malone, J., Harvey, G., Seers, K., Kitson, A., MCormack, B, and Titchen, A. (2004).  An exploration of the factors that influence the implementation of evidence into practice.  Journal of Clinical Nursing, 13: 913-24.

Scott, L. and Caress, A-L. (2005). Shared governance and shared leadership: Meeting the challenges of implementation.  Journal of Nursing Management, 13: 4-12.

Thomas, S., Billington, A. and Getliffe, K. (2004).  Journal of Nursing Management, 12: 252-57. 

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