and Management
Judith Walters, DNP, RN, PMHCNS-BC
L E A R N I N G O U T C O M E S
● Define historical development of leadership theories.
● Describe contemporary leadership theories.
● Describe primary characteristics of leaders and managers.
● Examine the value of self-awareness and emotional intelligence in leadership.
● Determine how leaders can identify different types of followers.
● Explain how leaders and managers can be effective mentors.
B
ecause nurses embody the largest number of professionals in health care, they are most often the closest to the patient and therefore offer a unique perspective of the entire system of care surrounding the patient. This places nurses in a prime position to be leaders. The Institute of Medicine (IOM) report The Future of Nursing:Leading Change, Advancing Health (2011) contended that strong nursing leadership is critical to addressing the demands of the increasingly complex health-care system. Further, “the nursing profession must produce leaders throughout the health care system, from the bedside to the boardroom, who can serve as full part- ners with other health professionals and be accountable for their own contributions to delivering high-quality care while working collaboratively with leaders from other health professions” (p. 221).
K E Y T E R M S Authentic leadership Connective leadership Behavioral theories Emotional intelligence Followership Mentorship Quantum leadership Self-awareness Transactional leadership Transformational leadership
To navigate the evolving health-care landscape, all nurses must recognize and embrace their leadership responsibilities and understand nursing leadership competencies. All nurses, regardless of their positions, must develop leadership skills with an emphasis on effective decision making, initiating and maintaining effective working relationships, using respectful communication, collaborating on interprofessional and intraprofessional teams, coordinating care effectively, and developing delegation skills and conflict resolution strategies (American Association of Colleges of Nursing [AACN], 2008).
Additionally, all nurses are managers in some way. They may be in a formal management position or managers at the bedside. Nurses in formal management positions are typically in a hierarchical position with subordinates. In this role, they focus on the following: order, consistency, and planning; organizing and budgeting, establishing and enforcing rules; and taking corrective action. The responsibilities of managers at the bedside include the following: managing care transitions; ac- tively participating on interprofessional and intraprofessional teams; identifying system issues; and developing working skills in delegation, prioritization, and overseeing patient care (AACN, 2008, p. 35).
Leadership and management, in fact, are not interchangeable. In the best scenario, a manager is a true and effective leader; however, an excellent leader may not have any management responsibilities within an organization. Although there are many similarities between leadership and management—both involve the direction and influence of others, and both entail the accomplishing of tasks and goals of an organ- ization—there are significant differences. Leadership is a process of influencing others through effective relationship skills, whereas management is a formal positon with specific functions. Ideally, a nurse can be both a leader and a manager simultaneously.
This chapter is designed to assist in preparing nurses to perform as leaders by providing information on historical perspectives, current leadership theories, char- acteristics of leaders, and followership. In addition, leadership and management competencies, mentoring, and self-awareness will be discussed.
Knowledge, skills, and attitudes related to the following core competencies are included in this chapter: patient-centered care; and teamwork and collaboration.
HISTORICAL DEVELOPMENT OF LEADERSHIP
Established in fields such as business, psychology, sociology, and anthropology, management theories were developed as a means to enhance productivity in busi- ness (Marquis & Huston 2015), with leadership theories growing from the science of management. Historical perspectives on leadership and management are still relevant today because modern theories of leadership incorporate some of the ideas first introduced almost a century ago. Nursing has traditionally borrowed various theoretical ideas from medicine, psychology, sociology, and business, with leader- ship theories developed from these various contributions.
Trait Theories
One early leadership theory from the 19th century was “The Great Man Theory,”
focused on the traits of a leader and noting that certain men were born leaders
(Raelin, 2015). The focus of leadership research during this time involved the study of popularly identified great leaders. The goal was to identify what traits these in- dividuals possessed, with the aim of being able to identify new potential leaders more quickly.
Leadership Styles
The next phase in the development of leadership theories (1940 to 1960) concen- trated on the identification of styles of leadership. The emphasis of study was on what leaders did, rather than on innate traits, and these theories were also known as behavioral theories(Raelin, 2015). These theories centered on how leaders and managers conducted themselves. Primary leadership styles were identified as autocratic (authoritarian), democratic (participative), and laissez-faire (Lewin, 1951). Table 3-1 notes characteristics associated with these primary leadership and management styles.
Situational and Contingency Leadership Theories
From 1950 to 1970, building on behavioral theories, researchers began to identify new contributing factors to leadership theories. One idea that evolved at this time was that situational factors contributed to the leadership style one embraced. This approach considers that a leader may be effective in certain situations and less effective in others. Another model, contingency leadership, involved a complex process of evaluating a leader’s style, the relationship with followers, and the task to be completed (Fiedler, 1967).
CONTEMPORARY THEORIES OF LEADERSHIP
There are numerous contemporary leadership theories that grew from examining the multiple factors that contribute to successful leadership. Many modern theories continue to include concepts developed in earlier research but have expanded to
Style Autocratic
Democratic
Laissez-faire
Table 3–1 Primary Styles of Leadership and Management Characteristics
● Makes decisions without input from the team
● Does not consider valuable suggestions from team members’ input
● Potentially demoralizes team members
● Expects team members to contribute to the decision-making process
● Encourages team input
● Analyzes and makes final decisions
● Increases participation in projects and creative solutions
● Brings about higher production and satisfaction
● Provides advice, support, and timelines with low-level involvement
● Lacks focus or time management, resulting in high job satisfaction with risk of low productivity
● Risks the potential of team members not having the knowledge to execute the tasks
● May find intrateam disagreements common, which may produce disharmony
include a multidimensional approach. In the late 20th century, leadership theorists started to notice that for leaders to be effective, the values and beliefs of the envi- ronment needed to be considered. Change cannot occur simply by a talented leader’s imposing it; rather, relationships within the organization need to be culti- vated to promote a productive and healthy environment. This marked a significant shift in leadership theories from those based on industrial models to theories that are more relationship focused. This progression is noteworthy for nursing because it incorporates the multifaceted nature of health-care organizations. Nurses find themselves being called to leadership in ever-changing, complex environments where there are multiple stakeholders, increasing pressures of cost containment, and pay-for-performance initiatives. In the past, leadership theories were broken down into two types: relational and attribution. Currently, leadership theories have become multifactorial.
Relational Leadership Theories
Relational leadership theories focus primarily on the relationship that occurs between the leader and the team member. There is less emphasis on a leader’s traits, the situ- ation or context, or the end result and more emphasis on the leader’s relations with others. Relational theories such as quantum, transactional, transformational, and connective share the objective of optimizing the rapport among team members and building teams.
Quantum Leadership
Quantum leadershipdraws some of its basic tenets from quantum theory in physics:
The transition has begun in moving from views that are orderly and linear to those that are holistic and relational (Porter-O’Grady, 1999, p. 38). Traditionally, leaders have looked at work activities from the basic perspective of identifying tasks, jobs to be completed, and roles to be performed. The quantum leader looks at the system, the processes, and the relationships between workers and tasks to determine efficiency and job performance. The unpredictability of a world dominated by chaos mandates models of leadership that incorporate flexibility and adaptability. Quantum leadership involves the premise of an increasingly complex, dynamically changing health-care environment. Nurses as leaders today are faced with ever-increasing complexity in both job duties and techno- logical advances. Quantum leadership offers nursing a framework within which to develop leadership skills to assist in advancing the goals of their organizations.
Transactional Leadership
Transactional leadershipis one of the most common styles of leadership in health- care institutions. The transactional leader focuses on the goals of the organiza- tion, with a directive style establishing expectations for team members and motivating with rewards. With this type of leadership, both the leader and the team member gain something from the interactions, although theirs is not
necessarily a shared vision. The leader is focused on getting the job done, and the team member is motivated by the reward earned. This approach limits innovation and the ability for team members to truly engage in the outcomes of their work. Given the focus of task completion, the concrete rewards that followers receive are more generally limited to a sense of a job well done (Burke et al., 2006).
Transformational Leadership
As health care has evolved and increased in complexity, it has become necessary for leadership models to address identified aims of quality improvement, particularly in keeping with the recommended aims of the IOM: the provision of safe, effective, patient-centered, timely, efficient, and equitable care (IOM, 2001). One leadership theory that fits well with these aims is transformational leadership.
Transformational leadershipinvolves an active involvement of both the leader and team members. It is a process in which leaders and team members “motivate each other to attain and achieve levels of success” (O’Neill, 2013, p. 179). There is a unified investment in achieving the goals of the organization with shared values. A transformational leader guides staff in creating an environment in which all members contribute to meeting the mission of the organization. The leader provides a vision that has included the input of all members, thus encour- aging members to reach their highest potential and often exceed expectations.
Transformational leaders transform organizations. In the process, all nurses at all levels of the organization are involved in decision making. Transformational leaders are able to help followers grow by responding to needs, empowering in- dividuals, and aligning goals and objectives across all levels in an organization (ANA, 2013).
Transformational leaders are comfortable with challenging themselves, learn from their failures, and consistently demonstrate effectiveness in organizational change and innovation (O’Neill, 2013). Transformational leadership is viewed as an effective type of leadership for nurses to lead the change necessary to meet the demands of the current health-care system. This type of leadership has been iden- tified as one of the five components of the Magnet Recognition Program, discussed in Chapter 8.
Connective Leadership
Although transformational leadership attends to the creation of relationships by consensus building, resolving conflict, and establishing common goals, another popular theory focuses on caring. Connective leadershipincorporates the needs of diverse stakeholders within the health-care environment through acknowledg- ment and use of the strengths of members and by including them in the leadership process (Lipman-Blumen, 1992). Nurse leaders and managers must consider not only whom they are guiding but where they may be leading them. Today’s health- care environment demands a seamless continuity of care across multiple settings.
Connective leaders identify and foster strengths of team members by including them in the processes of change within the organization (Klakovich, 1996). A suc- cessful connective leader can develop future leaders who begin contributing early in their career, well before undertaking a formal nursing leadership position.
Attribution Leadership Theories
Attribution leadership theories share the historical perspective of trait theories, by considering the characteristics or attributes of the leader as the cornerstone within leadership relationships. In contrast to trait theories, attribution theories also take into consideration either the context or the interrelational aspects. Nurse leaders are neither born nor practicing within a vacuum.
An attribution leadership theory used in nursing is authentic leadership. Leaders engaged in authentic leadership hold firmly to their values, beliefs, and principles and inspire their followers. The determination and courage of the authentic leader in difficult and challenging times create an environment that is predictable, efficient, and steadfast. In addition, the integrity of the leader is evidenced by a strong com- mitment to truth telling, thereby decreasing ambiguity in the system and increasing efficiency and productivity (Shirey, 2006). When leader’s integrity is at a high point, a healthier work environment is achievable. The health-care environment can pres- ent challenges from multiple conflicting stakeholders with competing agendas, and these challenges require fortitude and steadfastness from leaders. For example, fi- nancial pressures may be placed on nurse leaders and managers to adjust nursing care to fit within specific parameters that are not in keeping with their own value system (e.g., being asked to change nurse-patient ratios to unacceptable levels). An authentic leader will be challenged to hold steady to his or her beliefs and values.
The authentic leader must embrace self-awareness and self-regulation to en- hance moral leadership (Waite, McKinney, Smith-Glasgow, & Meloy, 2014, p. 283).
In moral leadership, the core ethical principles of nursing are held in highest regard.
An authentic leader, while holding these principles in mind, “develop(s) heart and compassion by getting to know the life stories of those with whom they work and by engaging co-workers in shared meaning” (Shirey, 2006 p. 261). The five distin- guishing characteristics of authentic leaders are purpose, heart, self-discipline, relationships, and values (p. 260).
EMERGING LEADERSHIP THEORIES
The newest and latest developments in nursing leadership and management in- volve aspects such as “strategic agility” (Shirey, 2015) and “system leadership”
(Senge, Hamilton, & Kania, 2015). While the health-care industry is constantly un- dergoing change and being required to adapt, it is the nurse leader and manager’s responsibility to ensure safety and quality. Nurse leaders and managers must
“incorporate strategic agility to be bold and mindful” (Shirey, 2015, p. 305). In con- trast to the singular focus on the leader’s responsibility, there is the case for system leaders to “develop in order to foster collective leadership” (Senge, Hamilton, &
Kania, 2015), to provide a broader perspective to solve larger problems. The current
development of leadership theories is moving toward a more comprehensive view, incorporating flexibility and adding broader perspectives.
PROFESSIONAL COMPETENCE IN NURSING LEADERSHIP
According to the American Nurses Association (2015), the public has a right to expect all nurses to demonstrate competence throughout their careers. Nurses are individually accountable for attaining and maintaining professional competence.
Nurses need to develop leadership competencies that “emphasize ethical and critical decision-making, initiating and maintaining effective working relationships, using mutually respectful communication and collaboration within interprofessional teams, care coordination, delegation, and developing conflict resolution strategies”
(AACN, 2008, p. 13). The ANA (2015) believes that competence in nursing practice can be defined, measured, and evaluated. Further, ANA (2013) believes competence in nursing leadership can also be defined and measured.
No one document or organization encompasses all required competencies for nursing leadership and management. However, many share the same themes (ANA, 2016). In Nursing: Scope and Standards of Practice (2015), the ANA identifies leadership as a standard of professional performance for all nurses stating, “the registered nurse leads within the professional practice setting and the profession”
(p. 75). The registered nurse:
● Contributes to the establishment of an environment that supports and maintains respect, 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 profes- sional organizations.
● Influences policy to promote health.
The ANA developed the Leadership Institute for all nurses with career goals of excelling in his or her role, refining leadership knowledge, skills, and attitudes, and enhancing leadership impact (ANA, 2013). The Leadership Institute identified specific leadership competencies that transcend those developed by other nursing organizations and identify leadership competencies across the course of profes- sional development (ANA, 2013, p. 5). The competencies are organized by three domains: Leading Yourself, Leading Others, and Leading the Organization.
LEADERSHIP CHARACTERISTICS
It is no longer a prevailing belief that leaders are born. Leaders must constantly learn new skills and competencies. Although certain innate qualities can make a person a better leader, leaders today cannot rely on natural instincts alone to lead
successfully. Common characteristics exhibited by successful leaders are illustrated in Box 3-1.
Five core characteristics common to the basis of leadership are character, com- mitment, connectedness, compassion, and confidence (Kowalski & Yoder-Wise, 2004). A person’s character is anchored in his or her values, based on standards established over time. A leader with character incorporates moral accountability while never losing sight of human dignity, humility, and caring. Character forms the backbone of a leader.
As an aspect of leadership, commitment encompasses a leader’s ability to make a promise, keep it, and carry through with the promise. Commitment is measured by how well a leader can be trusted to keep his or her word. Both char- acter and commitment can really be gauged only within the context of connected relationships, or connectedness. The strength of the connections a leader makes lies in respect and authenticity and will determine the effectiveness of his or her leadership.
Compassion is a hallmark of nursing and an essential aspect of leadership. Some nurse leaders and managers are able to recognize the individual strengths and
The American Organization of Nurse Executives (AONE), a subsidiary of the American Hospital Association, was established in 1967 to “promote nursing leadership excellence and shape public policy for health care nationwide” (AONE, 2016, para 1). The AONE mission—”to shape the future of health care through innovative and expert nursing leadership”(AONE, 2016, para 2)—applies to all nurses, whether the nurse functions in a frontline nurse position or as a nurse executive. The AONE has stood as a guiding light for nursing leadership in the health-care field and has functioned as an advocate through research, education, and professional development. The AONE is committed to developing and disseminating leadership competencies for nurses at all levels of responsibility and in a variety of settings. The core competencies for leadership are organized according to five distinct domains: 1) communication and relationship-building, 2) knowledge of the health- care environment, 3) leadership, 4) professionalism, and 5) business skills (AONE, 2015a). Each domain is broken down into specific knowledge and skills that nurse leaders and managers need to develop to achieve this competency.
Nurse Executive
The AONE (2015a) competencies for nurse executives outline the knowledge, skills, and attitudes current and aspiring nurse leaders and managers can use to guide practice, identify areas for growth, and plan for future careers. The competency domains and core competencies are available at http://www.aone.org/
resources/nec.pdf
Nurse Manager
The AONE (2015b) competencies for nurse managers outline the knowledge, skills, and attitudes nurse leaders and managers need to create safe and healthy environments that support the work of the health care team and promote optimal patient outcomes. The core competencies are organized according to the Nurse Manager Learning Domain Framework: The Science, Managing the Business; The Leader Within, Creating the Leader in Yourself; and The Art, Leading the People. The competency domains and core competencies are available at http://www.aone.org/resources/nurse-manager-competencies.pdf
❂ American Organization of Nurse Executives Competencies