Upon completion of this module, the learner should be able to:
- Consider the qualities of a leader versus a manager.
- Explore common leadership styles.
- Define emotional intelligence and consider how it enhances a leader’s performance.
- Identify leadership opportunities for nurses in health care organizations and educational institutions.
- Examine communication methods that promote a healthy work environment among diverse populations.
- Recognize the challenges of a leader within health care organizations.
- Understand leadership certification and training opportunities.
All nurses can be leaders. Nurses with diverse educational backgrounds, degrees, and training can be leaders. Registered nurses (RNs), licensed practical nurses (LPNs), and advanced practice registered nurses (APRNs) lead their patients and the health care team under their chain of command to optimal patient outcomes. Whether a formal or informal leader, the nurse has influence and power that can transform how others live, believe, and learn. In 2010, the Institute of Medicine (IOM) published a landmark report titled The Future of Nursing, which addressed the changes that should occur in health care and established a course of action that would facilitate high-quality nursing care. The actions were comprised of eight recommendations, including a call to equip nurses to lead the changes in health care (IOM, 2010). Leadership competencies were further reflected in the American Association of Colleges of Nursing (AACN, 2011) publication, The Essentials of Master’s Education in Nursing, focusing on the clinical nurse leader. The AACN has a mission of "transforming health care and improving health" as well as values that include "leadership, innovation, diversity and inclusion, and integrity" (AACN, 2019). Each of these organizations recognizes the need for leadership and support for nurses to become the leaders in health care. It has been noted that leadership is much more than power over others, but rather the ability to influence others (Maxwell, 1993; Dickson & Tholl, 2014). This module will explore various leadership styles and opportunities as health care is transformed today and in the future by those influencers.
Leadership versus Management
Leadership involves the influence of others, the shaping of a culture within an organization, and has implications that include relationships, interactions, and communication to drive the future vision or desired state. Leaders offer insight and perceptions on the current state and are able to analyze complex situations to develop plans for solutions and strategies for the future (Whitehead, et al., 2017). Being an expert manager is essential to an organization and its efficiency, yet very different from being an effective leader. Managers have duties that require oversight and supervision of human resources, operations, and the delivery of health care services. Some managers are also effective leaders and may be able to influence others around them, yet this skill is not required for effective management of resources (Yoder-Wise, 2015).
In addition to management and leadership, there must be followers who are willing to follow. A follower is not a passive role, but rather one that offers input, collaboration, and a willingness to be part of the leader’s vision and work toward the common goals of the organization. These categories of leaders, managers, and followers are not mutually exclusive but rather a part of a team that works collaboratively to transform health care in a positive and cohesive manner, and each role is necessary for success (Whitehead et al., 2017).
Leadership theories and styles first started to emerge more than one hundred years ago. One of the first to arise was the Trait Theory, which suggests that individuals are born into leadership roles and that they possess inherited traits of leadership. Leaders associated with this theory were often the sons from royal bloodlines, military power, extreme wealth, or areas of perceived success in the early 1900s. By the 1950s, it was recognized that birth alone is not an indicator of leadership potential. Theories during this decade were focused on traits that an individual leader had, along with behaviors and interactions with peers and subordinates. Styles of leadership grew out of these 1950s theories. By the 1960s and 1970s, situational-contingency theories were asserting that different situations called for different responses. They acknowledge that effective leaders can adapt to the required situation and recognize that certain individuals hold the traits that are required to lead, but also that the skills could be learned (Northouse, 2016).
More recently, theories have been based on a continuum of styles with transformational leadership at one end, laissez-faire at the other end, and transactional leadership in the middle of the continuum. The eight most common leadership styles are Democratic, Autocratic, Laissez-faire, Strategic, Transformational, Transactional, Coach-style, Servant, and Bureaucratic. Democratic leaders make final decisions based on the input of each team. Autocratic leaders is the opposite of the democratic leader and makes decisions without the input of others based on the good of the organization or personal preferences. The leader with a Laissez-faire style is very hands-off and often remains very limited with regards to their input. Strategic leaders focus on the organization's operations and growth opportunities rather than individual interests of employees. Transformational leaders work to transform and improve the organization's current processes and are always pushing the employees outside their comfort zone to make improvements in process and function. The Coach-style leader identifies and nurtures individual strengths of the team members and works to find strategies that will improve teamwork. Servant leaders work to serve others and focus on self-care of the employee while promoting the care of others. Bureaucratic leaders go "by the book" and may listen to employee input, but more likely to reject the input if it is outside their own desires or company policies and past processes. Transactional leadership uses rewards and punishments to achieve its goals (Whitehead et al., 2017).
Transformational leadership focuses on the needs of the followers and team members to motivate and foster personal growth among all team members. With transformational leaders, simultaneous to focusing on the team members’ needs, the organizational goals are also achieved. Transformational leaders inspire others and are commonly perceived as visionary, charismatic, and enthusiastic about their visions. They are responsive to the needs of their team members, patients, families, and customers; they seek to empower those around them to be their best (Whitehead et al., 2017).
In addition to the previous eight styles discussed above, nursing often adopts authentic leadership and servant leadership. With authentic leadership, the leader is self-aware, self-regulated, has a high level of transparency with others, and often cultivates the same values in those around them. The authentic leader has very clear values, which are reflected in their behaviors, thoughts, and interactions with others; desiring to cultivate the same behaviors in others. The servant leadership style is characterized by investing in the team members and having a true desire to serve those they interact with. The servant-leader has high moral standards, and their behaviors are congruent with those standards. They desire to facilitate the growth of those around them. The servant-leader places the needs of their customers and subordinates above their own interests to achieve the greatest outcomes (Whitehead et al., 2017).
Transformational leadership style is the most congruent with nursing philosophies and, along with servant leadership, has become a theme regarding the care of others (Whitehead et al., 2017).The transformational leadership style appears most often in the literature as the one that fits into the healthcare environment and is aligned with patient-centered care. As previously noted, these leaders can inspire positive changes in their followers. These leaders are concerned about the process as well as the people involved in the processes. The style was originally noted by leadership expert, James Burns, and was further developed by Bernard Bass who created Bass’s Transformational Leadership Theory. The theory is defined by the impact it has on others and suggests that transformational leaders garner respect, trust, and admiration from those who follow them. The main components of transformational leadership is intellectual stimulation, individualized consideration, inspirational motivation, and idealized influence. Organizations with transformational leaders tend to have very low turnover as there is a great amount of commitment to the leader. Employees working in this type of environment report a high level of well-being and workplace satisfaction. It is thought that the amount of trust, meaningfulness, and respect that is displayed in the workplace leads to this satisfaction and well-being (Choi et al., 2016).
Reflection: What kind of leadership style is most appealing to you as a follower? What kind of leader do you aspire to be?
There are consistent themes among the different leadership styles that include authenticity, self-awareness, insight to situations, and an ability to communicate effectively. Emotional intelligence (EI) is a term that describes an individual who possesses these personal characteristics. EI can be further described as an individual who has awareness, examination, and management of their own emotions and recognizes how their emotions impact interpersonal relationships, particularly in the workplace. Nurse leaders can utilize EI to develop and foster effective relationships and facilitate effective communication and teamwork across health care disciplines. Typically, a transformational, authentic, or servant leader in nursing also has a high level of EI. Individual, team, or organizational growth can culminate from a culture of transparent communication and insight into emotions by leadership (Porter-O'Grady & Malloch, 2018). Themes that emerge from individuals with a high EI include empathy, mindfulness, happiness, compassion, and a forgiving nature. Basically, those with a high EI have a highly positive impact on interpersonal relationships. Team building among members with high EI and emotionally competent behaviors provide a strong foundation. The leader is able to cultivate a spirit of mutual respect, maintain integrity, and facilitate collaboration while proactively managing conflict (Kemerer & Cwiekala-Lewis, 2016).
Nurses have many opportunities for leadership in healthcare organizations and academic institutions. Most nurses begin their careers as staff nurses in the clinical setting. Even in these early roles, the nurse can function as an informal or formal leader. Many nurses will move into unit-level management positions or may remain an influencer or informal leader as part of the healthcare team within their units. Other nurses will leave the clinical setting and move into other roles as leaders. Below are some examples of nursing leadership opportunities within healthcare organizations:
- Nurse Manager,
- Nurse Administrator,
- Nurse Supervisor,
- Director of Nursing,
- Vice President of Nursing,
- Chief Nursing Officer (CNO) (Denker et al., 2015).
Unique challenges accompany each of these roles. Nurse Managers are responsible for oversight of first-level nursing services and the utilization of resources within their units. Nurse Supervisors or Directors of Nursing may be responsible for oversight and management of several units within a hospital or clinical setting. The Vice President or Chief Nursing Officer roles are considered nurse executives and drive the delivery of health care systems and patient care services across an entire facility or health care system. Within these roles, the leader must have knowledge of accrediting requirements by the Joint Commission or other facility-specific accreditors. State and federal laws must also be understood, and policies and procedures should reflect compliance. Application of evidence-based practice (EBP), collaboration with other health care professionals, and budgetary maintenance further challenge the nurse leader in the clinical setting (Denker et al., 2015).
Examples of nursing leadership opportunities within educational institutions include:
- Assistant Deans,
- Chief Academic Officer,
- Vice President of Academics (Denker et al., 2015).
Educational leadership requires not only a high level of clinical knowledge, but also an extensive knowledge of the educational system, accrediting agencies for the overall institution, individual program accreditor(s), state and federal laws protecting students, human resource standards, and teaching and curriculum experience (Tagliareni & Brewington, 2017). The educational leader brings clinical practice and the educational system together, and many leaders in academics voice their need to be a clinical expert in addition to an educational expert. There are often special challenges within the educational system as the leader must advocate for needed resources and faculty required to establish and effectively deliver a nursing or healthcare program. Additionally, the program must build strong clinical relationships that allow clinical opportunities for their students. Safety, ethics, and evidence-based practice are aspects of the demands on healthcare education leaders (National League for Nursing [NLN], 2020).
The individual nurse must make the decision to seek out leadership positions or opportunities within their organization. Leadership competencies include the knowledge, skills, and attitudes (KSAs) needed to lead within an organization effectively. Broadly, the KSAs include EI, effective communication, self-awareness, and authenticity. KSAs for leadership can be defined through the American Organization of Nurse Leadership (AONL, previously the American Organization of Nurse Executives [AONE], 2018) core competencies for nurse leaders across specific practice areas. Competency statements address KSAs for nursing leadership roles, including the Nurse Executive, Post-Acute Care, Population Health, Nurse Manager, and System Certified Nurse Educator (AONL, 2018).
The AONL (2015) identified core competencies for nurse executives as communication, knowledge, leadership, professionalism, and business skills. Nurses in the formal leadership role can use the AONL competencies as a practice guideline or professional standard of practice. Before one can seek a leadership position, it is essential to self-assess KSAs in order to develop the areas that need refining. An often-used self-assessment for leadership skills is the Authentic Leadership Questionnaire (ALQ). This tool can be used to identify areas of strength and weakness as an authentic leader in four areas: self-awareness, relational transparency, balanced processing, and internalized moral perspective, as outlined in Table 1 (Shirey, 2015).
Authentic Leadership Questionnaire: Areas of Authentic Leadership
Additional types of leadership style quizzes are available online and can help the future or current leader determine their current style or future styles to adopt. These quizzes ask questions to help identify strengths, weaknesses, beliefs, or bias and enables prospective leaders to adopt the correct traits for a specific leadership style and work on the areas that may demonstrate weakness. Many of the quizzes will ask questions that may cause the nurse to wonder how it impacts their leadership abilities, yet they have been developed with a specific focus that will help determine leadership characteristics. Most only take a few minutes to complete and many are free to use (MindTools, 2020).
Required Competencies for Nurse Leaders
Leadership competencies require building and sustaining positive and effective relationships that promote safe and high-quality care or outcomes within the organization. Communication and EI skills that cultivate interpersonal relationships are among the key concepts necessary for strong leadership. Robust interpersonal skills are foundational for a leader. Further essential skills in leaders are understanding, appreciating, and using power and influence to promote positive change. Key constructs for leadership in health care or nursing education should include cultural humility, professional identity formation, person-centered care, and holistic health principles (IOM, 2010; Porter-O’Grady & Malloch, 2018).
Ethical leadership is foundational since the profession of nursing is grounded in the welfare of others. The nurse leader is responsible for patients, their families, coworkers, colleagues across the health care system, and community members. Ethical practice will advocate for the well-being of individuals and society and upholds the innate value of all people. Competencies grounded in ethical behaviors can contribute to trust and stronger interpersonal relationships. The aforementioned leadership styles of servant, transformational, and authentic leaders are reflective of ethical practice. Ethical practice includes the principles of truth, loyalty, equality, respect for others, doing well, and doing no harm (Yoder-Wise, 2015).
In today’s healthcare environment, a culture of excellence must exist in tandem with ethical leadership. In order to deliver safe and effective care, nurse leaders must create and maintain organizational cultures that emphasize high-performance and develop processes that maintain quality, safety, and organizational mission alignment. Leaders that intentionally model behaviors and practices reflective of the overall organizational culture and expectations translate principles into practice and deliver positive outcomes (Cochrane, 2017). Developing and maintaining a culture of excellence requires a commitment to pursue excellence each day personally and collectively as an organization. McCormack et al. (2018), define the importance of knowing oneself as a prerequisite to the delivery of person-centered nursing care and that knowing oneself impacts the overall work environment. Leaders across the entire healthcare industry note the need for teamwork and collaboration in order to deliver safe, high-quality care. Fostering strong teams also builds the following:
- Increased productivity,
- Mutual respect among coworkers,
- Increased employee satisfaction,
- Enhanced loyalty to the organization,
- Improvement in the quality of care delivered,
- Reduction in employee turnover, and
- Cost savings through staff retention (Interprofessional Education Collaborative [IPEC], 2016; Quality and Safety Education for Nurses Institute [QSEN], 2018).
Effective healthcare organizations or educational systems integrate leadership, monitor situations, offer mutual support, and implement intentional communication. According to the Agency for Healthcare Research and Quality (AHRQ, 2015), outcomes for effective teams include:
- Utilization of resources to optimize outcomes,
- Increased awareness of team roles and responsibilities,
- Constructive conflict resolution, and
- Elimination of barriers to quality and safety (AHRQ, 2015).
Leaders are positioned to cultivate a culture of excellence through their day-to-day work practices that keep a focus on the organization’s mission, vision, and values. Competent interpersonal skills that focus on a culture of mutual respect and civility develop efforts within the organization to promote safe, high-quality delivery of health care (AHRQ, 2015).
Reflection: Consider your own core values and your philosophy of nursing and nursing leadership. Do your personal values align with the mission, vision, and values of your current workplace? What problems might arise if your values are not in alignment with an organization you lead? What behaviors could you develop to lead a culture of excellence?
Communication Promoting Healthy Work Environments
While a leader may embrace or possess different leadership styles, there is a common theme among all: effective communication skills and interpersonal relationship building. Effective communication is a skill that is beneficial to everyone but is of utmost importance for a leader. As nurses, we learn the value of interpersonal communication with our patients and peers that includes verbal and non-verbal communication. We are taught to perform a quick survey of a patient, evaluate any pertinent data, and make quick decisions based on the available evidence. The leader role is no different. The leader must interact with their team, develop quick assessments of the climate of interactions, and make decisions on how to proceed with communication, both verbal and non-verbal, that will develop a healthy work environment. According to the American Nurses Association (ANA, 2017), a healthy work environment is one that is "safe, empowering, and satisfying….. a place of physical, mental, and social well-being” (para. 3). Through effective communication, leaders, workers, and managers can have a feeling of mental and social well-being (ANA, 2017).
The leader should communicate with a tone that is respectful and professional at all times. Nonverbal communication is articulated through facial expressions, body language, and eye contact. Porter-O'Grady and Malloch (2018) note that effective non-verbal communication can be displayed by:
- Maintaining eye-contact,
- Respecting personal space,
- Providing a firm handshake,
- Maintaining relaxed movements,
- Using open arm gestures,
- Showing the palms of your hands, signaling candor and credibility, or
- Nodding when people talk as to identify agreement or understanding (Porter-O’Grady & Malloch, 2018).
Non-verbal communication that is ineffective might include:
- The crossing of arms, or
- Eye-rolling (Porter-O’Grady & Malloch, 2018).
Nurse leaders count on their foundational skills, both verbal and non-verbal, in addition to enhanced communication skills to establish an atmosphere of integrity and trust, develop interpersonal relationships, and engage others in their daily work. Porter-O’Grady and Malloch (2018) identify advanced communication skills to include critical questioning, critical thinking, and critical listening. Critical questioning involves asking specific questions to clarify, validate perceptions, and understand any information being shared. Critical listening involves intentional listening to another person in an unbiased manner, demonstrating authentic presence with the other person, and valuing the other person's perspective. Critical thinking is a skill most nurses begin to develop during their education in nursing school; however, it is vital for the nurse leader. Critical thinking takes place once the listening and questioning have been completed, at which time careful analysis of the information and perceptions shared is used to develop a conclusion (Porter-O'Grady & Malloch, 2018).
Giving and receiving feedback in a professional manner is another competency for a leader. When providing feedback to another person, the following tips can be useful:
- Ensure that privacy and confidentiality are provided,
- Sandwich opportunities for improvement between positive feedback,
- Remove bias and personal feelings from feedback,
- When addressing subjective feelings, use "I" statements for the avoidance of blame,
- Ensure that feedback is timely after an incident and give the individual an opportunity to respond,
- Provide a future time for follow-up discussions (Porter-O’Grady & Malloch, 2018).
When receiving feedback from others, the following tips can be useful:
- Be receptive to feedback and maintain an open mind,
- If information is not clear, ask for specific examples and/or clarification,
- Summarize and validate the feedback to ensure that your interpretation is accurate,
- Ask the person giving feedback for direction if new information is provided or suggestions on new or different directions to consider,
- Seek an opportunity for future follow-up discussions as appropriate (Porter-O’Grady & Malloch, 2018).
Reflection: Consider the last time you received feedback from a leader in your organization. How did you feel after the interaction? What was your response? Would you do things differently now?
In addition to relationships between the leader and their immediate team, today’s healthcare environment demands teamwork, multidisciplinary collaboration between departments and other leaders, in addition to the management of situations that are often demanding. Ascertaining a proper understanding of the principles of effective team building is another competency for the healthcare leader. To add to these demands, workplaces are made up of multigenerational team members, which can lead to further conflict. Multigenerational teams can benefit from activities that promote inclusion, trust, open communication, and conflict resolution (Moore et al., 2016). Interprofessional collaborative practice has evolved out of increased awareness of patient safety and positive outcomes. With a shift in healthcare delivery models to person-centered care, it is vital for nursing leaders to develop strong interprofessional and interpersonal relationships to develop partnerships with patients, families, and populations (QSEN, 2018). The IPEC (2016) established competencies for interprofessional practice in four domains: values/ethics, roles/responsibilities, interprofessional communication, and teams/teamwork, as demonstrated in Table 2.
IPEC Core Competencies for Interprofessional Practice
Work with individuals of other professions to maintain a climate of mutual respect
and shared values.
Roles and Responsibilities
Use the knowledge of one's own role and those of other professions to assess and address the healthcare needs of patients appropriately and to promote and advance the health of populations.
Communicate with patients, families, communities, and professionals in health and other fields in a responsive and responsible manner that supports a team approach to the promotion and maintenance of health and the prevention and treatment of disease.
Teams and Teamwork
Apply relationship-building values and the principles of team dynamics to perform
effectively in different team roles to plan, deliver, and evaluate patient/population-centered care and population health programs and policies that are safe, timely, efficient, effective, and equitable.
(IPEC, 2016, p. 13)
Health care leaders are uniquely positioned to foster teamwork and interprofessional collaboration in a variety of settings, from clinical to academic. Effective teamwork can produce positive outcomes in all settings but requires leaders that are able to facilitate emotionally competent interactions. With a combination of leadership acumen, the emotionally intelligent leader is able to achieve the best outcomes for an organization (IPEC, 2016).
Challenges for the Nurse Leader
Regardless of the quality and expertise of communication, leaders will be presented with conflict and must develop skills for conflict resolution within an organization. Conflict can be constructive or destructive, based on management and resolution. Conflict will occur at all levels of an organization, and a nurse leader will have varying levels of conflict, from their subordinates to lateral leadership. Since health care involves collaboration with many stakeholders, caring for diverse populations, working in health care can lead to even more opportunities for conflict. A leader should recognize and initiate strategies to offset conflict quickly to impact positive resolution. The Thomas-Kilmann Conflict Management Model offers approaches to conflict management (Thomas, 2002).This model was developed by psychologists Kenneth Thomas and Ralph Kilmann in 2002 and is the gold-standard in corporate and workplace training. The five options to resolve conflict within this model are: competing, accommodating, avoiding, compromising, and collaborating, as described in Table 3.
Thomas-Kilmann Conflict Management Model Approaches
This method attempts to meet one’s own needs without concern or regard for the needs of others.
This method puts another person’s needs or concerns ahead of one’s own. This option is useful when another person has the best solution. The method is unassertive and very cooperative.
This method contains an attempt to avoid both conflict and addressing the other party’s concerns. It is a non-productive approach that is uncooperative and unassertive in nature.
This method involves both assertiveness and cooperativeness to find a solution that partially meets the concerns of all parties involved in the conflict.
This method involves assertiveness and cooperation and seeks a win-win for all involved.
Self-assessment of one’s current conflict management approach is crucial for the leader. By determining the current method of resolution, one can cultivate further methods and behaviors that enhance leadership competency (IPEC, 2016).
Reflection: Consider a recent workplace conflict that you may have observed or been part of. Think about how the situation was handled. Could other approaches have provided different outcomes?
Critical conversations may become part of conflict management. These conversations are held to address performance outcomes and professional behavior that is essential in maintaining organizational quality. Timely and intentional recognition of high performers is critical in retaining high-quality talent. Higher performers should be recognized with conversations that express gratitude for their work and high performance, recognize specific examples of achievement, and communicate their contributions to the overall organization. Individuals that may be performing in the middle should have critical conversations related to support and clear expectations to achieve their fullest potential. These conversations should include examples of things they are doing well, coaching in areas that need improvement with specific direction, and confirmation of the leader’s confidence in them for meeting future expectations. Conversations with low-performers can be the most difficult and should include specific descriptions of the behaviors needing improvement, explanation of the impact their behavior has, specific direction on future expectations, and a clear definition of any consequences that may occur without improvement in their performance. Trust is very important to build within a team, and critical conversations can open the door to trust and confidence in the leadership and their guidance (Donohue, 2018).
Self-care cannot be overlooked for a leader. Often, the demands of the fast-paced healthcare and educational systems and caring for others can lead to neglect of self. In order to lead others, one should be at their best self. Adequate self-care of the leader cultivates the ability to have positive interpersonal relationships and a resilient nature that can influence and impact those around them. Ways to maintain mental and emotional wellness include:
- Practice relaxation and stress management,
- Simplify life when possible,
- Limit unhealthy relationships,
- Maintain emotional connections to family and friends,
- Practice time management,
- Use emotional resources carefully,
- Assess and reduce negative stressors or distractors when possible (Cline, 2015; Whitehead et al., 2017).
Physical wellness is equally important and can be maintained through the following opportunities:
- Get adequate sleep and practice rest patterns,
- Maintain a healthy nutritional intake,
- Drink plenty of water and maintain hydration,
- Engage in regular physical activity that you enjoy,
- Eliminate unhealthy lifestyle choices,
- Surround yourself with positive people that support your healthy lifestyle (Cline, 2015; Whitehead et al., 2017).
Spiritual wellness is another opportunity for self-care, and the following suggestions can improve a leader’s spiritual well-being:
- Reflect on the connection to others,
- Spend time in meditation or prayer,
- Nurture a sense of gratitude,
- Respect personal values and beliefs, but equally respect the values and beliefs of others,
- Work to integrate kindness into everything (Whitehead et al., 2017).
Self-leadership is as important as leading others, and self-care is the initial step in the journey. Self-leadership can be challenging and requires self-awareness. Beyond identifying personal bias and beliefs, one should also consider how they relate to others, how their interactions are perceived by others, and strive to understand how they influence others, both negatively and positively. Self-reflection can be used to intentionally consider and fine-tune many of the competencies of a strong leader, including listening, collaborating with others, and communicating. Being able to self-lead is a way of managing one's self, which will aid in the recognition of areas of opportunity for improvement and taking actions to facilitate self-growth (Whitehead et al., 2017). Self-leading and self-care can result in a happier leader with work/life balance. Ways to maintain a healthier work/life balance include:
- Realizing the need for balance between work and personal life and working to pursue it intentionally,
- Setting realistic goals for personal and work performance while considering time and energy, available resources, and personal passions,
- Engaging in purposeful outside-of-work activities and personal self-care by blocking time on your work calendar,
- Monitoring progress toward goals and updating as needed to maintain work-life balance and self-care needs (Whitehead et al., 2017).
Managing change is another challenge for many leaders. Change occurs continuously in most organizations, but in health care, change is continuous and dynamic. Change can occur for many reasons and may be due to quality improvement, problem-solving, changing needs, compliance with regulatory or accreditation standards, institution of evidence-based practice, risk mitigation, a noted concern or technological advancement. Leaders from all aspects of health care are faced with the challenges of change, whether the implementation of a new curriculum in the educational setting or initiating a new staffing model as a nurse executive. However, effective leadership during change is vital. Change management theories and models can provide a foundation to facilitate change. Typical models used in health care are Lewin's Theory of Planned Change or the Plan-Do-Study-Act (PDSA Model). Lewin's model has three phases: unfreezing, moving, and refreezing. The unfreezing phase is preparing for the change. Moving involves the actual application of the change, and refreezing is the process of regaining stability as the changes are accepted and become the new norm (Whitehead et al., 2017). The PDSA model involves four phases: plan, do, study, and act. Planning is very similar to the unfreezing step above, followed by doing the change, which corresponds with Lewin’s moving step. After the change is initiated, the data or outcome of the change is studied to determine its effectiveness and establish any necessary modifications, followed finally by acting on what has been learned. This model is designed to then be repeated in a continuous loop (Yoder-Wise, 2015). Theories serve as foundational steps to keep the leader on track with the implementation of change or projects. Undoubtedly, one of the greatest barriers to change will be those being led. There will be pessimists, optimists, and those in the middle. Maxwell (1993) notes that a "pessimist complains about the wind, the optimist expects it to change, and the leader adjusts the sails." This best describes all the various players involved with change. Finding the cheerleaders or optimists will aid the leader in driving change and maintaining morale. While they may not change the pessimists’ mind, a strong leader can communicate the positive aspects of change and convince them to follow (Maxwell, 1993).
Leaders must face change within complex systems and may drive change from the micro-, meso-, and macro-levels. The microsystem of health care represents a department within an organization such as the school of nursing within a college or university. In a clinical setting, the microsystem represents a unit where patient care delivery or direct services are provided. The mesosystem represents the next level of an organization, such as the hospital, or other community-based organization. The mesosystem is led by nurse leader including a Chief Nursing Office (CNO) of a single hospital and directors. The macrosystem is the highest level and represents an entire organization or community. At this level, leaders may include government entities, professional organizations, or regulatory agencies. This leader includes Vice Presidents (VPs) of Nursing, Chief Executive Officers (CEOs), or other corporate or organization leadership titles/roles. In addition to these levels, the nurse leader must consider stakeholders, which can deliver support or resistance to change. The stakeholder is important through the change process. The nurse leader will interface with stakeholders within the micro-, meso-, and macro-system levels. The leader should consider the impact on each of these levels with any change and proactively offset any issues that may arise. CNOs and leaders at the meso- and macro-systems level manage higher level needs of the organization including compliance with accreditation requirements rather than staffing, unit budget concerns, or patient numbers on a given day (Yoder-Wise, 2015).
Changes should not occur for the sake of change; instead, they should be directed at impacting the patient or student delivery system based on evidence and best practices. The nurse leader should differentiate current policy, procedures, standards of care, best practices, and regulatory guidelines, which may serve as a support to the change initiative, and those which may prove to be a barrier to the process. Human, material, and financial resources should be considered with any change process, including support that will be needed at each level and any barriers that may be encountered (Whitehead et al., 2017).
Finally, nurse leaders must practice self-care, build a strong team culture, and work to deliver ethical and quality care. Additionally, the nurse leader must develop a professional identity and an individual performance improvement plan that works toward enhancing leadership skills and self-improvement. The Future of Nursing (IOM, 2010) included eight distinct recommendations that ensure excellence in the profession of nursing. These recommendations include a call for nurses to pursue professional development and advanced education to practice at their fullest potential and scope of practice, partner with other healthcare leaders, and lead health care while simultaneously developing the nursing workforce. Engaging in self-reflection, intentionally planning for professional development, and seeking opportunities for personal growth are critical for professional identity development as a nurse leader (IOM, 2010).
Leadership Training Opportunities
A study by Kelly et al. (2014) identified the need for training and education for frontline nurse leaders to advance their leadership KSAs. This study focused on the transformational leadership style and noted that frontline managers and directors are often ill-prepared to lead and lack transformational leadership behaviors, even though they may have strong organizational experience and knowledge of the workplace. Through their observations of over 500 frontline nurse leaders in 23 hospitals, they determined that nurse leaders with formal training in leadership and advanced education in leadership were best equipped to deliver transformational leadership that inspired a shared vision of their organization and challenged current processes, while leading evidence-based change projects (Kelly et al., 2014). As identified by the IOM (2010), advanced education allows the nurse to practice at their highest potential and leadership can be part of that growth and transformation. Most leadership positions require a minimum of a master’s degree such as the Master of Science in Nursing (MSN), or a leadership component, with a preference for PhD or DNP terminal degrees. Leadership skills are the focus of curriculum in these educational programs, yet additional training through certifications, training programs or executive coaching will heighten a leader’s KSAs (Kelly et al., 2014).
The AONL (2020) offers a specialty certification that recognizes excellence and expertise for the nurse executive. A review course is available with a focus on the AONL nurse executive competencies and their practical application. The AONL also offers membership and annual educational conferences giving the nurse executive an opportunity to share best practices, remain current and up-to-date within the field, and network with their peers. Additionally, an Emerging Nurse Leader Institute training offered by the AONL (2020) “prepares staff nurses with leadership responsibilities, assistant managers or nurses who aspire to leadership roles to train as future leaders” (para. 1).
The NLN (2020) Leadership Institute is another program for emerging nurse leaders in clinical practice or education who have recently transitioned into leadership positions. This program focuses on developing excellence in leadership. Additionally, the NLN has an advanced version for nurse executive leaders in education or clinical practice who have held their positions for at least six years and desire to reshape their practice and how they think about leadership. Both of these programs incorporate the transformational leadership style (NLN, 2020).
The American Nurses Association (ANA) has an online, self-paced leadership course in addition to a Nurse Executive Certification, the NE-BC. This certification is obtained through a competency-based examination and validates that the individual holds expertise in managing the daily operations of a clinical unit or service area within a healthcare organization (ANA, n.d.).
Many opportunities exist for ongoing education and support for the nurse executive and nurse leader. It is vital to stay engaged and network with peers. The nurse leader will also participate in training of other leaders, helping to build future leaders through mentoring and succession planning. Planning for the future is part of the leader’s role to ensure the ongoing success of an organization (Rosenthal et al., 2018).
Agency for Healthcare Research and Quality. (2015). Team STEPPS for office-based care. https://www.ahrq.gov/teamstepps/officebasedcare/index.html
American Association of Colleges of Nursing. (2011). The essentials of master's education in nursing. http://www.aacnnursing.org/portals/42/publications/mastersessentials11.pdf
American Association of Colleges of Nursing (2019). Vision and mission. https://www.aacnnursing.org/About-AACN/AACN-Governance/Vision-and-Mission
American Nurses Association. (n.d.). Nurse executive certification (NE-BC). Retrieved on January 7, 2020 from https://www.nursingworld.org/our-certifications/nurse-executive/
American Nurses Association. (2017). Healthy work environment. http://www.nursingworld.org/workenvironment
American Organization of Nurse Leadership. (2015). Nurse executive competencies. https://www.aonl.org/system/files/media/file/2019/06/nec.pdf
American Organization of Nurse Leadership. (2018). Nurse leader competencies. https://www.aonl.org/resources/nurse-leader-competencies
American Organization of Nurse Leadership. (2020). Emerging nurse leader institute. https://www.aonl.org/education/enli
Choi, S.L., Goh, C.F., Adam, M.B., & Tan, O.K. (2016). Transformational leadership, empowerment, and job satisfaction: the mediating role of employee empowerment. Human Resources Health, 14(1), 73. https://doi.org/10.1186/s12960-016-0171-2
Cline, S. (2015). Nurse leader resilience. Nursing Administration Quarterly, 39(2), 117-122. https://doi.org/10.1097/NAQ.0000000000000087
Cochrane, B. S. (2017). Leaders go first: Creating and sustaining a culture of high performance. Healthcare Management Forum, 30(5), 229-232. https://doi.org/10.1177%2F0840470417718195
Denker, A.L., Sherman, R.O., Hutton-Woodland, M., Brunell, M.L., & Medina, P. (2015). Florida nurse leader survey findings: Key leadership competencies, barriers to leadership, and succession planning needs. JONA: The Journal of Nursing Administration, 45 (7/8), 404-410. https//doi.org/10.1097/NNA.0000000000000222
Dickson, G., & Tholl, B. (2014). Bringing leadership to life in health: LEADS in a caring environment. Springer.
Donohue, W. (2018). Critical conversations as leadership: Driving change with card talk. Front Edge Publishing.
The Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. https://www.nap.edu/download/12956
Interprofessional Education Collaborative. (2016). Core competencies for interprofessional collaborative practice: 2016 update. Interprofessional Education.
Kelly, L.A., Wicker, T.L, & Gerkin, R.D. (2014). The relationship of training and education to leadership practice in frontline nurse leaders. The Journal of Nursing Administration. JONA, 44(3). 158-163. https//doi.org/10.1097/NNA.0000000000000044
Kemerer, D., & Cwiekala-Lewis, K. (2016). Emotional intelligence for leaders in nursing. Polish Nursing / Pielegniarstwo Polskie, 62(4), 562-565. https://doi.org/10.20883/pielpol.2016.60
Maxwell, J.C. (1993). Developing the leader in you. Thomas Nelson, Inc.
McCance, L.B., McCormack, B., & Brown, D. (2018). The development of the person-centred situational leadership framework: Revealing the being of person centredness in nursing homes. Journal of Clinical Nursing, 27(1-2), 427-440. https://doi.org/ 10.1111/jocn.13949
MindTools. (2020). What’s your leadership style? https://www.mindtools.com/pages/article/leadership-style-quiz.htm
Moore, J.M., Everly, M., & Bauer, R. (2016). Multigenerational challenges: Team-building for positive clinical workforce outcomes. OJIN: THe Online Journal of Issues in Nursing, 21(2), 3. https://doi.org/ 10.3912/OJIN.Vol21No02Man03
The National League for Nursing. (2020). NLN leadership institute: Lead, simulation, and executive. http://www.nln.org/professional-development-programs/leadership-programs
Northouse, P. G. (2016). Leadership: Theory and practice (7th ed.). Sage.
Porter-O'Grady, T., & Malloch, K. (2018). Quantum leadership: Creating sustainable value in health care (5th ed.). Jones & Bartlett Learning.
Quality and Safety Education for Nurses Institute. (2018). Graduate QSEN competencies. http://qsen.org/competencies/graduate-ksas/
Rosenthal, J., Routch, K., Monahan, K., & Doherty, M. (2018). The holy grail of effective leadership succession planning. https://www2.deloitte.com/us/en/insights/topics/leadership/effective-leadership-succession-planning.html
Shirey, M. R. (2015). Enhance your self-awareness to be an authentic leader. American Nurse Today, 10(8), 7. https://www.americannursetoday.com/enhance-self-awareness-authentic-leader/
Tagliareni, S. & Brewington, J. (2017). Roving leadership: Breaking through the boundaries. Wolters Kluwer.
Thomas, K. W. (2002). Introduction to conflict management: Improving performance using TKI. CPP, Inc.
Whitehead, D. K., Dittman, P., & McNulty, D. (2017). Leadership and the advanced practice nurse: The future of a changing health-care environment. F.A. Davis Company.
Yoder-Wise, P. S. (2015). Leading and managing in nursing (6th ed.). Elsevier.