About this course:
This course explores the historical development of various leadership theories, including transformational, transactional, and laissez-faire. It also discusses the relationship between effective leadership and patient and nurse outcomes.
This course explores the historical development of various leadership theories, including transformational, transactional, and laissez-faire. It also discusses the relationship between effective leadership and patient and nurse outcomes.
Upon completion of this module, learners should be able to:
- explore the role of the Institute of Medicine (IOM) Future of Nursing report in advancing nursing leadership
- discuss the similarities and differences between management and leadership
- describe the historical development of various leadership theories, including transformational, transactional, and laissez-faire
- explore the relationship between transformational leadership and patient and nurse outcomes
Nurses are responsible for offering high-quality, evidence-based care to optimize patient outcomes. As new treatments emerge, people are living longer, healthier lives. As the US population ages, more people live with chronic health conditions. These conditions have created a clinical environment that is more complex than ever before. In addition, the US healthcare system is fragmented and costly, with many challenges that impact the overall delivery of patient care. Some of these challenges include widespread staffing shortages, inexperienced healthcare personnel, healthcare disparities, and the lack of available resources for the overwhelming patient care needs. The Institute of Medicine (IOM, now the National Academies of Sciences, Engineering, and Medicine [NASEM]) published the Future of Nursing: Leading Change, Advancing Health report in 2011. In this report, the IOM highlighted that the US has an opportunity to transform the healthcare system and provide affordable, seamless, quality care to all patients. They further recommend that the care provided be patient-centered and supported by evidence to ensure optimal health outcomes. For this transformation to occur, remodeling of the healthcare system must occur. With more than 3 million nurses in the US, they represent the largest group of healthcare professionals. They are uniquely positioned to meet the demand for equitable, high-quality, safe, patient-centered care. The IOM report offers 4 recommendations for nurses to support the efforts to improve the health of the US population (IOM, 2011):
- Nurses should practice to the full extent of their training and education. This includes addressing barriers to the scope of practice regulations and transition to practice.
- Nurses should achieve higher levels of training and education through improved educational systems that ensure seamless academic progression. Nursing has multiple educational pathways that lead to entry-level nursing licensure. As the complexity of care has increased over the last decade, increased nursing competence is also required. In addition to basic foundational principles to care, nurses need education regarding public health, leadership, evidence-based practice (EBP), health policy, and teamwork and collaboration. Educational institutions must expand nursing curricula to meet the need for increased nurse competence. In addition, nurses must achieve higher levels of education, including more baccalaureate (BS), master (MS), and doctorate nurses.
- Nurses should be full partners, with physicians and other health professionals, in redesigning healthcare in the US. For nurses to be an active component of the transformation of the healthcare system, the nursing profession must produce leaders who can function throughout the healthcare system. Being full, active partners requires nurses to develop leadership skills and competencies to guide systemic changes at the unit, organizational, or national level. Effective nursing leadership is fundamental to advancing the nursing profession.
- Effective workforce planning and policymaking require better data collection and improved information infrastructure. Workforce planning is necessary to address staffing shortages across healthcare professionals. Effective planning has been limited by insufficient data collection and infrastructure. Significant funding has been designated for workforce data collection.
In 2016, NASEM published a report assessing the progress of the 2011 Future of Nursing report. Specifically, NASEM assessed the progress toward the recommendation for advancing nursing leadership in the healthcare system. NASEM found that leadership development opportunities have been established through the creation of nursing education programs; however, it was determined that there is insufficient evidence to determine whether nurses are being prepared to lead (NASEM, 2016). Given the increasing complexity of the healthcare system and the need for safe, equitable, quality care, healthcare organizations must focus on strategies to develop effective nurse leaders. Transformational leadership is a leadership style that encompasses characteristics and behaviors that positively influence organizational performance and patient outcomes. Since transformational leadership has been associated with improved performance and outcomes, it can play a significant role in developing a culture of safety and high-quality care within an organization (American Association of Colleges of Nursing [AACN], n.d.; Fischer, 2016).
Leadership versus Management
Based on recommendations from the IOM, healthcare organizations are tasked with developing nursing leaders. Nurses can function as leaders in formal or informal roles; both are important to the nursing profession. However, nurses must receive training on various leadership characteristics and styles and be equipped with the skills necessary to be a leader. First, nurses must understand the difference between leadership and management. These terms are often used interchangeably, but they are inherently different. The relationship between leadership and management has often been a topic of debate, with many believing that leadership is superior to management; however, both fill essential needs. Some sources argue that leadership is one of the functions within management, while others argue that leadership requires more complex skills and that management is only a part of the leadership role. A manager can be a manager and not a leader; a leader can be a leader and not a manager (Finkelman & Kenner, 2016; Marquis & Huston, 2021).
Management is the process of directing all or part of an organization by deploying and manipulating resources. A manager holds a formal administrative position and focuses on planning, organizing, and controlling. In contrast, leaders are out front, taking risks and challenging the status quo. They gain their leadership role through their ability to influence others and not necessarily through a formal title (Finkelman & Kenner, 2016; Marquis & Huston, 2021). See Table 1 for a comparison of traditional management and leadership components.
Comparison of Traditional Management and Leadership Components
(Finkelman & Kenner, 2016; Marquis & Huston, 2021)
Given the complexity of the healthcare system, nurse managers must shift from a traditional focus on operational task completion to incorporating leadership skills such as collaboration, communication, delegation, motivation, and coordination. They must also recognize the importance of data and outcomes, manage resources, build teams, improve staff performance, and evaluate the effectiveness of interventions. They need to use critical thinking, clinical reasoning, and clinical judgment and be flexible and adaptable to change. Integrating management and leadership skills is critical to the success of healthcare organizations. Successful clinical nurse leaders can balance good management and leadership skills (Finkelman & Kenner, 2016; Marquis & Huston, 2021).
Historical Development of Leadership Theories
Historically, strong management skills were considered more valuable than leadership skills. As a result, leadership theories were not discussed until the 20th century, when early theories focused on broad conceptualizations of leadership. From 1900 to 1940, the Great Man theory and trait theories were predominantly discussed. The Great Man theory asserts that leadership is inherent at birth: some people are born to lead, while others are born to be led. This theory also posits that great leaders will arise when the situation demands it. Similarly, trait theories suggest that people are born with certain characteristics or personality traits that make them better leaders than others. Researchers identified numerous traits that define great leaders by studying the lives of prominent people in history. However, trait theories did not account for the impact of followers and the situation. Although many identified traits are still used today to describe effective leaders, opponents of trait theories argue that leadership is not just inherited but can be a skill that is developed (Marquis & Huston, 2021). See Table 2 for the characteristics associated with effective leadership.
Characteristics Associated with Effective Leadership
Collaborative priority setting
Emotional balance and control
(Marquis & Huston, 2021).
From 1940 to 1980, researchers shifted away from studying the traits of leaders and focused more on the behaviors of leaders (i.e., the leadership style). The first 3 leadership styles identified were authoritarian, democratic, and laissez-faire. Authoritarian leadership can be found in large bureaucracies such as the armed forces. With an authoritarian leadership style, staff derive security from this approach's high productivity and predictability. However, this approach limits autonomy, creativity, and self-motivation (Marquis & Huston, 2021). The following behaviors characterize authoritarian leaders:
- decision-making is unilateral
- communication flows downward
- strong control is maintained over staff
- emphasis is on the difference in status
- criticism is punitive
- staff are directed with commands and motivated by coercion (Marquis & Huston, 2021)
Democratic leadership promotes autonomy and collaboration between staff and administrators. This leadership style is appropriate for staff who work together for extended periods or when collaboration is necessary. However, the collaborative process can be time-consuming, causing frustration among the staff (Marquis & Huston, 2021). The following behaviors characterize democratic leaders:
- emphasis is on the team rather than the individual
- communication flows up and down
- decision making involves the team
- less control is maintained
- criticism is constructive
- direction occurs through suggestions and guidance
- economic and ego awards are used to motivate (Marquis & Huston, 2021)
Laissez-faire leadership is a nondirected leadership style appropriate when problems are poorly defined and brainstorming is needed to generate potential solutions. In this type of leadership, the formal leader turns over the decision-making to the group and steps away from participation. This leadership style can be highly productive when group members are self-directed and motivated. However, when group members are distracted or poorly motivated, this style can result in frustration and disinterest in the group (Finkelman & Kenner, 2016; Marquis & Huston, 2021). The following behaviors characterize laissez-faire leaders:
- spreads decision-making throughout the group
- does not criticize
- emphasizes the group
- uses upward and downward communication between group members
- is permissive and provides little to no direction
- motivates by support when requested by group members (Marquis & Huston, 2021)
From 1950 to 1980, theorists began to challenge the idea that leaders had a singular predominant leadership style that they used consistently in every situation. Instead, many theorists posited that most leaders fell on a continuum between authoritarian and laissez-faire. This idea that leadership style was dynamic, moving along a continuum in response to different situations, was known as situational or contingency theory. With situational or contingency theories, a person's leadership style is based on the nature of the situation, the manager's skills, and the group members' abilities (Marquis & Huston, 2021).
From 1970 to the present day, theorists have integrated even more variables that influence leadership style, including organizational culture, the environment, the work, the values of the leader and the followers, the influence of the leader, and the complexity of the situation. The integration of these factors led to interactional and transformational leadership styles. Interactional leadership theory involves the relationship between the leader's personality and the specific situation. This style is a dynamic two-way process where the leader and the follower contribute to the working relationship. This leadership style challenges the authoritarian approach and holds that effective leadership is accomplished through synergistically working with others. Effective leadership requires maintaining group effectiveness, communicating well, and demonstrating fairness, competence, and dependability (Marquis & Huston, 2021).
Transactional and Transformational Leadership
In 2003, Burns introduced the premise that leaders and followers can raise each other to higher levels of morality and motivation (i.e., transformational leadership). He suggested that there are 2 primary types of leadership, transactional and transformational. Transactional leadership is a traditional management style in which the manager is concerned with day-to-day tasks and operations. Transactional leaders give directions, set goals, and use rewards to reinforce behaviors to meet established goals (Burns, 2003).
In contrast, a transformational leader has a vision and can empower others with that vision. Theorists argue that collective empowerment is one of the crucial tenants of transformational leadership. Burns (2003) developed this theory to address the aspects of an organization that lead to success, encourage enthusiasm, and identify the values employees place on their work. Other characteristics of transformational leaders include the ability to elevate followers to higher morals (i.e., do the right thing for the right reason), treat others with compassion, and encourage followers to be more innovative. The goal is for the leader and the employee to discover meaning and purpose in their work while also growing and gaining maturity (Smith, 2011). The American Nurses Association (ANA, n.d.) suggests that transformational leaders do more than delegate; instead, they help others achieve their highest potential (Marquis & Huston, 2021).
Kouzes and Posner (2017) are known for furthering the work on transformational leadership. They suggest 5 exemplary leadership practices that, when employed, foster a culture where relationships between leaders and followers thrive (Marquis & Huston, 2021). These 5 practices include:
- modeling the way: requiring self-awareness and value clarification so that behaviors are congruent with values
- inspiring a shared vision: a vision that encourages followers to participate in goal attainment
- challenging the process: identifying opportunities and taking action
- enabling others to act: fostering trust, collaboration, and sharing of power
- encouraging the heart: recognizing, appreciating, and celebrating followers' achievements of shared goals (Kouzes & Posner, 2017)
Transformational leadership qualities are considered highly desirable; however, other theorists caution against only using this leadership style. Instead, many theorists suggest that transformational leadership should be combined with some traditional transactional qualities, going as far as to say that transformational leaders will fail without some traditional management skills. This premise has led to the creation of a full-range leadership model (FRLM), a leadership style that applies transformational, transactional, and laissez-faire principles. FRLM includes elements of transformational leadership (i.e., building trust, acting with principle and integrity, inspiring others, innovating, and developing others), transactional elements (i.e., contingent reward and management by exception), and laissez-faire leadership. It is hypothesized that transactional elements, such as goal setting, can be augmented by the transformational engagement of followers. The laissez-faire style is included because leaders may also need to step back and allow the team to do the work they can. Further work by Rowold and Schlotz (2009) on FRLM has suggested 9 factors impacting leadership style and affecting followers. Table 3 outlines the 9 factors of FRLM (Marquis & Huston, 2021).
Factors in the Full-Range Leadership Model
Inspirational motivation: a leader's representation of the vision
Idealized influence (attributed): the charisma of the leader to create trust and confidence in followers
Idealized influence (behavior): creating a collective sense of mission and values and prompting followers to act on the values
Intellectual stimulation: leaders challenge the assumptions of followers' beliefs and analyze possible solutions
Individualized consideration: leaders individualize followers, recognizing unique strengths, needs, and challenges
Contingent reward: a leader provides followers with meaningful rewards based on task completion
Active management-by-exception: a leader actively searches for deviations from rules and takes corrective action when necessary
Management-by-exception passive: a leader intervenes only after errors have been detected or standards have been violated
Non-leadership: absence of leadership
(Marquis & Huston, 2021; Rowold & Schlotz, 2009)
Leadership Style and Outcomes
Healthcare organizations are tasked with providing safe, high-quality, evidence-based care while controlling healthcare costs. Research has shown that the leadership styles of managers and other organizational leadership can impact staff performance and healthcare organizational performance. The complexity of the healthcare system requires leaders to use a variety of leadership styles—more specifically, an FRLM—to create a flexible and efficient work environment. Nurse managers have various roles and responsibilities, including managing the day-to-day workflow, training and supervising staff, and empowering staff to provide high-quality, safe, patient-centered care. Given the challenges of the current healthcare environment (i.e., staffing shortages, limited bed availability, and more complex patient care needs), nurse managers must have the appropriate leadership and managerial training to be successful. Contrary to their title, the nurse manager role goes beyond administrative duties. Unfortunately, nurses are often promoted into positions of leadership without proper training. Healthcare organizations must recognize the need for and support leadership training to optimize patient and staff outcomes. This training should focus on developing skills and fostering characteristics associated with effective leadership; see Table 2. Influential leaders can use a combination of effective leadership styles, including transformational, transactional, and at times, laissez-faire (Alloubani et al., 2019; Pishgooie et al., 2018; Specchia et al., 2021).
Nurse managers are critical in enhancing the safety and quality of the care their nursing staff provides. Safety and quality of care are recognized as priorities for healthcare organizations worldwide. However, healthcare organizations are prone to errors, increasing the risk of adverse patient outcomes. The IOM report, To Err is Human, estimated that preventable medical errors cause 98,000 patient deaths and 1 million injuries annually. The physical and economic impact of these errors is significant, making prevention a top priority for organizational leadership. Research has shown that patient safety is linked to the quality of nursing care and leadership effectiveness. Many studies have linked transformational leadership with reduced adverse patient safety outcomes. Boamah and colleagues (2018) investigated whether transformational leadership impacted patient safety outcomes using a mediating factor of structural empowerment. Their findings suggest that managers with a transformational leadership style improve the quality of patient care by creating work environments that empower nurses to provide high-quality care. These results are consistent with other studies that linked leadership style to better patient outcomes and fewer complications (Boamah et al., 2018). Alloubani and colleagues (2019) also investigated the impact of leadership style on the quality of care. They found a significant positive correlation between a transformational leadership style and high-quality nursing care.
One of the most significant challenges facing healthcare organizations today is the critical shortage of experienced nurses. Healthcare organizations have been tasked with finding effective strategies to increase nurse recruitment and retention. In addition to the quality of care provided, as discussed previously, research has shown that a nurse manager's leadership style is linked to various nurse outcomes, including stress, job satisfaction, and retention (Magbity et al., 2020; Pishgooie et al., 2018; Specchia et al., 2021). Boamah and colleagues (2018) found a relationship between a transformational leadership style and nursing job satisfaction. They found that the transformational leadership component—inspirational motivation—had the most substantial impact on nurse outcomes. The researchers concluded that the strong relationship between staff empowerment and job satisfaction suggests that improving the quality of the work environment may be an essential strategy for nurse retention. Alloubani and colleagues (2019) noted that nurse managers most frequently used transformational and transactional leadership styles, with transformational leadership seen as more inspirational. They found a significant positive correlation between a transformational leadership style, leader effectiveness, and job satisfaction. Healthcare organizations must foster nursing leaders trained in various leadership styles to ensure safe, high-quality care and boost nurse satisfaction and retention (Magbity et al., 2020; Pishgooie et al., 2018; Specchia et al., 2021).
Alloubani, A., Akhu-Zaheya, L., Abdelhafiz, I. M., & Almatari, M. (2019). Leadership styles' influence on the quality of nursing care. International Journal of Health Care Quality Assurance, 32(6), 1022-1033. https://doi.org/10.1108/IJHCQA-06-2018-0138
American Association of Colleges of Nursing. (n.d.). Trailblazing innovation: Integrating the documentary 5B into nursing education. Retrieved December 22, 2022, from https://www.aacnnursing.org/5B-Tool-Kit/Themes/Leadership
American Nurses Association. (n.d.). Leadership and excellence. Retrieved December 22, 2022, from https://www.nursingworld.org/continuing-education/ce-subcategories/leadership
Boamah, S. A., Spence Laschinger, H. K., Wong, C., & Clarke, S. (2018). Effect of transformational leadership on job satisfaction and patient safety outcomes. Nursing Outlook, 66(2), 180-189. https://doi.org/10.1016/j.outlook.2017.10.004
Burns, J. M. (2003). Transforming leadership. Grove Press.
Finkelman, A., & Kenner, C. K. (2016). Professional nursing concepts: Competencies for quality leadership (3rd ed.). Jones & Bartlett Learning, Inc.
Fischer, S. A. (2016). Transformational leadership in nursing: A concept analysis. Journal of Advanced Nursing, 72(11), 2644-2653. https://doi.org/10.1111/jan.13049
Institute of Medicine. (2011). The future of nursing Leading change, advancing health. The National Academies Press. http://nap.nationalacademies.org/12956
Kouzes, J. M., & Posner, B. Z. (2017). The leadership challenge: How to make extraordinary things happen in organizations (6th ed.). John Wiley & Sons, Inc.
Magbity, J. B., Ofei, A. M. A., & Wilson, D. (2020). Leadership styles of nurse managers and turnover intention. Hospital topics, 98(2), 45-50. https://doi.org/10.1080/00185868.2020.1750324
Marquis, B. L., & Huston, C. J. (2021). Leadership roles and management functions in nursing: Theory and application (10th ed.). Wolters Kluwer.
National Academies of Sciences, Engineering, and Medicine. (2016). Assessing progress on the Institute of Medicine report The Future of Nursing. The National Academies Press. http://nap.nationalacademies.org/21838
Pishgooie, A. H., Atashzadeh-Shoorideh, F., Falco-Pegueroles, A., & Lotfi, Z. (2018). Correlation between nursing managers' leadership styles and nurses' job stress and anticipated turnover. Journal of Nursing Management, 27(3), 527-534. https://doi.org/10.1111/jonm.12707
Rowold, J., & Schlotz, W. (2009). Transformational and transactional leadership and followers’ chronic stress. Leadership Review, 9, 35–48. https://www.researchgate.net/publication/254378228_Transformational_and_Transactional_Leadership_and_Followers%27_Chronic_Stress
Smith, M. A. (2011). Are you a transformational leader. Nursing Management, 42(9), 44-50. https://doi.org/10.1097/01.NUMA.0000403279.04379.6a
Specchia, M. L., Cozzolino, M. R., Carini, E., Di Pilla, A., Galletti, C., Ricciardi, W., & Damiani, G. (2021). Leadership styles and nurses' job satisfaction. Results of a systematic review. International Journal of Environmental Research and Public Health, 18(4), 1552. https://doi.org/10.3390/ijerph18041552