A leader is not a special individual who is tapped on the shoulder and handed a magic wand; rather, it is the one who steps forward and offers to use his or her talents for the good of all purposes in health care. (Rawls, 2014).
The Institute of Medicine report (2010) calls for nurses to step up to leadership roles in the ever-changing healthcare delivery in the United States (U.S.). It tells nurses to head for board rooms, legislatures, and research. While this is happening, we should recognize that every well-prepared, successful nurse is a leader. This has been the case from the early modern professional nurse who had the calling and courage to show up to care for the sick, to the steady advancement from handmaiden to independent practitioner. The presence of nurses in the U.S. Congress, on hospital boards, or in advanced academic research will only improve the quality of the person-centered care everyone deserves to receive.
Volumes have been written on leadership. It is taught in the military and it is also taught in business school. It is not synonymous with power nor management. It has been briefly described as the ability to bring order out of chaos. A leader has been defined as one “having social influence to elicit a maximum effort from others toward the achievement of a goal” (Kruse, 2013). Influence can be derived from organizational hierarchy or from interpersonal relationships. Leadership implies that there are followers motivated to achieve a purpose. Contemporary healthcare delivery recognizes the interdependence of many professions at many levels. The role of leader or follower might change according to the needs of varying circumstances and goals. Leadership practices are “intertwined with the context in which they occur and do not simply depend on the characteristics of individuals” (Cummings, 2021). The long-term success of leadership depends on characteristics of the leader, the group and its dynamics, dyads, organizations, and political systems (Dinh as cited in Scott 2020). Leadership and its effect on job satisfaction determines an organization’s effectiveness, success and the quality of its product (Hussain & Hassan, 2021)..
There are many adjectives used to describe a “good leader.” Brown (2018) defines a leader as “anyone who takes responsibility for finding the potential in people and processes and who has the courage to develop that potential.” Courage includes, first, showing up. Brown advises leaders to be vulnerable, to show emotion, to receive (as well as give) feedback from team members in a balanced, non-defensive way. Self-awareness and self-acceptance involve facing fears and overcoming them. Being able to live and act in the face of uncertainty takes courage. Being honest, having difficult conversations, making difficult decisions, and being uncomfortable takes courage. Admitting mistakes and apologizing for them takes courage.
A second element of leadership for Brown is connection: building relationships by caring for team members, by being willing to listen and learn from them, and by creating a sense of safety and belonging. Trust is the basis for these relationships. Empathy, non-judgmental interactions, and clear expectations are important elements. Having respect for others is shown by keeping confidences, never belittling, blaming, or shaming, and assuming good intentions when people make mistakes. Leaders build connection and trust by modeling ethical behavior themselves.
Leadership implies pioneering in uncharted territory and leading others on a path (Scully, 2014). Nurse leaders are needed to bring order out of somewhat chaotic and disparate contemporary healthcare delivery, not just at the bedside, but also in the policy and research areas (Scully). Good leadership qualities include critical thinking, problem-solving, conscientious, innovative, collaborative, flexible, resilient, life-long learners, creative, risk-taking, possessing vision, efficient, and competent in their professional fields.
Leadership attributes associated with group satisfaction were found to be integrity, inspirational, visionary, performance oriented, team promoter, decisive, humble and diplomatic. Those that did not promote job satisfaction were leaders who were status conscious, conflict generators, preoccupied with procedure, concerned with appearances, autocratic, and self-centered. (Hussain and Hassan 2021)
Leadership style will vary depending on the individual leader and the desired outcome. These range from autocratic to laissez-faire. Autocratic leaders tend to be firm, self-assured, and dominating. They make all decisions with little to no input from others. They are not concerned about the needs of their subordinates. Laissez-faire leadership leaves planning and decision making to the group. Group members feel empowered and important to successful outcomes. The leader functions as a resource while plans and decisions are made by the group. This also takes a lot of weight off the leader. Neither of these extreme styles is associated with high degrees of job satisfaction in many organizations. Group satisfaction is highest with a democratic style of leadership which allows for open communication, group responsibility and group decision-making (Moiden, 2002).
Another grouping of leadership differentiates “passive/avoidance,” “transactional” and “transformative” style and purpose. Passive/avoidance leadership is as laissez faire described above. Transactional leadership is usually task focused, intent on getting things done. It tends to maintain the status quo when practiced. It is bureaucratic in that it is hierarchical with clear chains of command. The leader motivates with rewards, punishments, and negative feedback (Grace, 2018). There is a laissez-faire element in that workers are left to their own devices until there is a problem, whereupon the transactional leader steps in. Grace (2018) describes transactional leadership as “managerial in nature.”
Transformational leadership is associated with positive change. It is concerned with the relationship between leader and follower, with importance given to follower empowerment and self-actualization. Institutional change draws this kind of leadership because the overall good of the group is part of the goal (Scott, 2020).
At least 28 “styles” of leadership have been put forth, observing the characteristics of leaders and the organizations they serve. Styles vary by the relationship between leaders and followers and by the needs and goals of organizations. There are many overlapping characteristics among the various leadership styles, with differences in priorities and their applicability to any given situation or context. To conceptualize styles, it might be helpful to consider these opposing tensions:
From Hussain and Hassan (2021)
There have been attempts to put styles on a continuum from democratic to autocratic but again, the overlaps can be confusing. The following groupings might help envisioning similar characteristics. Further information on styles can be found on each of those listed.
The leadership needed for innovation in healthcare is discussed by Weintraub and McKee. Organizational cultures and innovation/change theory intersect with leadership style to create conditions necessary for new, improved outcomes. An open culture with free information exchange, application of an innovation process, group cohesion, and transformational leadership should be guided by a dedicated innovation team if healthcare delivery is going toa achieve its ideal of universal quality care for all. (Weintraub & McKee, 2019)
The proliferation of leadership theories, each with its own style or model, may make it difficult for nursing educators to define and develop the desired skills needed for improving our healthcare delivery. With optimal person-centered care as one of our goals, we need to identify which elements are best suited to specific contexts. For example, one can see where an operating room suite or emergency department needs different leadership and management styles than does a community addiction treatment clinic.
Reed (2017) discusses “critical intangibles” in healthcare leadership, those hard-to-define and hard-to-measure elements upon which success rests. Trust is the bedrock. Leaders should trust their followers and followers must trust their leaders. Lack of trust can cause followers not to do what is expected of them. Modeling integrity is important to attain and maintain the respect of followers, motivating their efforts to achieve desired outcomes. If mistakes are not owned and apologies of others not accepted, there is little incentive for trust and improved performance. The ability of a leader to recognize and manage feelings and responses – included in “emotional intelligence” – is one such skill. Biases and crises may elicit behaviors with unfortunate results if emotions are misread and mismanaged.
These critical intangibles are as important for the bedside nurse as they are for public health officials dealing with pandemics. To lead a hospitalized person from a state of dis-ease to a higher state of wellness requires the same skills that a policy advocate needs to convince a legislator to pass laws promoting the common good. Nurses are the largest group in the healthcare workforce, three million strong. Nursing is often said to be the most trusted profession. Every nurse is a leader.
Questions and exercises to consider with classmates and/or colleagues:
A Leader Is Not Handed a Magic Wand; A Leader Steps Forward Karen Rawls, Culture of Health Blog, May 19, 2014
Brown, B. (2018). Dare to Lead: Brave Work. Tough Conversations. Whole Hearts. Random House.
Cummings, G., Lee, S., Tate, K., Penconek, T., Micaroni, S., Paananen, T., & Chatterjee, G. (2021). The essentials of nursing leadership: A systematic review of factors and educational interventions influencing nursing leadership. International Journal of Nursing Studies, 115:103842. doi: 10.1016/j.ijnurstu.2020.103842.
Grace, P. (2018). Enhancing nurse moral agency: the leadership promise of Doctor of Nursing Practice preparation. OJIN: The Online Journal of Issues in Nursing, Vol. 23, No. 1.
Hussain, M. & Hassan. H. (2021). The leadership styles dilemma in the business world. International Journal of Organizational Leadership, 5(4), 411-425.
Kruse, K. (2013). What is leadership? Forbes. Posted online April 9, 2013.
Moiden, N. (2002). Evolution of leadership in nursing. Nursing Management, 9(7), 20-25.
National Academies of Sciences, Engineering, and Medicine. (2016). Assessing Progress on the Institute of Medicine Report The Future of Nursing. Washington, DC: National Academies Press.
Reed, S. B. (2017). Five key attributes of leadership: engaging and motivating employees are critical obligations of healthcare leaders. Healthcare Financial Management, 71(7).
Scott, H. K., Carr-Chellman, D.J. & Hammes, L. (2020). Profound leadership: an integrative literature review." The Journal of Values-Based Leadership, 13(1), Article 11.
Scully, N.J., (2015). Leadership in nursing: The importance of recognizing inherent values and attributes to secure a positive future for the profession. Collegian, 22, 439-444. http://dx.doi.org/10.1016/j.colegn.2014.09.0
Weintraub, P. &, McKee, M. (2019). Leadership for innovation in healthcare: An exploration. International Journal of Health Policy and Management, 8(3), 138-144.