Leadership in health care takes many forms and styles. Every nurse needs to be prepared to lead as appropriate for their scope of practice, role in the healthcare system, and as a member of a care team.
For entry-level nursing students, we recommend schools prepare students with situational leadership skills. Situational leadership is an adaptive style that is well suited for a variety of nursing roles at both the entry- and advanced-levels of practice.
Situational leadership skills have the potential to help nurses meet the core concepts of clinical practice more effectively. These include clinical judgement; communication; compassionate care; diversity, equity, and inclusion; evidence-based practice; health policy; and the social determinants of health. Adaptable as needed, the style of the leader may change continually to meet the needs of others in the organization based on the situation.
The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity underscores the critical need to develop a more diverse nursing workforce as key to achieving the goals of reducing health disparities, providing culturally relevant care for all populations, and leading to health equity. Diversity encompasses more than race or ethnicity. Diverse workplaces are composed of individuals with varying characteristics including, but not limited to, religious and political beliefs, mental and physical abilities/disabilities, gender, age, ethnicity, education, socioeconomic background, sexual orientation, and geographic location. It is critical to build an inclusive environment where all students receive individualized support and are encouraged to thrive academically and professionally. Equally important, "nurse leaders have a responsibility to address structural racism, cultural racism, and discrimination based on identity (e.g., sexual orientation, gender), place (e.g., rural, urban), and circumstances (e.g., disability, mental health condition) within the nursing profession and to help build structures and systems at the societal level that address these issues to promote health equity" (National Academy of Medicine, 2021, pp. 10-11).
Definitions
Situational leadership in nursing is defined as the ability to:
Diversity, equity, and inclusion are defined as:
Diversity references a broad range of individual, population, and social characteristics, including but not limited to age; sex; race; ethnicity; sexual orientation; gender identity; family structures; geographic locations; national origin; immigrants and refugees; language; physical, functional, and learning abilities; religious beliefs; and socioeconomic status. Inclusion represents environmental and organizational cultures in which faculty, students, staff, and administrators with diverse characteristics thrive. Inclusive environments require intentionality and embrace differences, not merely tolerate them. Everyone works to ensure the perspectives and experiences of others are invited, welcomed, acknowledged, and respected in inclusive environments. More broadly, equity is interrelated with diversity and inclusion. Equity is the ability to recognize the differences in the resources or knowledge needed to allow individuals to fully participate in society, including access to higher education, with the goal of overcoming obstacles to ensure fairness (Kranich, 2001). To have equitable systems, all people should be treated fairly, unhampered by artificial barriers, stereotypes or prejudices (Cooper, 2016). These definitions can be found in the AACN Position Statement - Diversity, Equity, and Inclusion in Academic Nursing (2021).
1.2d Examine influence of personal values in decision making for nursing practice
1.2e Demonstrate ethical decision making
9.1b Reflect on one’s actions and their consequences.
9.1d Change behavior based on self and situational awareness.
9.1e Report unethical behaviors when observed.
9.1g Advocate for the individual’s right to self-determination.
9.3a Engage in advocacy that promotes the best interest of the individual, community, and profession.
9.3c Demonstrate professional and personal honesty and integrity.
9.3d Take responsibility for one’s roles, decisions, obligations, actions, and care outcomes.
9.3f Demonstrate adherence to a culture of civility
9.5b Demonstrate the core values of professional nursing identity
9.5c Demonstrate sensitivity to the values of others.
9.5d Demonstrate ethical comportment and moral courage in decision making and actions.
9.5e Demonstrate emotional intelligence.
9.6a Demonstrate respect for diverse individual differences and diverse communities and populations
9.6b Demonstrate awareness of personal and professional values and conscious and unconscious biases.
9.6c Integrate core principles of social justice and human rights into practice.
10.3a Compare and contrast leadership principles and theories.
10.3b Formulate a personal leadership style.
10.3c Demonstrate leadership behaviors in professional situations.
10.3d Demonstrate self-efficacy consistent with one’s professional development.
10.3f Modify one’s own leadership behaviors based on guided self-reflection.
10.3g Demonstrate self-awareness of one’s own implicit biases and their relationship to one’s culture and environment.
10.3h Communicate a consistent image of the nurse as a leader.
10.3i Recognize the importance of nursing’s contributions as leaders in practice and policy issues.
1. Federal Plan for Equitable Long-Term Recovery and Resilience
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The plan focuses on seven vital conditions to frame a plan for health and well-being for individuals and communities. As trusted professionals, nurses can play a critical role providing leadership within the community to address health inequities and enhance wellness and resilience.
Faculty Suggestions for Use: Recommended for classroom discussions on leadership and policy development.
2. The Development of the Person-Centered Situational Leadership Framework
Lynch, B. M., McCance, T., McCormack, B., & Brown, D. (2017). The development of the person-centered situational leadership framework: revealing the being of person-centeredness in nursing homes. Journal of Clinical Nursing, 27(1-2), 427–440.
The Person-Centered Situational Leadership Framework captures seven core attributes of the leader that facilitate person-centeredness in others. This framework relates to harmonizing actions with the vision; balancing concern for compliance with concern for person-centeredness; connecting with another person in the moment; intentionally encouraging the other person to act; listening to the other person with the heart; and unifying through collaboration, appreciation, and trust. This framework can close the gap in knowledge about leadership. It can be applied to many practice settings.
Faculty Suggestions for Use: Recommended as a basis for classroom exercises focused on mindfulness and relaxation.
3. Leadership and Job Satisfaction Among Azorean Hospital Nurses: An Application of the Situational Leadership Model.
Furtado, Carlos Do Rego Furtago, L., Da Graca Bapitsta, M., & Silva, F. (2011). Leadership and job satisfaction among Azorean hospital nurses: an application of the situational leadership model. Journal of Nursing Management vol. 19(8), 1047-57. doi:10.1111/j.1365-2834.2011.01281.
Nurse leader satisfaction can be linked to their ability to implement situational leadership styles. Nurse managers can develop staff nurses’ skills through awareness of their own leadership, while promoting nurse satisfaction.
Faculty Suggestions for Use: Recommended for use to introduce wellness and leadership concepts in the classroom and then to encourage students to self-practice.
4. Nursing Leadership Must Confront Implicit Bias as a Barrier to Diversity in Health Care Today
Stamps, D. C. (2021) Nursing leadership must confront implicit bias as a barrier to diversity in health care oday. Nurse Leader, 19 (2), 630 -638.
Nurse leaders must be aware of implicit bias and help all nurses, from novice to senior, recognize its existence as a barrier to diversity. Raising awareness will help to create a safe environment for nurse retention at all levels and support patient outcomes decreasing healthcare disparities. Identification of types of bias and strategies to mitigate the impact are multifactorial; however, can be accomplished to impact retention and patient outcomes. There are triggers that can assist the person to identify bias.
This article can serve as the foundation to a discussion post or reflection paper. Unconscious bias is common, persistent, and can be activated quickly and unknowingly despite a nurse’s best intentions. We cannot eliminate bias; however, we can interrupt it and the outcomes in healthcare disparities.
Faculty Suggestions for Use: Recommended for use to introduce reframing in the classroom and then encouraged self-practice.
5. A Model to Streamline Career Progression For Nurse Managers and Retain Emerging Leaders: Nursing Management,
Stamps, D., Beales, S., Toor, M. (2019). A model to streamline career progression for Nurse managers and retain emerging leaders. Nursing Management, 50(10), 29–34.
Career progression leads to the development of nurse leaders and improves retention, which has an impact on quality patient outcomes. Retaining experienced RNs who are emerging leaders is important for the continuity of patient safety and organizational quality. When an organization creates an environment that supports professional development this can lead to retention.
Faculty Suggestions for Use: Recommend as a read and discussion, or reflection.
Self-Care and Leadership Development
It is very difficult to take care of others if you're not taking care of yourself; therefore, developing leadership skills starts with yourself and managing your own health and well-being whether it is financial, emotional, or physical well-being. Improving one’s own well-being impacts others and trickles out to the people you work with and lead. It is impossible to talk about leadership without self-care and the ability to regulate one’s own well-being.
Integrating Leadership and DEI into Nursing Education
Content related to situational leadership, as well as diversity, equity, and inclusion, can be woven throughout the entire nursing curriculum, including leadership courses. Some of the areas of focus will be on how to lead effectively during a crisis, when patient or team satisfaction can be improved, and when the quality of patient care can be impacted. Content related to situational leadership, addressing implicit biases, and improving health inequities can be integrated across the curriculum in almost all coursework including didactic and clinical experiences.
Suggestions for Curriculum Integration
Situational Leadership Case Scenarios for Classroom Activities
Situational leadership scenarios can be used during a leadership course or throughout the nursing curriculum.
Below are five scenarios that could be used for discussion and application of situational leadership. These exemplars can be used in a variety of ways, including role plays, case studies and/or simulations but always with debriefing. It is recommended that faculty build upon these and other scenarios developed specifically for your program. Students and faculty may have their own experiences they can share and debrief.
Self-assessment, looking inward, exploring one’s own wellness and resilience are important, but it is also equally important to look at one’s own biases are. They also play an important role in one’s leadership and the outcome of patient care. Self-awareness is important to developing the competencies needed to leading others.
These case scenarios were used and recommended by faculty as excellent for classroom activities or group work in a transition-to-practice or senior leadership course.
Case Scenario #1 - Addressing Bias in Patient Care
A 44-year old African American woman comes in for an annual physical with her longtime primary care provider. Her sister accompanied her to the appointment due to patient mobility issues and to help her sister advocate for better pain management. The provider was defensive at the onset of the visit due to the sister’s stance on previous care. During the discussion about pain management, the provider suggested the patient was drug seeking, dismissing/downplaying patient concerns. The provider then cut the visit short due to the perceived tension he felt by the sister’s advocacy. Therefore, the patient didn’t receive her physical, pain meds or follow up, and later saw that “drug seeking” was added to her patient record.
Issues: Previous experience Care based on provider attitude Bias: Drug seeking Stereotype: Didn’t know her pain assessment Microaggression: Cutting visit short because of sister’s advocacy Ideal Encounter: Pause and dissect stereotypical behaviors. LEAN IN to identify what's there that’s not being said. Personal views are limiting and sometimes dangerous. Labeling a patient can be colored by personal biases and can impact care
Case Scenario #2 - Supporting Diverse Nursing Students
A 27-year old, English as a Second Language (ESL) nursing student in her last semester reached out to her faculty adviser for help/support. She had been diagnosed with COVID and had lost of two family members to COVID. She was passing all subjects, until the last few exams, when she began feeling defeated. The student could benefit from a referral to a school counselor or behavioral health counselor; however, her advisor offers that "nursing school is tough and maybe you should consider withdrawing or taking a leave of absence."
Issues: Bias: Faculty did not perceive that it was her job to help the student navigate to the finish line Stereotype: Did language play a role or a difference in cultures? Microaggression: Is there a commitment to enhancing diversity in the nursing workforce? Ideal Encounter: It is our job to meet people where they are and to provide holistic care/support. Cultural responsiveness is a way of being that affirms our own culture without negating others and seeing diversity as a benefit. Having an inclusive and supportive environment is beneficial for our students.
Case Scenario #3 - Knowing Your Role
Student nurses are on a medical surgical unit for clinical training. They receive report from each nurse assigned to the patient they are assigned by their faculty. During morning care the covering RN asks the student to administer medications to the patient. The student states he is unable to complete the task without his clinical faculty present. The nurse assigned to the patient states, “don’t worry I am here, you can do it without your faculty”.
Outcome: Student did not administer the medications without his faculty present. He went to his faculty immediately; he understood his scope and responsibility as a student and wanted to be sure he didn’t jeopardize patient safety. The assigned RN was not happy; however, the clinical faculty did take the opportunity to huddle with the staff nurse and nurse manager to explain student scope of practice and the role of assigned RNs.
Leadership Skills: Delegation, education, communication, ability to teach and mentor, integrity, maintaining compliance and promoting ethical practice.
Case Scenario #4 - Developing Innovative Career Paths for Future Nurses
Many nurses have left the bedside or the nursing profession since the pandemic. This impact is presenting new challenges to health systems struggling to meet their mission of providing high quality care. In addition to the impending retirement of nurses, health systems must implement innovative approaches to healthcare delivery. One way is to implement career paths for current employees to become nurses. Though this is a longer pathway and depletes internal talent, providing support for individuals to go back to school and become a nurse is rewarding and benefits the employer. Short-term goals could rest with hiring incentives, tuition forgiveness, retention bonuses, additional days off for service provided, and addressing the social determinants of health for nurses to support health and wellness.
Outcome: Meeting with community and health system stakeholders to create a workforce development track that can be offered to healthcare workers and community members. This approach allows for growth of the current workforce and provides a path for developing nurses for the future. Leadership Skills: Personal, professional, and leadership development, advocating for the team, communication, innovation, collaboration, change management, commitment, and ability to teach and mentor.
Case Scenario #5 - Staff Implemented Wellness Strategy
Many nurses and other healthcare workers are experiencing burnout at an unprecedented rate. During a shared governance meeting on a medical surgical acute care unit, nurses shared “Code Lavender”. Recently two RNs attended a conference and learned about the impact of providing a safe place to debrief when feeling stressed. What other strategies might the unit nurses recommend or take a leadership role in implementing to address burnout? Outcome: Nurses felt supported leading to a feeling of well-being. Leadership Skills: Communication, ability to teach and mentor, change management, advocating for staff, relationship building, and commitment.
Journal Articles
Chatalalsingh, C. & Reeves, S. (2014). Leading team learning: what makes interprofessional teams learn to work well? Journal of Interprofessional Care, 28(6), 513-518. doi:10.3109/13561820.2014.900001 Doyle, K. & Hungerford, C. (2015). Leadership as a Personal Journey: An Indigenous Perspective. Issues in Mental Health Nursing, 36(5), 336-345. doi: 10.3109/01612840.2015.1009663
García García, I. & Santa-Bárbara, E.S. (2009). Relationship between nurses' leadership styles and power bases. Revista Latina Americana Enfermagem, 17(3), 295-301. doi:10.1590/s0104-11692009000300003
Intaraprasong, B., Potjanasitt, S., Pattaraarchachai, J., & Meennuch, C. (2012). Situational leadership styles, staff nurse job characteristics related to job satisfaction and organizational commitment of head nurses working in hospitals under the jurisdiction of the Royal Thai Army. Journal of the Medical Association of Thailand, 95(Suppl 6), S109-S119.
Lynch, B. M., McCormack, B., & McCance, C. (2011). Development of a model of situational leadership in residential care for older people. Journal of Nursing Management, 19(8), 1058-69. doi:10.1111/j.1365-2834.2011.01275
Murray-García, J. L., Harrell, S., García, J. A., Gizzi, E., & Simms-Mackey, P. (2014). Dialogue as skill: Training a health professions workforce that can talk about race and racism. American Journal of Orthopsychiatry, 84(5), 590–596. doi.org/10.1037/ort0000026
National Academy of Science, Engineering, and Medicine. (2021). The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi.org/10.17226/25982
Nonaillada, J., & Martin, R.A. (2022). Applying Situational Leadership to Redeployment Duties During COVID-19: Lessons Learned. Quality Management in Health Care, 31(4), 274-277. doi: 10.1097/QMH.0000000000000350
Schreuder, J.A.H., Groothoff, J.W., Jongsma, D. et al. (2013). Leadership Effectiveness: A Supervisor’s Approach to Manage Return to Work. Journal of Occupational Rehabilitation, 23, 428–437. doi.org/10.1007/s10926-012-9409-6
Tervalon, M. & Jann Murray-García. (1998). Cultural Humility versus Cultural Competence: A Critical Distinction in Defining Physician Training Outcomes in Multicultural Education. Journal of Health Care for the Poor and Underserved, 9(2), 117–25. doi.org/10.1353/hpu.2010.0233
Resources and References
American Nurses Association: National Commission to Address Racism in Nursing
American Organization for Nursing Leadership: Leading Through Crisis: A Resource Compendium for Nurse Leaders
Campaign for Action:
Health Quality BC: Cultural Humility and Nursing in BC / BC Patient Safety & Quality Council
National Academy of Medicine: The Future of Nursing Podcast
Deborah Stamps, EdD, Executive Vice President & Chief Nursing Education and Diversity Officer, Rochester Regional Health