It is desirable that nurse managers are leaders but this is not always necessary or achievable. (Weick & Evans 2003). Effective leaders are important to the profession as they set the tone of the working environment and inspire others to perform at their highest level (Weick & Evans 2003). Bowles and Bowles (200:70) define leadership as:
‘…an interpersonal relationship of influence, the product of personal characteristics rather than mere occupation of managerial positions. It is these personal characteristics which attract, enthuse and motivate followers towards organizational goals…’
Various leadership styles have been discussed and debated over time. The transformational leadership style appears to be well suited to the nursing profession (Bowles & Bowles 2000; Sofarelli & Brown 1998). A leader of this type works well in a team situation, which is beneficial in a busy healthcare setting (Weick & Evans 2003, Thyer 2003). A leader who promotes collaboration between staff to set goals and make decisions will achieve efficient outcomes and a more supportive atmosphere (Weick& Evans 2003). Dunham-Taylor (200, cited in Chambers 2002:127) state that a transformational leader has the following attributes:
The ability to identify and communicate a vision for the future: articulate and gain commitment to shared values, and empower colleagues to work towards achieving organizational goals…
Kouzes and Posner (1997, cited in Weick & Evans 2003:22) describe five behavioural attributes which contribut to the ability to be a transformational leader. These are the ability to:
- Challenge the process—creative problem solving, question procedures and solicit new ideas. Encourage colleagues to share new information and to participate in new learning experiences.
- Inspire a shared vision—ensure goals are shared, desirable, and achievable.
- Enable others to act—support and encourage others, let them know that extra effort is appreciated.
- Model the way—active participation engenders trust and encourages others to participate.
- Encourage the heart—show appreciation when others make an effort. Active listening is a necessity.
Traditional managers were appointed to positions of authority and were given the power to delegate and control the work process (Sofarelli & Brown 1998). As Spence (1996, cited in Thyer 2003:221) identifies, leadership does not have to be tied to a position of authority. Leadership can be seen as an ‘innate’ quality based on ‘the ability to care, to dream, to think, to imagine, and to speak up’. It has also been said however that anyone can be a leader with the right motivation, encouragement and practise. (Bowles & Bowles 2000). Leadership, according to Weick and Evans (2003:23), ‘is an earned right and a privilege’.
Weick and Evans (2003:26) say ‘the key to leadership is to believe in the vision and enjoy the journey.’ The following suggestions for the successful integration of transformational leadership are also given:
- They suggest that you should learn not to waste time, the consequences of wasted time are frustration and work left undone.
- They warn the would-be leader that they must learn to be self-motivated—others are quick to criticise and slow to praise. You just cannot let a lack of positive support get you down, maybe find a mentor or friend to talk to when the going is tough.
- Self-confidence is important as confidence and success are often closely related.
- They warn potential leaders of the possibility of becoming arrogant and note that it is difficult to remain confident when setbacks occur.
- Active listening. If you ask relevant questions this is one way to let others know that you are interested in them and their ideas.
- It is important to take risks and make decisions after considering facts. If you say you will do something, better make sure you do or get back to the other person to explain what went wrong.
- It is important to remember that ‘attitude is vital to leadership success…and attitude is a choice, not a forgone conclusion’. Positive thinking and positive messages are important to focus on to be a successful leader, Weick and Evans (2003:27)
Transformational leadership and the registered nurse
Registered nurses work not only in many different environments but also in a range of different specialities and they must all perform their work to a high standard. The Australian Nursing Council (ANC) has developed national standards for professional conduct, these ensure the community that the standard of care provided will be both safe and effective (ANC 2002). Registered nurses are responsible for their own actions and may be held accountable under civil or criminal law if they do not perform their duties according to the prescribed standards (Mair 2000). ANC national standards are outlined in three documents; these include (ANC 2002):
- The ANC National Competency Standards for Registered and Enrolled Nurses
- The Code of Ethics for Nurses in Australia
- The Code of Professional Conduct for Nurses in Australia
The National Competency Standards outline ‘the various roles and functions nurses fulfil and identify a combination of the attributes a competent nurse must have’ (ANC 2002). These standards are included in 14 competency units that cover such areas as legal and ethical requirements, assessment of patient needs, abilities to use knowledge and reasoning skills, access and application of research findings to practice, and skills such as collaboration, communication, and education.
As a newly registered nurse these standards of practice have to be adhered to and kept in the forefront of ones’ mind. This will be challenging. The novice registered nurse must deal with time management issues, completion of tasks, attending to accurate written documentation, communication with other healthcare professionals, other nurses and patients, often in difficult circumstances. Adopting the positive attitude and skills required of a ‘transformational’ leader, will enable the newly registered nurse to integrate new experiences and achieve confidence in their abilities, whilst continually aiming to provide quality patient care. Performing the role of the registered nurse can be a rewarding experience or can lead to stress, exhaustion, and eventually burnout (Olofsson, Bengtsson, & Brinke 2003). These negative effects result in nurses leaving the profession altogether. As a student registered nurse we are taught that with a positive attitude we can see ourselves as part of the solution to making the workplace one in which the experiences for staff and patients are positive ones. This appears to be a very tall order! Transformational leadership offers us some strategies in the hope that we will be able to achieve this goal.
Reflections on a practice situation: What might have been different if a ‘transformational’ leadership style could have been accessed?
I will be looking at my first and only clinical experience thus far
to reflect on a time when I believe the qualities and theories of transformational leadership may have proved valuable. This my first I wanted to explore how transformational leadership skills could enhance life in a real clinical setting. I will identify the registered nurse I spoke to as A.C.
A.C had been a registered nurse for 3 years working in a busy public hospital in many different wards including, A&E, gerontic, medical and surgical. She decided to further enhance her skills by undertaking a post-graduate course in mental health nursing (psychiatric in those days). This was undertaken at another large public hospital that provided care solely for mental health clients. The course involved 18 months of clinical practice interspaced with study blocks.
The particular episode we discussed and that A.C. remembers clearly due to its less than satisfactory outcome for her and the patient, involved an elderly man in his 80’s whom we will call Mr J. He had had been admitted to a very busy acute admissions ward in the hospital. He was diagnosed with dementia and A.C had been given the responsibility of his admission. This involved a nursing assessment and routine observations. During this time his wife with whom he lived with at home and usually managed his behaviour well (even though she herself was in her 70’s) gave A.C some information regarding Mr J’s daily routine and how she managed to calm him when he was anxious. As Mr J had always been very active part of this routine was 3 daily walks lasting around 20 mins each. The walks were also used to calm Mr J when he was becoming difficult and usually meant that he was calmer and more relaxed after this physical activity. Mr J was in a bay with six others, all elderly, all with various mental health issues A.C was also responsible for the observations for the other patients in the bay.
Later on the day of his admission Mr J was became extremely agitated, moaning and trying to get out of his bed. As A.C approached, he acted as if he knew her and initially responded in a positive fashion when she started to talk to him. Then his mind wondered and his speech became unintelligible, he started pulling at his clothes and grabbing A.C’s uniform and generally seemed as if he were angry about something. A.C decided, based on her assessment and the previous information given to her by his wife, that possibly taking Mr J for a walk around the unit may be beneficial before utilising PRN medication to calm him down.
As A.C was assisting Mr J from his bed another nurse, the ward C.N came into the bay. She noted the agitated state of Mr J and told A.C to go and get PRN medication for him. A.C started to communicate to the C.N her plan to take Mr J for a walk but the C.N stated to her:
that she didn’t have the time for that, get him his PRN and we’ll use physical restraints if we have to-the registrar is here now so I’ll get him to order it!
A.C hesitated but then followed on with preparing the PRN order as directed by her senior staff member the C.N.
A.C and I discussed what she could have done differently in this situation. In observing the competency standards and with some understanding of transformational leadership could the outcome have been different? A.C owed this patient a duty of care, this is a legal requirement and written into the professional standards. A.C felt that she had not observed this duty of care as she was unable to put into practise her assessment of the situation based on the information supplied by his primary carer (his wife). A.C had an ethical (and a moral) duty to care for this vulnerable patient and believed that a walk would have had a good chance of assisting Mr J and could have reduced his suffering and possible harm more than the administration of PRN medication and physical restraints if used prematurely.
While A.C did have other duties to perform, if A.C, the C.N and other team members used ‘transformational’ skills to set a few goals and manage their time more effectively this patient (Mr J) may have received enhanced care.
A transformational leader is in a position of being able to harness passion and creativity in order to achieve higher levels of participation (Gunter, 2001, Hatcher 2003). This in turn would impact at all levels of healthcare settings and also at departmental levels and other levels where policies are made. If transformation began at these higher levels then the outcome of increased funding would impact on patient-staff ratios, support for and access to education and information and flexible working hours .(Upenieks2003) The C.N in A.C’s scenario would not have been as highly stressed and had the time to actively listen to A.C. in regards to her thoughts on Mr J’s care.
It must be noted however that policy makers are often afraid to tell people that they will only receive the healthcare that taxpayers are prepared to pay for. Healthcare is in competition in democratic societies with other public goods all wanting a share of the taxation dollar. (Dingwell & Allen 2001). This means in real terms that individual patients will often receive less than they want/expect from the healthcare setting they find themselves in. A client in the mental health setting is part of a minority group and will find it even more difficult as this means even less of the taxation dollar will go their way. There are of course numerous other healthcare settings where this would be true also.
As much as a nurse may want to defend and attempt to practise the core values of nursing that they have been taught they will often as A.C. and her C.N found, find themselves in situations where they need to compromise due to the resource constraints imposed on them by insensitive politicians and managers(Dingwell & Allen 2001).
By challenging the process, inspiring others to take an active interest, encouraging others if they were willing to offer suggestions or help, and by modelling the taking of a pro-active approach to Mr J’s care A.C would have benefited Mr J, the other staff and would have felt more personally and professionally competent. This would be transformational leadership in action at the ground level (Kouzes and Posner, 1997, cited in Weick & Evans 2003:22). This can be done on a person-by-person approach regardless of the former stated bureaucratic constraints.
Potential benefits to the patient when transformational leadership is followed
Patients can benefit in a number of ways when staff use transformational theories in their work processes. As discussed in the scenario above, direct benefits could come from creative solutions being found to problems. The communication between staff who work as a team would also be improved.
Additional benefits may be more indirect and still affect patient care for the better. Transformational leadership promotes support between colleagues and superiors and encourages positive feedback, which inturn helps to prevent emotional exhaustion and burnout (Stordeur, D'hoore, & Vandenberghe 2001; Olofsson, etal. 2003). Standards of patient care also improve when staffs are not emotionally exhausted (Olofsson et al. 2003). Better communication between staff and joint decision-making activities lead to feelings of increased autonomy and trust (Stordeur et al. 2001). Communication and trust between staff are important issues to address as problems with horizontal violence should be less of an issue and patient care could improve as a result (Faugier & Woolnough 2002). Trofino (2000) suggests that under these conditions, absenteeism is decreased, staff retention rates are increased and the money that organisations must spend on advertising for new staff and orientation procedures is decreased. This then would leave more money available for equipment and additional staff. In addition, a stable workforce enhances the quality of patient care because staff become familiar with the types of patients and services that are available throughout the hospital and community (Trofino 2000).
Conclusion
Historically the nursing profession has been autocratically managed. This has created problems within the profession that have resulted in high levels of stress, ineffective communication patterns, distrust, and horizontal violence. The transformational leadership model was assessed as a possible vehicle for changing hospitals into more cohesive and productive places to work. If widely accepted and utilised, this model does have potential to transform nursing into a more dynamic and productive profession, as ‘attitude is vital to leadership success…and attitude is a choice, not a forgone conclusion’ (Weick and Evans 2003:27). As a student, to be made aware of alternate ways that could be adopted before joining the workforce can only enhance any future clinical experiences.
Since leadership can be understood as an ‘innate’ quality and based on ‘the ability to care, to dream, to think, to imagine, and to speak up’ (Spence 1996, cited in Thyer 2003:221), all students can accept the role of leaders with practice. I found it interesting to reflect on a scenario with a qualified registered nurse who felt that even now 15 years later she wishes she had had the confidence to speak up and transform the outcome of a particular patient. Competency standards and transformational leadership theories can be a workable partnership as was shown by the alternate outcome of this scenario. If I found myself in a similar situation today I know that I would act in a more pro-active fashion to provide better care for my patients.
I also acknowledge that part of that pro active approach may require a need to address the political and to remember that nurses are influenced and affected by the current economic rationalisation climate and mindset we are submerged in. As nurses we have to accept the limitations of living and working in a society where there is limited resources but on a personal level by doing the best we can in any given situation we will and can ‘transform’ the outcome for all and for the better.
Australian Nursing Council (ANC) 2002 National Nursing Competency Standards for the Registered Nurse and Enrolled Nurse, 3rd edn. 2000 (online accessed October 5th 2003)
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