Nursing

Developing leadership in nursing: exploring core factors Elizabeth A. Curtis, Jan de Vries, Fintan K. Sheerin This article provides an introduction to the issue of nursing leadership, addressing definitions and theories underpinning leadership, factors that enhance leadership in nursing, and the nature of leadership content taught in undergraduate programmes. Highlighted are differences between leadership and management, and the notion that leadership can be ‘learned’. The authors also point out that there is a discrepancy between how leading undergraduate nursing programmes prepare students primarily in the transition of education to practice, and the suggestion from a number of nursing publications that leadership in nurses should be fostered throughout their education. Key words: Nursing leadership n Management n Factors that enhance leadership n Undergraduate programmes  he importance of effective leadership in health care has  been  emphasized  by  a  number  of  authors  (Dunham  and Fisher, 1990; Hewison and Griffiths, 2004; Carney,  2006; Greenfield, 2007; Sutherland  and Dodd, 2008),  and  nursing  leadership  is  pivotal  to  this  as  nurses  represent  the  largest  discipline  in  health  care  (Oliver,  2006;  Marquis  and Huston, 2009; Roussel et al, 2009; Sullivan and Garland,  2010).  Research  on  leadership  has  demonstrated  a  positive  relationship with improved patient safety outcomes (Tregunno  et  al,  2009);  healthy  work  environments  (Shirey,  2009);  job  satisfaction  (Heller  et  al,  2004;  Sellgren  et  al,  2007);  lower  turnover  rates  (Gelinas  and  Bohen,  2000);  and  positive  outcomes  for  organizations,  patients  (Wong  and  Cummings,  2007) and healthcare providers (Cummings et al, 2005).  While  it  can  be  argued  that  there  are  many  challenges  confronting  nurse  leaders  at  the  present  time  (new  roles,  new  technology,  financial  constraints,  greater  emphasis  on  participation,  cultural  diversity  and  education),  it  must  be  emphasized  that  leadership  should  not  be  viewed  as  an  optional  role  or  function  for  nurses.  Leadership  must  exist  in  every  healthcare  facility  where  effecting  change  and  achieving  high  standards  of  patient  care  are  stipulated  in  job titles, such as Director of Nursing, Nurse Consultant, or  Elizabeth A. Curtis is Lecturer in Nursing, School of Nursing  and Midwifery, Trinity College Dublin; Jan de Vries is Lecturer in  Psychology, School of Nursing and Midwifery, Trinity College Dublin;  and Fintan K. Sheerin is Lecturer in Intellectual Disability, School of  Nursing and Midwifery, Trinity College Dublin Accepted for publication: February 2011 Abstract Modern  Matron  (Sullivan  and  Garland,  2010).  However,  the  taking  on  of  a  leadership  role  by  itself  is  not  sufficient  for  ensuring  effectiveness.  The  leader  must  be  knowledgeable  about  leadership  and  be  able  to  apply  leadership  skills  in  all  aspects  of  work.  Heller  et  al  (2004)  suggest  that  on  the  whole,  nurses  are  not  adequately  prepared  for  the  role  of  leader  during  their  nursing  education  programmes. This  gap  between  adequate  educational  preparation  and  the  demands  of  the  clinical  setting  can  result  in  ineffective  leadership  in  nursing.  This  is  the  first  of  two  articles  about  promoting  and  developing  leadership  in  nursing. The  purpose  of  this  first  article  is  three-fold:  firstly,  to  reaffirm  issues  concerning  definitions and theories underpinning leadership; secondly, to  examine  the  factors  that  enhance  leadership  in  nursing;  and  thirdly to convey information about the nature of leadership  content taught in undergraduate programmes. T What is leadership' Leadership conjures up a variety of thoughts, reflections and  images.  These  may  include  power,  influence,  followership,  dynamic  personality,  charisma,  goals,  autocratic  behaviour,  innovation,  cleverness,  warmth  and  kindness.  We  may  also  think  about  leaders  we  have  worked  with  in  the  past,  or  are  currently  working  with,  and  reflect  on  the  qualities  and  behaviour  of  an  effective  leader  (Jewell,  1998;  Daft,  2004;  Muchinsky,  2006).  Over  the  years,  researchers  have  explored  different dimensions of leadership as is evidenced by the many  definitions that exist, including:  ‘The process by which an agent induces a subordinate to behave in a desired manner.’ (Bennis, 1959) ‘Leadership … is the ability to influence people toward attainment of goals.’ (Daft, 2000) ‘Leadership is defined as influence, that is, the art or process of influencing people so that they will strive willingly and enthusiastically toward the achievement of group goals.’ (Weihrich and Koontz, 2005) ‘Leadership involves the use of interpersonal skills to influence others to accomplish a specific goal.’ (Sullivan and Garland, 2010) A  common  theme  that  seems  to  run  through  many  definitions is that ‘leadership involves influencing the attitudes,  beliefs, behaviours and feelings of other people’ (Spector, 2006).  Although these definitions may be confusing, it is worth noting  306  British Journal of Nursing, 2011, Vol 20, No 5 professional issues that there is no one correct definition of leadership. This vast  range of definitions can contribute to a greater understanding  of the many factors that influence leadership, as well as provide  different perspectives of the concept (Hughes et al, 2006).  a  study  to  examine  the  characteristics  of  excellent  nursing  leadership,  Dunham  and  Fisher  (1990)  put  forward  the  following as a description:  ‘...administrative competence, adequate education, business skills, clinical expertise and an understanding of leadership principles.’ What  was  interesting  about  the  findings  from  this  study  is  that  nursing  leadership,  as  perceived  by  nurse  executives,  differed  from  general  leadership  because  of  its  emphasis  on  nurses  assuming  responsibility  for  influencing  and  improving  the  practice  environment. These  findings  are  not  dissimilar  to  those reported by Antrobus and Kitson (1999), who suggested  that ‘all  leaders  in  whatever  position  they  were  in  combined  their  sphere  of  influence  with  clinical  practice’.  In  other  words,  nursing  knowledge  derived  from  nursing  practice  was  instrumental in influencing their leadership. Other terms used  to  describe  nursing  leadership  include  ‘empowering  others,  facilitating  learning,  developing  nursing  knowledge,  working  with  and  through  others  to  achieve  success’  (Antrobus  and  Kitson, 1999). La Monica (1994) stated that ‘anytime a person  is a recognised authority and has followers who counts on this  person’s  expertise  to  carry  out  their  objectives,  the  person  is  a leader’. She further suggests that a person is a leader if they  provide assistance to others. Therefore, a student nurse is a leader  to patients and clients, a staff nurse is also a leader to patients and  clients, and a ward manager is a leader to all team members. In  addition to defining leadership, it is useful to draw attention to  the fact that although they are sometimes used interchangeably,  the terms ‘leadership’ and ‘management’ are quite different.  Leadership theory Leadership  has  generated  a  sizeable  amount  of  research  and  theory  (Weihrich  and  Koontz,  2005;  Muchinsky,  2006;  Spector,  2006)  and  the  theories  are  often  described  using  different classifications. Spector (2006) for example, classifies  the theories in the following manner:  ■  (a)  the  trait  approach,  which  is  concerned  with  personal  traits that contribute to effective leadership ■  (b)  the  behaviour  approach,  which,  like  trait  theory,  explores leadership from the perspective of the leader and  focuses on leader behaviours ■  (c) the contingency approach (Fielder’s contingency theory  and path-goal theory) suggests that leadership is about the  interaction  between  a  person  (leader),  his/her  behaviour  and the situation  ■  (d)  the  leader–member  exchange  approach  (charismatic  or  transformational  leadership)  is  concerned  with  the  relationships between subordinate and supervisor.  While  any  of  these  leadership  theories  can  be  used  to  help  nurses  lead,  some  writers  have  supported  the  use  of  transformational leadership as a suitable choice for advancing  nursing leadership (Trofino, 1995; Sofarelli and Brown, 1998;  Bowles and Bowles, 2000; Carney, 2006; Sullivan and Garland,  2010). Transformational leadership is about vision, ability to  inspire  followers,  trust,  sharing  a  bond  with  followers,  and  being able to empower others. Authors such as Carney (2006),  Jooste (2004), Thyer (2003) and Bowles and Bowles (2000),  have  proposed  that  transformational  leadership  is  a  suitable  model for directing and guiding nursing leadership. A study  by Bowles and Bowles (2000) compared the transformational  leadership  behaviours  of  firstline  managers  working  in  Nurse  Development  Units  (NDUs)  and  those  working  in  non-NDUs. The  NDU  scheme  was  established  in  the  UK  to  explore  innovative  nursing  practice  and  increase  the  quantity and quality of nurse leaders. The findings indicated  that  the  leaders’  self-evaluations  were  similar  for  both  groups.  However,  leadership  of  leaders  working  in  NDUs  was rated more highly by the observer evaluations than was  that  of  leaders  from  non-NDUs.  Furthermore,  leaders  from  the  NDUs  demonstrated  more  transformational  leadership  behaviours than did their colleagues in non-NDUs. Another  interesting  finding  from  this  study  was  that  leaders  from  NDUs were not regarded as ‘more credible role models or as  being more active in promoting the capability and confidence  of their staff ’ (Bowles and Bowles, 2000).  Leadership vs management According to Marquis and Huston (2009), there is still some  confusion  about  the  relationship  between  leadership  and  management.  Some  view  leadership  as  one  of  a  number  of  functions  of  managers,  while  others  argue  that  the  skills  required for leadership are more complex than those needed  for  management.  Hughes  et  al  (2006)  make  the  following  distinctions between managers and leaders: ■  Managers administer, leaders innovate ■  Managers maintain, leaders develop ■  Managers control, leaders inspire ■  Managers have a short-term view, leaders have a long-term  view ■  Managers ask how and when, leaders ask what and why ■  Managers initiate, leaders originate ■  Managers accept the status quo, leaders challenge it. These  differences  in  the roles of  managers and leaders are  consistent  with  those  reported  in  the  literature  on  nursing  (Marquis  and  Huston,  2009;  Marriner Tomey,  2009;  Parkin,  2009;  Roussel  et  al,  2009;  Sullivan  and  Decker,  2009). What  needs  emphasizing,  however,  is  that  a  job  title  on  its  own  does not make a leader. What determines a leader is his/her  behaviour. A leader innovates, inspires, guides, and challenges  as  is  evidenced  in  the  distinctions  cited  above.  However,  are  these  behaviours  and  practices  present  in  nursing  leaders'  In  the  sections  below  the  authors  explore  the  factors  that  contribute to nursing leadership and the nature of the content  taught on undergraduate nursing degree programmes.  Nursing leadership Although  many  of  the  research  articles  (Bellack  et  al,  2001;  Kleinman,  2003;  Heller  et  al,  2004;  Cummings  et  al,  2008;  Picker-Rotem, 2008), chapters on leadership (Marriner Tomey,  2009;  Roussel  et  al,  2009;  Halligan,  2010),  and  books  on  leadership and management (Wedderburn Tate, 1999; Hewison,  2004; Carney, 2006) reviewed for this article defined leadership,  few  offered  a  definition  for  the  term ‘nursing  leadership’.  In  British Journal of Nursing, 2011, Vol 20, No 5  307 A  systematic  review  of  research  on  factors  contributing  to  nursing leadership by Cummings et al (2008) divides the research  into studies of behaviours and practices of nursing leaders, their  traits  and  characteristics,  the  impact  of  the  healthcare  context  and  practice  settings,  and  educational  participation  of  nursing  leaders. Although the reviewers are far from impressed with the  designs  of  the  24  studies  deemed  worthy  of  inclusion  in  the  review, their overall conclusions suggest that there is evidence  that leadership in nurses can be developed through educational  activities,  modelling  and  practicing  leadership.  In  terms  of  behaviours and practices, they conclude that relationship skills  are more important than financial and technical abilities, and that  demonstrated  leadership  tends  to  foster  leadership  behaviours  in  others.  Particular  traits  and  characteristics  that  have  been  shown  to  promote  leadership  are  openness,  extroversion  and  motivation  to  manage.  Furthermore,  age  and  experience  facilitates  leadership,  while  gender  seems  unimportant.  Leader  effectiveness  was  seen  to  decrease  in  healthcare  settings  in  which leaders had less contact with care-givers. Opportunities  to  practice,  observe  and  model  leadership  skills  led  to  greater  self-efficacy in nurses’ leadership behaviours. Finally, leadership  training programmes were mostly found to be effective, not just  in bringing about short-term change, but also in the long term.  In  the  context  of  this  article,  the  findings  suggest  that  the  ‘gap’  between  education  and  the  leadership  demands  of  the  clinical  setting,  as  identified  by  Heller  et  al  (2004),  could  perhaps be bridged by employing successful training methods  as used in the studies reported by Cummings et al (2008). The  emphasis on relationship skills as the most important leadership  skill  would  suggest  that  leadership  development  programmes  should  include  this  element.  In  this  light,  it  is  not  surprising  that student nurses valued relationship qualities, such as effective  communication and being approachable, highly in the people  ultimately responsible for helping them bridge the gap between  their  training  and  practice  (Zilembo  and  Monterosso,  2008).  While  temperamental  factors  mentioned  by  Cummings  et  al  (2008),  such  as  extroversion  and  openness,  may  not  be  readily  affected  by  education,  there  are  undoubtedly  other  communication  and  relationship  building  skills  that  can  be  developed  in  training  and  placement.  For  instance,  emotional  intelligence, the ability to integrate and manage emotions and  reason,  could  be  developed  through  training. A  recent  review  exploring  the  relationship  between  ‘emotional  intelligence’  and nursing leadership cautiously suggests a central role for this  ability (Akerjordet and Severinsson, 2010). While  the  impact  of  each  of  these  factors  provides  some  insight  into  how  leadership  in  nursing  can  be  promoted,  it  is  generally  understood  that  a  more  holistic  analysis  of  their  combined  impact  and  how  they  interact  is  needed  to  predict  the prevalence and effectiveness of such leadership. In particular,  the interaction between personal and workplace factors needs  to  be  examined. Wagner  et  al’s  (2010)  systematic  review  of  publications on the role of empowerment in nursing leadership  suggests  that  efforts  by  the  organization  to ‘empower’  nurses  promotes  positive  work  behaviours  and  attitudes,  including  leadership  behaviour.  One  study  suggests  that  this  effect  can  also  be  promoted  through  leadership  education  programmes  (Chang et al, 2008).  Factors that contribute to nursing leadership Leadership preparation of nurses in undergraduate programmes It is clear from the discussion above that leadership is considered  to  be  of  significant  importance  to  nursing.  Furthermore,  it  appears that nurses are increasingly being expected to undertake  leadership  roles  in  different  settings.  What  is  the  evidence,  however,  that  nurses  are  being  adequately  prepared  to  engage  in such roles' In order to answer this, the authors of this article  undertook  a  cursory  examination  of  evidence  of  leadership  content in undergraduate nursing programmes provided by the  largest nursing school in Ireland (Trinity College Dublin), and  the  top-ranking  nursing  schools  in  the  UK  (Edinburgh)  and  USA (University of Washington at Seattle). These latter schools  were identified by the Times Good University Guide (The Times,  2010), and the US News and World Report (2010) respectively. The  University  of  Edinburgh  (2010)  views  organization  and  management  to  be  key  components  of  leadership  and  of  autonomous  practice.  This  is  taught  in  year  4  of  the  undergraduate  nursing  programme  and  is  supported  by  a  management placement. Within the University of Washington  at Seattle (2010), the BSN program sets as one of its objectives  that  the  graduate  will  ‘apply  leadership  concepts,  skills,  and  decision-making  in  the  provision  and  oversight  of  nursing  practice  in  a  variety  of  settings’. This  is  presented  within  the  context of transitioning to professional practice. Trinity College  Dublin  (2010)  also  addresses  clinical  leadership  in  year  4  of  its  BSc  programme  as  a  component  of  the  management  and  health policy module. Integration of theory and practice takes  place during a protracted final year placement.  It  appears  that  there  are  both  similarities  and  differences  across  undergraduate  nursing  education  in  top  schools. With  the  limited  amount  of  information  available  from  some  of  the  online  sources,  however,  it  was  unclear  what  the  actual  components  of  clinical  nurse  leadership  education  are. The  American Association of Colleges of Nursing (AACN) (2007)  has provided some detail in this regard, albeit for postgraduate  programmes,  in  their  White  Paper  on  the  Education  and  Role  of  the  Clinical  Nurse  Leader. The  core  competencies/ components of such a role are proposed to be:  ■  Critical thinking ■  Communication  ■  Assessment ■  Nursing technology and resource management ■  Health promotion, risk reduction and disease prevention  ■  Illness and disease management ■  Information and health care technologies ■  Ethics ■  Human diversity ■  Global health care ■  Healthcare systems and policy ■  Provider and manager of care ■  Designer, manager and coordinator of care ■  Membership of a profession.  While there is evidence that leadership is being taught within  undergraduate  nursing  programmes,  the  evidence  is  that  it  is  largely consigned to the content of the transition from student  to nurse. This may be appropriate. The scope of leadership set  out in the AACN document, however, suggests that leadership  is not a ‘stand alone’ entity, but rather that it imbues many other  308  British Journal of Nursing, 2011, Vol 20, No 5 professional issues components  of  the  curriculum.  It  may  be  more  appropriate,  therefore,  for  it  to  be  taught  longitudinally  through  the  continuum,  as  such  an  approach  could  prepare  nurses  to  see  practice  as  part  of  leadership  instead  of  the  current  situation  whereby leadership is being presented as part of practice. 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Churchill Livingstone, Edinburgh Weihrich  H,  Koontz  H  (2005)  Management: A Global Perspective.  11th  edn.  McGraw Hill, Singapore Wong C,A Cummings GG (2007) The relationship between nursing leadership  and patient outcomes: a systematic review. J Nurs Manag 15(5): 508–21 Zilembo  M,  Monterosso  L  (2008)  Nursing  students  perceptions  of  desirable  leadership  qualities  in  nurse  preceptors:  a  descriptive  survey.  Contemp Nurse 27(2): 194–206 Conclusions The  importance  of  leadership  to  the  effective  provision  of  health care is unquestionable, as is the centrality of leadership  to  nursing,  not  only  at  formal  management  level,  but  at  all  grades,  from  student  nurse  to  director  of  nursing/matron.  Therefore,  it  is  now  apparent  that  leadership  is  not  only  a  function of management but is something that should pervade  professional nursing practice. It seems logical to conclude that  the  development  of  excellence  in  nursing  leadership  should,  therefore, begin at the earliest stages of basic nursing education  and training. The evidence is otherwise, however—despite the  fact that the professional literature has, for some time, indicated  that leadership is an essential part of nursing practice and that all  nurses’ roles are, in one way or other, leadership roles. In  the  second  and  concluding  article  on  this  subject,  the  authors will further explore the role that nurse education and  training could play in the development of nursing leadership. In  doing so, the authors will seek to challenge nursing educators  and  service  providers,  responsible  for  the  wider  educational  development  of  nurses,  to  consider  the  implications  of  our  recommendations. BJN Conflict of interest: none Akerjordet  K,  Severinsson  E  (2010)  The  state  of  the  science  of  emotional  intelligence related to nursing leadership: an integrative review. J Nurs Manag  18(4): 363–82 American  Association  of  Colleges  of  Nursing  (2007)  White  Paper  on  the  Education and Role of the Clinical Nurse Leader. http://tinyurl.com/45ay6fb  (accessed 28 February 2011) Antrobus S, Kitson A (1999) Nursing leadership: influencing and shaping health  policy and nursing practice. 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J Contin Educ Nurs 35(5): 203–10 Hewison  A  (2004)  Management for Nurses and Health Professionals: Theory into Practice. Blackwell Science, Oxford Hewison A, Griffiths M (2004) Leadership development in health care: a word of  caution. J Health Organ Manag 18(6): 464–73 Hughes RL, Ginnett RC, Curphy GJ (2006) Leadership: Enhancing the Lessons of Experience. 5th edn. McGraw Hill, Boston KEy PoiNtS n Leadership and management skills are different; while managers generally control others and maintain the status quo, leaders empower others, inspire innovation, and challenge traditional practices n most important leadership skills are relational skills The n Leadership qualities are not innate, they can be trained and developed n Leadership in nurses should be fostered throughout their education, not just at the end when they make the transition to practice n gap between nursing education and leadership demands can conceivably The be filled by professional training, but more high-quality research is needed to establish the ideal content and format of such training British Journal of Nursing, 2011, Vol 20, No 5  309 Copyright of British Journal of Nursing (BJN) is the property of Mark Allen Publishing Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. 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