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Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Management and Professional Concepts [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2022.

Nursing Management and Professional Concepts [Internet].

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Chapter 4 - Leadership and Management

4.1. leadership & management introduction, learning objectives.

• Compare and contrast the role of a leader and a manager

• Examine the roles of team members

• Identify the activities managers perform

• Describe the role of the RN as a leader and change agent

• Evaluate the effects of power, empowerment, and motivation in leading and managing a nursing team

• Recognize limitations of self and others and utilize resources

As a nursing student preparing to graduate, you have spent countless hours on developing clinical skills, analyzing disease processes, creating care plans, and cultivating clinical judgment. In comparison, you have likely spent much less time on developing management and leadership skills. Yet, soon after beginning your first job as a registered nurse, you will become involved in numerous situations requiring nursing leadership and management skills. Some of these situations include the following:

• Prioritizing care for a group of assigned clients
• Collaborating with interprofessional team members regarding client care
• Participating in an interdisciplinary team conference
• Acting as a liaison when establishing community resources for a patient being discharged home
• Serving on a unit committee
• Investigating and implementing a new evidence-based best practice
• Mentoring nursing students

Delivering safe, quality client care often requires registered nurses (RN) to manage care provided by the nursing team. Making assignments, delegating tasks, and supervising nursing team members are essential managerial components of an entry-level staff RN role. As previously discussed, nursing team members include RNs, licensed practical/vocational nurses (LPN/VN), and assistive personnel (AP).[ 1 ]

Read more about assigning, delegating, and supervising in the “ Delegation and Supervision ” chapter.

An RN is expected to demonstrate leadership and management skills in many facets of the role. Nurses manage care for high-acuity patients as they are admitted, transferred, and discharged; coordinate care among a variety of diverse health professionals; advocate for clients’ needs; and manage limited resources with shrinking budgets.[ 2 ]

Read more about collaborating and communicating with the interprofessional team; advocating for clients; and admitting, transferring, and discharging clients in the “ Collaboration Within the Interprofessional Team ” chapter.

An article published in the  Online Journal of Issues in Nursing  states, “With the growing complexity of healthcare practice environments and pending nurse leader retirements, the development of future nurse leaders is increasingly important.”[ 3 ] This chapter will explore leadership and management responsibilities of an RN. Leadership styles are introduced, and change theories are discussed as a means for implementing change in the health care system.

4.2. BASIC CONCEPTS

Organizational culture.

The formal leaders of an organization provide a sense of direction and overall guidance for their employees by establishing organizational vision, mission, and values statements. An organization’s  vision statement  defines why the organization exists, describes how the organization is unique from similar organizations, and specifies what the organization is striving to be. The  mission statement  describes how the organization will fulfill its vision and establishes a common course of action for future endeavors. See Figure 4.1 [ 1 ] for an illustration of a mission statement. A  values statement  establishes the values of an organization that assist with the achievement of its vision and mission. A values statement also provides strategic guidelines for decision-making, both internally and externally, by members of the organization. The vision, mission, and values statements are expressed in a concise and clear manner that is easily understood by members of the organization and the public.[ 2 ]

Mission Statement

Organizational culture  refers to the implicit values and beliefs that reflect the norms and traditions of an organization. An organization’s vision, mission, and values statements are the foundation of organizational culture. Because individual organizations have their own vision, mission, and values statements, each organization has a different culture.[ 3 ]

As health care continues to evolve and new models of care are introduced, nursing managers must develop innovative approaches that address change while aligning with that organization’s vision, mission, and values. Leaders embrace the organization’s mission, identify how individuals’ work contributes to it, and ensure that outcomes advance the organization’s mission and purpose. Leaders use vision, mission, and values statements for guidance when determining appropriate responses to critical events and unforeseen challenges that are common in a complex health care system. Successful organizations require employees to be committed to following these strategic guidelines during the course of their work activities. Employees who understand the relationship between their own work and the mission and purpose of the organization will contribute to a stronger health care system that excels in providing first-class patient care. The vision, mission, and values provide a common organization-wide frame of reference for decision-making for both leaders and staff.[ 4 ]

Learning Activity

Investigate the mission, vision, and values of a potential employer, as you would do prior to an interview for a job position.

Reflective Questions

1. How well do the organization’s vision and values align with your personal values regarding health care?

2. How well does the organization’s mission align with your professional objective in your resume?

Followership

Followership  is described as the upward influence of individuals on their leaders and their teams. The actions of followers have an important influence on staff performance and patient outcomes. Being an effective follower requires individuals to contribute to the team not only by doing as they are told, but also by being aware and raising relevant concerns. Effective followers realize that they can initiate change and disagree or challenge their leaders if they feel their organization or unit is failing to promote wellness and deliver safe, value-driven, and compassionate care. Leaders who gain the trust and dedication of followers are more effective in their leadership role. Everybody has a voice and a responsibility to take ownership of the workplace culture, and good followership contributes to the establishment of high-functioning and safety-conscious teams.[ 5 ]

Team members impact patient safety by following teamwork guidelines for good followership. For example, strategies such as closed-loop communication are important tools to promote patient safety.

Read more about communication and teamwork strategies in the “ Collaboration Within the Interprofessional Team ” chapter.

Leadership and Management Characteristics

Leadership and management are terms often used interchangeably, but they are two different concepts with many overlapping characteristics.  Leadership  is the art of establishing direction and influencing and motivating others to achieve their maximum potential to accomplish tasks, objectives, or projects.[ 6 ],[ 7 ] See Figure 4.2 [ 8 ] for an illustration of team leadership. There is no universally accepted definition or theory of nursing leadership, but there is increasing clarity about how it differs from management.[ 9 ]  Management  refers to roles that focus on tasks such as planning, organizing, prioritizing, budgeting, staffing, coordinating, and reporting.[ 10 ] The overriding function of management has been described as providing order and consistency to organizations, whereas the primary function of leadership is to produce change and movement.[ 11 ] View a comparison of the characteristics of management and leadership in Table 4.2a .

Management and Leadership Characteristics[ 12 ]

View in own window

Not all nurses are managers, but all nurses are leaders because they encourage individuals to achieve their goals. The American Nurses Association (ANA) established  Leadership  as a Standard of Professional Performance for all registered nurses. Standards of Professional Performance are “authoritative statements of action and behaviors that all registered nurses, regardless of role, population, specialty, and setting, are expected to perform competently.”[ 13 ] See the competencies of the ANA  Leadership  standard in the following box and additional content in other chapters of this book.

Competencies of ANA’s Leadership Standard of Professional Performance

• Promotes effective relationships to achieve quality outcomes and a culture of safety

• Leads decision-making groups

• Engages in creating an interprofessional environment that promotes respect, trust, and integrity

• Embraces practice innovations and role performance to achieve lifelong personal and professional goals

• Communicates to lead change, influence others, and resolve conflict

• Implements evidence-based practices for safe, quality health care and health care consumer satisfaction

• Demonstrates authority, ownership, accountability, and responsibility for appropriate delegation of nursing care

• Mentors colleagues and others to embrace their knowledge, skills, and abilities

• Participates in professional activities and organizations for professional growth and influence

• Advocates for all aspects of human and environmental health in practice and policy

Read additional content related to leadership and management activities in corresponding chapters of this book:

• Read about the culture of safety in the “ Legal Implications ” chapter.

• Read about effective interprofessional teamwork and resolving conflict in the “ Collaboration Within the Interprofessional Team ” chapter.

• Read about quality improvement and implementing evidence-based practices in the “ Quality and Evidence-Based Practice ” chapter.

• Read more about delegation, supervision, and accountability in the “ Delegation and Supervision ” chapter.

• Read about professional organizations and advocating for patients, communities, and their environments in the “ Advocacy ” chapter.

• Read about budgets and staffing in the “ Health Care Economics ” chapter.

• Read about prioritization in the “ Prioritization ” chapter.

Leadership Theories and Styles

In the 1930s Kurt Lewin, the father of social psychology, originally identified three leadership styles: authoritarian, democratic, and laissez-faire.[ 14 ],[ 15 ]

Authoritarian leadership  means the leader has full power. Authoritarian leaders tell team members what to do and expect team members to execute their plans. When fast decisions must be made in emergency situations, such as when a patient “codes,” the authoritarian leader makes quick decisions and provides the group with direct instructions. However, there are disadvantages to authoritarian leadership. Authoritarian leaders are more likely to disregard creative ideas of other team members, causing resentment and stress.[ 16 ]

Democratic leadership  balances decision-making responsibility between team members and the leader. Democratic leaders actively participate in discussions, but also make sure to listen to the views of others. For example, a nurse supervisor may hold a meeting regarding an increased incidence of patient falls on the unit and ask team members to share their observations regarding causes and potential solutions. The democratic leadership style often leads to positive, inclusive, and collaborative work environments that encourage team members’ creativity. Under this style, the leader still retains responsibility for the final decision.[ 17 ]

Laissez-faire  is a French word that translates to English as, “leave alone.” Laissez-faire leadership gives team members total freedom to perform as they please. Laissez-faire leaders do not participate in decision-making processes and rarely offer opinions. The laissez-faire leadership style can work well if team members are highly skilled and highly motivated to perform quality work. However, without the leader’s input, conflict and a culture of blame may occur as team members disagree on roles, responsibilities, and policies. By not contributing to the decision-making process, the leader forfeits control of team performance.[ 18 ]

Over the decades, Lewin’s original leadership styles have evolved into many styles of leadership in health care, such as passive-avoidant, transactional, transformational, servant, resonant, and authentic.[ 19 ],[ 20 ] Many of these leadership styles have overlapping characteristics. See Figure 4.3 [ 21 ] for a comparison of various leadership styles in terms of engagement.

Leadership Styles

Passive-avoidant leadership  is similar to laissez-faire leadership and is characterized by a leader who avoids taking responsibility and confronting others. Employees perceive the lack of control over the environment resulting from the absence of clear directives. Organizations with this type of leader have high staff turnover and low retention of employees. These types of leaders tend to react and take corrective action only after problems have become serious and often avoid making any decisions at all.[ 22 ]

Transactional leadership  involves both the leader and the follower receiving something for their efforts; the leader gets the job done and the follower receives pay, recognition, rewards, or punishment based on how well they perform the tasks assigned to them.[ 23 ] Staff generally work independently with no focus on cooperation among employees or commitment to the organization.[ 24 ]

Transformational leadership  involves leaders motivating followers to perform beyond expectations by creating a sense of ownership in reaching a shared vision.[ 25 ] It is characterized by a leader’s charismatic influence over team members and includes effective communication, valued relationships, and consideration of team member input. Transformational leaders know how to convey a sense of loyalty through shared goals, resulting in increased productivity, improved morale, and increased employees’ job satisfaction.[ 26 ] They often motivate others to do more than originally intended by inspiring them to look past individual self-interest and perform to promote team and organizational interests.[ 27 ]

Servant leadership  focuses on the professional growth of employees while simultaneously promoting improved quality care through a combination of interprofessional teamwork and shared decision-making. Servant leaders assist team members to achieve their personal goals by listening with empathy and committing to individual growth and community-building. They share power, put the needs of others first, and help individuals optimize performance while forsaking their own personal advancement and rewards.[ 28 ]

Visit the Greenleaf Center site to learn more about  What is Servant Leadership ?

Resonant leaders  are in tune with the emotions of those around them, use empathy, and manage their own emotions effectively. Resonant leaders build strong, trusting relationships and create a climate of optimism that inspires commitment even in the face of adversity. They create an environment where employees are highly engaged, making them willing and able to contribute with their full potential.[ 29 ]

Authentic leaders  have an honest and direct approach with employees, demonstrating self-awareness, internalized moral perspective, and relationship transparency. They strive for trusting, symmetrical, and close leader–follower relationships; promote the open sharing of information; and consider others’ viewpoints.[ 30 ]

Characteristics of Leadership Styles

Outcomes of Various Leadership Styles

Leadership styles affect team members, patient outcomes, and the organization. A systematic review of the literature published in 2021 showed significant correlations between leadership styles and nurses’ job satisfaction. Transformational leadership style had the greatest positive correlation with nurses’ job satisfaction, followed by authentic, resonant, and servant leadership styles. Passive-avoidant and laissez-faire leadership styles showed a negative correlation with nurses’ job satisfaction.[ 31 ] In this challenging health care environment, managers and nurse leaders must promote technical and professional competencies of their staff, but they must also act to improve staff satisfaction and morale by using appropriate leadership styles with their team.[ 32 ]

Systems Theory

Systems theory  is based on the concept that systems do not function in isolation but rather there is an interdependence that exists between their parts. Systems theory assumes that most individuals strive to do good work, but are affected by diverse influences within the system. Efficient and functional systems account for these diverse influences and improve outcomes by studying patterns and behaviors across the system.[ 33 ]

Many health care agencies have adopted a culture of safety based on systems theory. A  culture of safety  is an organizational culture that embraces error reporting by employees with the goal of identifying systemic causes of problems that can be addressed to improve patient safety. According to The Joint Commission, a culture of safety includes the following components[ 34 ]:

• Just Culture:  A culture where people feel safe raising questions and concerns and report safety events in an environment that emphasizes a nonpunitive response to errors and near misses. Clear lines are drawn by managers between human error, at-risk, and reckless employee behaviors. See Figure 4.4 [ 35 ] for an illustration of Just Culture.
• Reporting Culture:  People realize errors are inevitable and are encouraged to speak up for patient safety by reporting errors and near misses. For example, nurses complete an “incident report” according to agency policy when a medication error occurs or a client falls. Error reporting helps the agency manage risk and reduce potential liability.
• Learning Culture:  People regularly collect information and learn from errors and successes while openly sharing data and information and applying best evidence to improve work processes and patient outcomes.

“Just Culture Infographic.png” by Valeria Palarski 2020. Used with permission.

The Just Culture model categorizes human behavior into three categories of errors. Consequences of errors are based on whether the error is a simple human error or caused by at-risk or reckless behavior[ 36 ]:

• Simple human error:  A simple human error occurs when an individual inadvertently does something other than what should have been done. Most medical errors are the result of human error due to poor processes, programs, education, environmental issues, or situations. These errors are managed by correcting the cause, looking at the process, and fixing the deviation. For example, a nurse appropriately checks the rights of medication administration three times, but due to the similar appearance and names of two different medications stored next to each other in the medication dispensing system, administers the incorrect medication to a patient. In this example, a root cause analysis reveals a system issue that must be modified to prevent future patient errors (e.g., change the labelling and storage of look alike-sound alike medications).[ 37 ]
• At-risk behavior:  An error due to at-risk behavior occurs when a behavioral choice is made that increases risk where the risk is not recognized or is mistakenly believed to be justified. For example, a nurse scans a patient’s medication with a barcode scanner prior to administration, but an error message appears on the scanner. The nurse mistakenly interprets the error to be a technology problem and proceeds to administer the medication instead of stopping the process and further investigating the error message, resulting in the wrong dosage of a medication being administered to the patient. In this case, ignoring the error message on the scanner can be considered “at-risk behavior” because the behavioral choice was considered justified by the nurse at the time.[ 38 ]
• Reckless behavior:  Reckless behavior is an error that occurs when an action is taken with conscious disregard for a substantial and unjustifiable risk. For example, a nurse arrives at work intoxicated and administers the wrong medication to the wrong patient. This error is considered due to reckless behavior because the decision to arrive intoxicated was made with conscious disregard for substantial risk.[ 39 ]

These categories of errors result in different consequences to the employee based on the Just Culture model:

• If an individual commits a simple human error, managers console the individual and consider changes in training, procedures, and processes.[ 40 ] In the “simple human error” example above, system-wide changes would be made to change the label and location of the medications to prevent future errors from occurring with the same medications.
• Individuals committing at-risk behavior are held accountable for their behavioral choices and often require coaching with incentives for less risky behaviors and situational awareness.[ 41 ]In the “at-risk behavior” example above, when the nurse chose to ignore an error message on the barcode scanner, mandatory training on using barcode scanners and responding to errors would likely be implemented, and the manager would track the employee’s correct usage of the barcode scanner for several months following training.
• If an individual demonstrates reckless behavior, remedial action and/or punitive action is taken.[ 42 ] In the “reckless behavior” example above, the manager would report the nurse’s behavior to the State Board of Nursing for disciplinary action. The SBON would likely mandate substance abuse counseling for the nurse to maintain their nursing license. However, employment may be terminated and/or the nursing license revoked if continued patterns of reckless behavior occur.

See Table 4.2c describing classifications of errors using the Just Culture model.

Classification of Errors Using the Just Culture Model

Systems leadership  refers to a set of skills used to catalyze, enable, and support the process of systems-level change that is encouraged by the Just Culture Model. Systems leadership is comprised of three interconnected elements:[ 43 ]

• The Individual:  The skills of collaborative leadership to enable learning, trust-building, and empowered action among stakeholders who share a common goal
• The Community:  The tactics of coalition building and advocacy to develop alignment and mobilize action among stakeholders in the system, both within and between organizations
• The System:  An understanding of the complex systems shaping the challenge to be addressed

4.3. IMPLEMENTING CHANGE

Change is constant in the health care environment.  Change  is defined as the process of altering or replacing existing knowledge, skills, attitudes, systems, policies, or procedures.[ 1 ] The outcomes of change must be consistent with an organization’s mission, vision, and values. Although change is a dynamic process that requires alterations in behavior and can cause conflict and resistance, change can also stimulate positive behaviors and attitudes and improve organizational outcomes and employee performance. Change can result from identified problems or from the incorporation of new knowledge, technology, management, or leadership. Problems may be identified from many sources, such as quality improvement initiatives, employee performance evaluations, or accreditation survey results.[ 2 ]

Nurse managers must deal with the fears and concerns triggered by change. They should recognize that change may not be easy and may be met with enthusiasm by some and resistance by others. Leaders should identify individuals who will be enthusiastic about the change (referred to as “early adopters”), as well as those who will be resisters (referred to as “laggers”). Early adopters should be involved to build momentum, and the concerns of resisters should be considered to identify barriers. Data should be collected, analyzed, and communicated so the need for change (and its projected consequences) can be clearly articulated. Managers should articulate the reasons for change, the way(s) the change will affect employees, the way(s) the change will benefit the organization, and the desired outcomes of the change process.[ 3 ] See Figure 4.5 [ 4 ] for an illustration of communicating upcoming change.

Identifying Upcoming Change

Change Theories

There are several change theories that nurse leaders may adopt when implementing change. Two traditional change theories are known as Lewin’s Unfreeze-Change-Refreeze Model and Lippitt’s Seven-Step Change Theory.[ 5 ]

Lewin’s Change Model

Kurt Lewin, the father of social psychology, introduced the classic three-step model of change known as Unfreeze-Change-Refreeze Model that requires prior learning to be rejected and replaced. Lewin’s model has three major concepts: driving forces, restraining forces, and equilibrium. Driving forces are those that push in a direction and cause change to occur. They facilitate change because they push the person in a desired direction. They cause a shift in the equilibrium towards change. Restraining forces are those forces that counter the driving forces. They hinder change because they push the person in the opposite direction. They cause a shift in the equilibrium that opposes change. Equilibrium is a state of being where driving forces equal restraining forces, and no change occurs. It can be raised or lowered by changes that occur between the driving and restraining forces.[ 6 ],[ 7 ]

• Step 1: Unfreeze the status quo.  Unfreezing is the process of altering behavior to agitate the equilibrium of the current state. This step is necessary if resistance is to be overcome and conformity achieved. Unfreezing can be achieved by increasing the driving forces that direct behavior away from the existing situation or status quo while decreasing the restraining forces that negatively affect the movement from the existing equilibrium. Nurse leaders can initiate activities that can assist in the unfreezing step, such as motivating participants by preparing them for change, building trust and recognition for the need to change, and encouraging active participation in recognizing problems and brainstorming solutions within a group.[ 8 ]
• Step 2: Change.  Change is the process of moving to a new equilibrium. Nurse leaders can implement actions that assist in movement to a new equilibrium by persuading employees to agree that the status quo is not beneficial to them; encouraging them to view the problem from a fresh perspective; working together to search for new, relevant information; and connecting the views of the group to well-respected, powerful leaders who also support the change.[ 9 ]
• Step 3: Refreeze.  Refreezing refers to attaining equilibrium with the newly desired behaviors. This step must take place after the change has been implemented for it to be sustained over time. If this step does not occur, it is very likely the change will be short-lived and employees will revert to the old equilibrium. Refreezing integrates new values into community values and traditions. Nursing leaders can reinforce new patterns of behavior and institutionalize them by adopting new policies and procedures.[ 10 ]

Example Using Lewin’s Change Theory

A new nurse working in a rural medical-surgical unit identifies that bedside handoff reports are not currently being used during shift reports.

Step 1: Unfreeze:  The new nurse recognizes a change is needed for improved patient safety and discusses the concern with the nurse manager. Current evidence-based practice is shared regarding bedside handoff reports between shifts for patient safety.[ 11 ] The nurse manager initiates activities such as scheduling unit meetings to discuss evidence-based practice and the need to incorporate bedside handoff reports.

Step 2: Change:  The nurse manager gains support from the Director of Nursing to implement organizational change and plans staff education about bedside report checklists and the manner in which they are performed.

Step 3: Refreeze:  The nurse manager adopts bedside handoff reports in a new unit policy and monitors staff for effectiveness.

Lippitt’s Seven-Step Change Theory

Lippitt’s Seven-Step Change Theory expands on Lewin’s change theory by focusing on the role of the change agent. A  change agent  is anyone who has the skill and power to stimulate, facilitate, and coordinate the change effort. Change agents can be internal, such as nurse managers or employees appointed to oversee the change process, or external, such as an outside consulting firm. External change agents are not bound by organizational culture, politics, or traditions, so they bring a different perspective to the situation and challenge the status quo. However, this can also be a disadvantage because external change agents lack an understanding of the agency’s history, operating procedures, and personnel.[ 12 ] The seven-step model includes the following steps[ 13 ]:

• Step 1: Diagnose the problem.  Examine possible consequences, determine who will be affected by the change, identify essential management personnel who will be responsible for fixing the problem, collect data from those who will be affected by the change, and ensure those affected by the change will be committed to its success.
• Step 2: Evaluate motivation and capability for change.  Identify financial and human resources capacity and organizational structure.
• Step 3: Assess the change agent’s motivation and resources, experience, stamina, and dedication.
• Step 4: Select progressive change objectives.  Define the change process and develop action plans and accompanying strategies.
• Step 5: Explain the role of the change agent to all employees and ensure the expectations are clear.
• Step 6: Maintain change.  Facilitate feedback, enhance communication, and coordinate the effects of change.
• Step 7: Gradually terminate the helping relationship of the change agent.

Example Using Lippitt’s Seven-Step Change Theory

Refer to the previous example of using Lewin’s change theory on a medical-surgical unit to implement bedside handoff reporting. The nurse manager expands on the Unfreeze-Change-Refreeze Model by implementing additional steps based on Lippitt’s Seven-Step Change Theory:

• The nurse manager collects data from team members affected by the changes and ensures their commitment to success.
• Early adopters are identified as change agents on the unit who are committed to improving patient safety by implementing evidence-based practices such as bedside handoff reporting.
• Action plans (including staff education and mentoring), timelines, and expectations are clearly communicated to team members as progressive change objectives. Early adopters are trained as “super-users” to provide staff education and mentor other nurses in using bedside handoff checklists across all shifts.
• The nurse manager facilitates feedback and encourages two-way communication about challenges as change is implemented on the unit. Positive reinforcement is provided as team members effectively incorporate change.
• Bedside handoff reporting is implemented as a unit policy, and all team members are held accountable for performing accurate bedside handoff reporting.

Read more about additional change theories in the  Current Theories of Change Management pdf .

Change Management

Change management  is the process of making changes in a deliberate, planned, and systematic manner.[ 14 ] It is important for nurse leaders and nurse managers to remember a few key points about change management[ 15 ]:

• Employees will react differently to change, no matter how important or advantageous the change is purported to be.
• Basic needs will influence reaction to change, such as the need to be part of the change process, the need to be able to express oneself openly and honestly, and the need to feel that one has some control over the impact of change.
• Change often results in a feeling of loss due to changes in established routines. Employees may react with shock, anger, and resistance, but ideally will eventually accept and adopt change.
• Change must be managed realistically, without false hopes and expectations, yet with enthusiasm for the future. Employees should be provided information honestly and allowed to ask questions and express concerns.

4.4. SPOTLIGHT APPLICATION

Jamie has recently completed his orientation to the emergency department at a busy Level 1 trauma center. The environment is fast-paced and there are typically a multitude of patients who require care. Jamie appreciates his colleagues and the collaboration that is reflected among members of the health care team, especially in times of stress. Jamie is providing care for an 8-year-old patient who has broken her arm when there is a call that there are three Level 1 trauma patients approximately 5 minutes from the ER. The trauma surgeon reports to the ER, and multiple members of the trauma team report to the ER intake bays. If you were Jamie, what leadership style would you hope the trauma surgeon uses with the team?

In a stressful clinical care situation, where rapid action and direction are needed, an autocratic leadership style is most effective. There is no time for debating different approaches to care in a situation where immediate intervention may be required. Concise commands, direction, and responsive action from the team are needed to ensure that patient care interventions are delivered quickly to enhance chance of survival and recovery.

4.5. LEARNING ACTIVITIES

Learning activities.

(Answers to “Learning Activities” can be found in the “Answer Key” at the end of the book. Answers to interactive activities are provided as immediate feedback.)

Sample Scenario

An 89-year-old female resident with Alzheimer’s disease has been living at the nursing home for many years. The family decides they no longer want aggressive measures taken and request to the RN on duty that the resident’s code status be changed to Do Not Resuscitate (DNR). The evening shift RN documents a progress note that the family (and designated health care agent) requested that the resident’s status be made DNR. Due to numerous other responsibilities and needs during the evening shift, the RN does not notify the attending physician or relay the information during shift change or on the 24-hour report. The day shift RN does not read the night shift’s notes because of several immediate urgent situations. The family, who had been keeping vigil at the resident’s bedside throughout the night, leaves to go home to shower and eat. Upon return the next morning, they find the room full of staff and discover the staff performed CPR after their loved one coded. The resident was successfully resuscitated but now lies in a vegetative state. The family is unhappy and is considering legal action. They approach you, the current nurse assigned to the resident’s care, and state, “We followed your procedures to make sure this would not happen! Why was this not managed as we discussed?”[ 1 ]

1. As the current nurse providing patient care, explain how you would therapeutically address this family’s concerns and use one or more leadership styles.

2. As the charge nurse, explain how you would address the staff involved using one or more leadership styles.

3. Explain how change theory can be implemented to ensure this type of situation does not recur.

IV. GLOSSARY

The process of altering or replacing existing knowledge, skills, attitudes, systems, policies, or procedures.[ 1 ]

Anyone who has the skill and power to stimulate, facilitate, and coordinate the change effort.

Organizational culture that embraces error reporting by employees with the goal of identifying systemic causes of problems that can be addressed to improve patient safety. Just Culture is a component of a culture of safety.

The upward influence of individuals on their leaders and their teams.

A culture where people feel safe raising questions and concerns and report safety events in an environment that emphasizes a nonpunitive response to errors and near misses. Clear lines are drawn between human error, at-risk, and reckless employee behaviors.

The art of establishing direction and influencing and motivating others to achieve their maximum potential to accomplish tasks, objectives, or projects.[ 2 ],[ 3 ]

Roles that focus on tasks such as planning, organizing, prioritizing, budgeting, staffing, coordinating, and reporting.[ 4 ]

An organization’s statement that describes how the organization will fulfill its vision and establishes a common course of action for future endeavors.

The implicit values and beliefs that reflect the norms and traditions of an organization. An organization’s vision, mission, and values statements are the foundation of organizational culture.

A set of skills used to catalyze, enable, and support the process of systems-level change that focuses on the individual, the community, and the system.

The concept that systems do not function in isolation but rather there is an interdependence that exists between their parts. Systems theory assumes that most individuals strive to do good work, but are affected by diverse influences within the system.

The organization’s established values that support its vision and mission and provide strategic guidelines for decision-making, both internally and externally, by members of the organization.

An organization’s statement that defines why the organization exists, describes how the organization is unique and different from similar organizations, and specifies what the organization is striving to be.

Licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/ .

• Cite this Page Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Management and Professional Concepts [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2022. Chapter 4 - Leadership and Management.
• PDF version of this title (18M)

In this Page

• LEADERSHIP & MANAGEMENT INTRODUCTION
• BASIC CONCEPTS
• IMPLEMENTING CHANGE
• SPOTLIGHT APPLICATION
• LEARNING ACTIVITIES

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The essentials of nursing leadership: A systematic review of factors and educational interventions influencing nursing leadership

Affiliations.

• 1 Faculty of Nursing, Edmonton Clinic Health Academy, University of Alberta, 11405 87 Ave NW, Edmonton, AB T6G 1C9, Canada. Electronic address: [email protected].
• 2 Department of Nutrition, Dietetics and Food, School of Clinical Sciences at Monash Health, Monash University, Level 1, 264 Ferntree Gully Rd, Notting Hill, VIC 3168, Australia.
• 3 Faculty of Nursing, Edmonton Clinic Health Academy, University of Alberta, 11405 87 Ave NW, Edmonton, AB T6G 1C9, Canada.
• 4 Faculty of Nursing, Edmonton Clinic Health Academy, University of Alberta, 11405 87 Ave NW, Edmonton, AB T6G 1C9, Canada; Technical High School of Campinas, State University of Campinas (UNICAMP), Barão Geraldo, Campinas - São Paulo 13083-970, Brazil.
• PMID: 33383271
• DOI: 10.1016/j.ijnurstu.2020.103842

Background: Nursing leadership plays a vital role in shaping outcomes for healthcare organizations, personnel and patients. With much of the leadership workforce set to retire in the near future, identifying factors that positively contribute to the development of leadership in nurses is of utmost importance.

Objectives: To identify determining factors of nursing leadership, and the effectiveness of interventions to enhance leadership in nurses.

Design: We conducted a systematic review, including a total of nine electronic databases.

Data sources: Databases included: Medline, Academic Search Premier, Embase, PsychInfo, Sociological Abstracts, ABI, CINAHL, ERIC, and Cochrane.

Review methods: Studies were included if they quantitatively examined factors contributing to nursing leadership or educational interventions implemented with the intention of developing leadership practices in nurses. Two research team members independently reviewed each article to determine inclusion. All included studies underwent quality assessment, data extraction and content analysis.

Results: 49,502 titles/abstracts were screened resulting in 100 included manuscripts reporting on 93 studies (n=44 correlational studies and n=49 intervention studies). One hundred and five factors examined in correlational studies were categorized into 5 groups experience and education, individuals' traits and characteristics, relationship with work, role in the practice setting, and organizational context. Correlational studies revealed mixed results with some studies finding positive correlations and other non-significant relationships with leadership. Participation in leadership interventions had a positive impact on the development of a variety of leadership styles in 44 of 49 intervention studies, with relational leadership styles being the most common target of interventions.

Conclusions: The findings of this review make it clear that targeted educational interventions are an effective method of leadership development in nurses. However, due to equivocal results reported in many included studies and heterogeneity of leadership measurement tools, few conclusions can be drawn regarding which specific nurse characteristics and organizational factors most effectively contribute to the development of nursing leadership. Contextual and confounding factors that may mediate the relationships between nursing characteristics, development of leadership and enhancement of leadership development programs also require further examination. Targeted development of nursing leadership will help ensure that nurses of the future are well equipped to tackle the challenges of a burdened health-care system.

Keywords: Interventions; Leadership; Nursing workforce; Systematic Review.

Copyright © 2020. Published by Elsevier Ltd.

Publication types

• Systematic Review
• Delivery of Health Care*
• Leadership*

Top Nursing Leadership Roles & How to Become a Nurse Leader

Nursing leadership roles, skills & education needed to be a nurse leader, what does effective nurse leadership look like, nurse leadership styles, why do we need nurse leaders, next steps to become a nurse leader.

The American Nurses Association (ANA) Leadership Institute describes a nurse leader as “a nurse who is interested in excelling in a career path, a leader within a healthcare organization who represents the interests of the nursing profession, a seasoned nurse or healthcare administrator interested in refining skills to differentiate them from the competition or to advance to the next level of leadership.”

The truth is, nursing leadership can take a lot of different forms. In this article, we’ll explore the different leadership roles available for nurses, the skills nurses need to lead, leadership styles, and more.

Popular Online Healthcare Leadership Programs

The University of Scranton offers multiple online degrees in the growing healthcare industry. The comprehensive coursework is based on real-world scenarios and is equally rigorous and rewarding. The return on investment will be as big as the change you can make in a variety of healthcare leadership roles!

Enrollment: Nationwide

• MHA - Master of Health Administration
• Certificate - Healthcare Administration
• Dual MBA-MHA
• MBA - Health Care Management Specialization

GCU's College of Nursing and Health Care Professions has a nearly 35-year tradition of preparing students to fill evolving healthcare roles as highly qualified professionals.

• MSN - Nursing Leadership in Health Care Systems
• MBA & MSN - Nursing Leadership in Health Care Systems
• MSN - Health Care Quality & Patient Safety

Whether you’re taking the first steps toward a nursing degree, seeking to advance as a nurse or want to hone your craft with specialized study, there’s a path for you at Purdue Global’s School of Nursing. Our programs were designed so that you can easily balance your lives at home and work with school - without sacrificing the rigor and cutting-edge curriculum of a quality nursing education.

Enrollment: Nationwide, but certain programs have state restrictions. Check with Purdue for details.

• MSN - Executive Leader

WGU's award-winning online programs are created to help you succeed while graduating faster and with less debt. WGU is a CCNE accredited, nonprofit university offering nursing bachelor's and master's degrees.

• BSN-to-MSN - Nursing Leadership & Management
• RN-to-MSN - Nursing Leadership & Management

As a pioneer in distance learning since 1985, Liberty University’s online nursing programs are designed to prepare practicing nurses to serve with integrity by teaching advanced skills from an ethical perspective. Liberty's programs are based on industry best practices and up-to-date research – so you can get the tools you need to stay on the cutting edge of nursing care and innovation. 

• BSN-to-MSN - Nurse Admin

Nursing leadership roles can vary ranging from running a hospital to running a unit. Here are some of the leadership roles available in the nursing profession.

1. Chief Nursing Officer (CNO)

A CNO is a top-level, nonclinical, administrative position within a healthcare system. 

They are considered the top-level nurse within an organization and they oversee other nurses and the implementation of patient care. 

The CNO is the voice of the nurses in an organization and they must work together with the staff to deliver the mission, values, and vision of the healthcare organization. 

2. Clinical Nurse Leader (CNL)

CNLs provide oversight and improvement over much of the activity in a specific clinical setting. 

They coordinate collaborative care for patients, analyze outcomes and quality of care, act as mentors to staff and liaisons, and collect and integrate data to further their understanding of outcomes. 

CNLs work in the space between bedside and administration. 

Popular Online Master of Science in Nursing (MSN) Programs

• MSN - Family NP
• MSN - Adult-Gerontology Acute Care NP
• MSN - Health Informatics
• MSN - Nursing Education
• MSN - Public Health Nursing

Earn a valuable nursing credential at Purdue Global’s School of Nursing. Expand your expertise and prepare to take on leadership and independent practice opportunities. Complete your courses online, on your schedule.

• Accelerated BSN-to-MSN
• MSN - Psychiatric Mental Health NP
• MSN - Nurse Educator
• BSN-to-MSN - Family NP
• BSN-to-MSN - Psychiatric Mental Health NP
• BSN-to-MSN - Nursing Education
• RN-to-MSN - Nursing Education

Earn your nursing degree from one of the largest nursing education providers in the U.S. Walden University’s BSN, MSN, post-master’s APRN certificate, and DNP programs are accredited by the Commission on Collegiate Nursing Education (CCNE). Get enhanced practicum support with our Practicum Pledge.

Enrollment: Nationwide, excluding CT, ND, NY and RI. Certain programs have additional state restrictions. Check with Walden for details.

• MSN - Psychiatric-Mental Health NP
• MSN - Adult-Gerontology Primary Care NP
• MSN - Pediatric NP - Primary Care
• MSN - Nursing Informatics
• MSN - Nurse Executive
• MSN & MBA - Dual Degree

3. Nurse Administrator/ Executive

Nurse administrators manage day-to-day operations for nursing staff either on a specific unit or throughout an entire hospital. 

Other responsibilities include budget and financial planning, creating operational strategies, as well as decision-making regarding staffing and protocols. 

Specific job duties will depend on the size and organization of the facility of employment. 

4. Nurse Manager

Nurse managers typically manage a specific unit or department. Nurse Managers create schedules for employees, give annual performance reviews, and help create policies within the unit. The average annual nurse manager salary ranges from $107,248 to $121,300, making it a lucrative leadership position for nurses.

>> Related:  Charge Nurse vs Nurse Manager: What's the Difference?

5. Nursing Director

The nursing director's responsibilities include overseeing the nursing staff, as well as communicating between the nursing and medical teams and other healthcare professionals throughout the organization. They are responsible for reviewing policies and procedures, implementing changes, developing a budget, and supporting the staff.

This high level of responsibility warrants one of the highest nursing leadership salaries. Read our comprehensive guide to learn more about director of nursing salary expectations and factors.

Nurse leaders are required to have a specific set of skills in order to be effective. Common skills include 

• Strong decision-making skills
• Conflict resolution
• Effective communication
• Adaptability
• Prioritizing quality and safety 
• Strong bedside clinical skills
• Knowledge of budget and policy
• Business mindedness
• Delegation skills 
• Strong critical thinking skills
• A positive attitude
• Honesty and loyalty
• Passion for their jobs

The education needed to become a nurse leader varies depending on the position. For example, a Chief Nursing Officer would benefit from a Master’s degree in Business Administration (MBA) or a Master’s Degree in Healthcare Administration (MHA). 

More education is always better for leaders in healthcare. Most nurse leaders can expect to earn a degree in an MSN to be an effective leader. Additional education and degrees open many doors for individuals and will make you more competitive with potential employers. 

This will vary depending on the location and position but ideally, a nurse leader should be committed to providing the best care to patients in the unit as well as the staff. 

Nurse leaders should be able to positively influence their employees and strive for excellence and commitment. 

A good nurse leader should be present on a consistent basis in the unit, department, or healthcare setting. 

There are a variety of leadership styles for becoming an effective nurse leader. These include, 

• Transformational
• Laissez-faire

Transformational leaders will utilize a collaborative leadership style by using a shared vision for a unit/department/healthcare setting to encourage and inspire change. 

Democratic leadership uses a shared leadership style in which others (staff nurses/other healthcare professionals) guide decision-making and management. 

A laissez-faire leadership style is a facilitative one in which a leader makes few decisions. Autocratic leadership is a unilateral style in which the leader delegates to others with rules and orders. 

Servant leadership is a supportive style in which the leader provides team members with the skills, tools, and relationships they need to perform to the best of their ability. 

Nurse leaders are essential to the organization of a healthcare system. They allow bedside nurses to function effectively, patients to receive appropriate and safe care, and ideally will advocate for the nursing staff on a variety of issues. 

Nurse leaders can help create a positive work environment for staff and patients alike. 

Furthermore, nurse leaders will help alleviate staffing concerns, manage payroll, and should be available to staff on a regular and consistent basis. 

If you are already an RN, becoming a nurse leader will take time and dedication. 

The first step is speaking with your nurse manager and inquiring about training to become a charge nurse on a unit or a nurse supervisor. This can act as an introduction to leadership positions. Responsibilities will vary but they will include multi-tasking, overseeing nursing assignments, reassignments and more. 

If the roles and responsibilities of a nurse leadership still excite you, consider gaining additional education in the form of an MSN, MBA, and/or MHA. These are often a requirement for most nurse leader positions.

Kathleen Gaines (nee Colduvell) is a nationally published writer turned Pediatric ICU nurse from Philadelphia with over 13 years of ICU experience. She has an extensive ICU background having formerly worked in the CICU and NICU at several major hospitals in the Philadelphia region. After earning her MSN in Education from Loyola University of New Orleans, she currently also teaches for several prominent Universities making sure the next generation is ready for the bedside. As a certified breastfeeding counselor and trauma certified nurse, she is always ready for the next nursing challenge.

Education: MSN Nursing Education - Loyola University New Orleans BSN - Villanova University BA- University  of Mary Washington

Expertise: Pediatric Nursing, Neonatal Nursing, Nursing Education, Women’s Health, Intensive Care, Nurse Journalism, Cardiac Nursing 

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What does nursing leadership and management look like?

Written by Michael Feder

This article was reviewed by Raelene Brooks , Dean, College of Nursing.

Many roles in the nursing profession require leadership skills, particularly in interpersonal communication, problem-solving, and quality improvement and safety. You’ll need to strike a balance between providing quality patient care while managing a variety of other tasks, or direct reports, in a healthcare environment. Let’s take a look at some of the qualities of good leadership and how to become a better nurse leader.

The major qualities of good nursing leadership

Nurse leaders share a variety of key qualities that they may implement on a day-to-day basis:

• Make evidence-based practice decisions  about assessments, treatments, therapy and other modalities that help improve patients’ quality of life.
• Communicate effectively ,   which improves interprofessional collaboration, allowing nurses and patients to connect and make progress toward health-related goals.
• Mentor others  to help train the next generation of healthcare experts.
• Practice with integrity ,   maintaining strong moral principles and following the Code of Ethics for Nurses  while fulfilling daily duties.
• Efficiency and productivity  to optimize internal schedules, patient assessments and meetings with patients’ family members.

A combination of professionalism, communication, quality improvement and problem-solving allows a nurse to prioritize patient interests while performing assessment and providing any required care.

Skills that help make a better nurse leader 

Nurse leaders depend on a variety of soft and hard skills to provide value for patients and fellow team members. Here are just a handful of examples to consider:

Hard skills

• Information technology — Collect and evaluate information within informatics systems and through other IT programs.
• Evidence-based practice — Analyze research concepts and methods for evidence-based practice.
• Applied statistics — Explore the use of applied statistics and research results to support evidence-based practice.
• Regulatory compliance — Integrate safety, regulatory and ethical requirements.
• Advanced clinical practice — Analyze knowledge of advanced pharmacology, pathophysiology and physical assessment to improve direct population health.
• Project development — Apply leadership and communication skills through the development and assessment of an applied project, including evidence-based guidelines, design, an implementation plan, an evaluation plan and dissemination.

Soft skills

• Empathy  — Demonstrate a genuine interest in patient needs, interests and outcomes, and practice sensitivity.
• Problem-solving — Apply evidence to improve complex systems of healthcare for diverse populations.
• Decision - making — Lead the advancement of the nursing profession to influence interprofessional decision-making.
• Critical thinking — Exercise clinical judgment, which can impact the outcomes and care of patients.
• Interprofessional collaboration  — Work together in a healthcare setting to accomplish goals, maximize efficiency and achieve optimal outcomes for patients.

The importance of effective nursing leadership

Effective leaders help to improve the performance of everyone around them. Nursing leaders help promote a safe and evidence-based practice environment in a healthcare setting — not only for healthcare professionals but also for patients and their family members.

Effective nursing leadership can impact individual career outcomes for many of a nurse’s fellow employees. Nurse leaders often help mentor less-experienced healthcare professionals, providing valuable on-the-job training and peer feedback to help them take next steps in their own careers.

These same nursing leaders also take pride in their work — and deliver safe and quality improvement outcomes   — in ways that reflect well on practitioners or physicians who collaborate with them, as well as entire healthcare organizations.

How to develop your nurse leadership skills

Improving your nurse leadership skills can take time. It’s important to choose an education partner with a history of creating effective leaders in healthcare.

Here are a few ways you can improve your leadership skills in the nursing profession:

• Obtain additional nursing education  — Learn critical skills in nursing with a Bachelor of Science in Nursing (BSN) or a Master of Science in Nursing with a concentration in Nurse Administration .
• Join professional organizations  — In such groups, either locally or online, you can network with other healthcare professionals and exchange ideas and information on leadership in your profession.
• Find a mentor  — Consider asking a nurse in your organization if they’ll serve as your mentor, someone who can answer questions and provide an example of professional nursing in action.

Leadership roles in nursing

Nursing leadership roles typically allow you to promote smooth facility operations while you advocate for better patient outcomes.

Here are a few leadership roles in nursing.

• Nurse supervisor  — Nursing supervisors provide a bridge between hospital management and clinical care providers. As a nursing supervisor, you might lead nurses in providing services like medication, treatment and therapy.
• Clinical manager  — Clinical managers help supervise a facility’s nursing staff. They strive to uphold strong standards in patient care, leveraging experience in a clinical role to make sure all patients receive adequate, correct care.
• Director of nursing  — Nursing directors manage a facility’s nursing operations, including most other leadership staff on a nursing floor. They help create goals for nursing staff members and implement policies that promote efficiency, compliance and productive patient outcomes.

These nursing positions offer varying levels of leadership. Depending on your employer, education, certifications and years of experience, you might qualify for a role in nursing leadership.

Leadership styles that can be beneficial in the nursing profession

Nursing leaders are like all other leaders: Each operates in a slightly different way. Depending on your personality and skill set, you might employ a particular leadership style in your nursing profession.

These are  common leadership styles  you might find in a nursing environment. While they may go by other designations, the standard styles include:

• Autocratic  — Leaders make decisions after little to no input from direct reports. Autocratic leadership benefits experienced nursing leaders who might understand exactly how to proceed in a delicate or time-sensitive situation where patients need immediate care.
• Participative  — Leaders field and consider feedback before reaching decisions. Democratic leadership is ideal for nursing leaders making decisions about schedules, shifts or conflicts that affect the entire nursing team.
• Transformational  — Leaders exceed expectations to implement change that helps everyone realize a shared vision. Transformational leadership can help nursing leaders encourage nurses to be empathetic, particularly when dealing with patients who might have mental health challenges requiring extra care or sensitivity.
• Delegative  — Leaders adopt a hands-off approach to leadership. Nursing leaders who use a laissez-faire leadership model are typically confident in the abilities of the nurses working under them, to the point where supervision isn’t always necessary.
• Transactional  — Leaders use a reward and discipline system to encourage correct behavior. Nurses who use a transactional leadership style might work with younger individuals who may need more attention and who could benefit more from a system that prioritizes efficiency while correcting errors.
• Bureaucratic  — Leaders prioritize company needs and rely on policies to keep team members in place. Nurse leaders often need to deploy a bureaucratic leadership style in situations where there’s little room for mistakes, particularly when patient outcomes are at stake.
• Servant  — Leaders build strong relationships as they focus on individual needs. Nurses might use a servant leadership approach to create an environment where openness and growth of younger nurses are encouraged.

No matter the size of your next nursing clinic, or your individual nursing role, you can implement one or more of these leadership styles to become a more effective leader in your workplace.

Develop your nurse leadership skills at University of Phoenix

If you’re interested in developing the skills to be a better nurse leader, a degree from University of Phoenix can help. The University offers a Registered Nurse (RN) to BSN degree as well as a Master of Science in Nursing degree with a concentration in Nurse Administration. These programs help registered nurses prepare to enhance their nursing career by teaching sought-after skills that can help them become leaders who impact organizational change. To learn more, visit the University of Phoenix website .

ABOUT THE AUTHOR

A graduate of Johns Hopkins University and its Writing Seminars program and winner of the Stephen A. Dixon Literary Prize, Michael Feder brings an eye for detail and a passion for research to every article he writes. His academic and professional background includes experience in marketing, content development, script writing and SEO. Today, he works as a multimedia specialist at University of Phoenix where he covers a variety of topics ranging from healthcare to IT.

ABOUT THE REVIEWER

Dr. Raelene Brooks, dean of the College of Nursing, has been a registered nurse for more than 25 years and practiced extensively in the areas of ICU, trauma and critical care. Her publications include a focus on nursing education, critical care and diversity, equity and inclusion. She is a leader in creating, guiding and launching innovative curriculum.

This article has been vetted by University of Phoenix's editorial advisory committee.  Read more about our editorial process.

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