Leading as a Pactice scholar (Nursing)
Instructions: Nursing Doctorate level writing, 2 pages, APA format absolutely zero plagiarism
Please see attached supplemental reading material
Due today 12/16/2020 in 8hrs (2:30PM -US Central time
Questions to address:
· How will you establish personal credibility as a leader? How will you model the way for others?
· What strategies will you use to inspire a shared vision for those you lead?
· How will you challenge the current process to lead change?
· What strategies will you use to enable others to act?
· How will you recognize the contributions of others?
Instructions:Doctorate level writing, 2 pages, APA format absolutely zero plagiarism
Please see attached supplemental reading material
· How will you establish personal credibility as a leader? How will you model the way for others?
· What strategies will you use to inspire a shared vision for those you lead?
· How will you challenge the current process to lead change?
· What strategies will you use to enable others to act?
· How will you recognize the contributions of others?
Supplement reading
Marshall, E. S. & Broome, M.E. (2017). Transformational leadership in nursing: From expert clinician to influential leader (2nd ed.). Springer Publishing Company.
· Part II, Chapter 6:
Frameworks for Becoming a Transformational Leader
, pp. 144-165
CHAPTER 6
Frameworks for Becoming a Transformational Leader
Marion E. Broome and Elaine Sorensen Marshall
While many people believe that transforming organizations … is the most difficult, the truth is that transforming ourselves is the hardest job. And if we transform ourselves, we transform our world.
—Dag Hammarskjold
OBJECTIVES
•To deepen appreciation for two current models: authentic leadership and the leadership challenge model
•To identify and explore competencies and/or habits for leadership
•To develop a vision in leadership
•To recognize the importance of the use of evidence to support vision
•To define and understand the significance of power as a leader
•To consider the role of a leader as an entrepreneur
•To understand servant leadership
•To recognize the responsibility of a leader for generativity
Stephen Covey devoted a career to convincing us that there are seven or eight habits of a successful leader (Covey, 1989, 2004). Hamric, Spross, and Hanson (2009, p. 254) reviewed current leadership models and concluded that only three habits are most important to the transformational leader in clinical practice: (a) empowerment of colleagues and followers, (b) engagement of stakeholders within and outside nursing in the change process, and (c) provision of individual and system support during change initiatives. But we all know there are many more essential habits for the effective transformational leader. Consequential leadership requires the cultivation of a lifetime of habits that build others and strengthen self. In Chapter 1, we reviewed various dimensions of transformational leadership—the focus of this book. At the beginning of this chapter, we introduce two complementary leadership frameworks that you may find useful in thinking about your own personal leadership philosophy, style, and behaviors: Authentic Leadership (Avolio & Gardner, 2005) and Leadership Challenge (Kouzes & Posner, 2010). Consideration of these models provides a foundation for examining and developing personal leadership styles. A discussion of how competencies of leadership have evolved over time expands the conversation. We then show how leaders can take these frameworks to build their own leadership skills and competencies.
TWO MODELS TO USE IN BUILDING A FOUNDATION TO BECOME A TRANSFORMATIONAL LEADER
Authentic Leadership Model
Authentic leadership is one of the frameworks that emphasizes relationships between leaders and followers and focuses on the self-development potential of the leader. At the same time, the model reflects a recognition that this potential and subsequent interactions are in service of the larger organization and context, as well as the individuals within the organization. Authentic leaders are perceived as hopeful and optimistic, exhibiting behaviors reflective of a moral compass they can articulate. Such individuals speak with a clear voice for the needs of those in their organization (Avolio & Gardner, 2005). Key characteristics of these leaders include self-awareness, relational transparency, internalized moral perspective, and balanced information processing (Bamford, Wong, & Laschinger, 2013).
Nurse leaders who are authentic are able to be honest and open in their relationships with individuals to whom they report, as well as those who work for them. Their sense of integrity also facilitates, actually mandates, their need to seek diverse perspectives from others and use multiple sources of evidence when making an important decision. Bamford et al. (2013) conducted a secondary analysis of data from 280 nurses who worked with nurse managers. Those nurses who worked for nurse leaders who exhibited higher levels of authentic leadership were more fully engaged in the workplace and reported a greater sense of alignment in multiple areas of their work life.
Leadership Challenge Model
Kouzes and Posner (2007, 2010) developed a model of leadership by analyzing practices of leaders to provide emerging leaders with a description of behaviors and practices that develop strengths. The model consists of five practices: (a) model the way, (b) inspire a vision, (c) challenge the process, (d) enable others to act, and (e) encourage the heart.
The nurse leader who models the way understands his or her own beliefs and is able to articulate how the mission of the organization is an important responsibility of all. Such leaders are visible and committed to the organization and those who work with them. They are experts in their field. It is through their efforts to connect with others and set an example of how to maximize their own and others’ strengths that they are able to inspire a vision for the organization. Their assessment of the group’s potential based on listening to the hopes and aspirations of others and enthusiasm about where the organization is capable of going enlists others in working toward a common goal. However, as the leader begins to set the stage it becomes clear that traditional ways of being and doing will need to be challenged in order to develop new thinking and ways of behavior to achieve the goals. The leader will then engage in questioning and challenging existing processes. Experimenting with new ways of doing things and challenging others to develop their skills and take risks will enable them to act. Enabling others to act will require the leader to set a challenge and provide resources for them to draw on to meet the challenge. As they achieve success others will grow and develop leadership skills themselves. From the collaborations they form while working to solve the challenge, they will learn the value of working with others with complementary knowledge and skills. The final exemplary practice, to encourage the heart, is one threaded throughout the leadership journey although clearly more important to stress at times when the challenges are more difficult. Individuals working with the leader rely on coaching, celebrating small victories, and the presence of the leader when stress runs high in the organization. Kouzes and Posner developed the Leadership Practices Inventory® series (2016) which allows individuals to assess their own leadership strengths in each of the five exemplary practices and provides tools and activities to use to grow their leadership skills.
These two leadership frameworks reflect a clear emphasis on authentic and meaningful relationships between the leader and others. Leaders in each framework articulate their beliefs that serve as a foundation for their vision for the organization and for how the potential of others can be developed and leveraged for success of all. Leaders who are relationship based have a clear moral compass, are secure in their belief system, and are open to and seek out diverse perspectives in order to shape how they think about challenges and solutions. These models are broader and more philosophical, and frankly more inspiring from our perspective, than some other approaches that include lists of competencies for leadership performance.
LEADERSHIP COMPETENCIES: HABITS FOR PERFORMANCE
There is growing agreement on the need for better leadership in health care but little consensus or evidence regarding which specific areas of knowledge, skills, attitudes, habits, or competencies are best suited to the leaders of the next century (Baker, 2003) or how they are best acquired. Thus, it seems that every leadership guru creates a list. We have lists of competencies from experts and expert panels, from authorities in business and health care, from government agencies, from the Institute of Medicine, and from every practice discipline.
Much of the literature on leadership in health care actually refers to specific management skills with a focus on performance. And performance is usually defined by competencies. Although the idea of competency carries an intuitive, implied definition, there is little agreement on a generally accepted operational definition. There are numerous examples of competency lists for health care managers and many definitions of the concept. One author mused, “Definitions and terminology surrounding the concept of competency are replete with imprecise and inconsistent meanings, resulting in [a] certain level of bewilderment among those seeking to identify the concept” (Shewchuk, O’Connor, & Fine, 2005, p. 33). A commonly accepted definition of competency is the following: “a cluster of related knowledge, skills, and attitudes that: (1) affect a major part of one’s job, role, or responsibility, (2) correlate with performance on the job, (3) can be measured against well accepted standards, and (4) can be improved by training and development” (Lucia & Lepsinger, 1999, in Shewchuk et al., 2005, p. 33). Five underlying characteristics of competencies are motives, traits, self-concept, knowledge, and skills that optimize job performance (Shewchuk et al., 2005; Spencer & Spencer, 1993).
Competency models originate from private and public sector business and industry as well as academe, each one with its own list of dimensions. The dimensions usually include items related to productivity, personal characteristics, and personnel relationships (Simonet & Tett, 2013). Such models have now found their way into health care organizations.
Many of the competency models rely on some sort of 360-degree evaluation model, which refers to regular, formal, and direct leader feedback related to performance on specific goals based on stated organizational values. This model begins with self-evaluation and then integrates formal evaluation from superiors, peers, and subordinates. The critiques are reviewed with an immediate supervisor, and a plan for improvement is developed. This evaluation model is commonly used in business and increasingly incorporated into health care environments (Burkhart, Solari-Twadell, & Haas, 2008; Day, Fleenor, Atwater, Sturm, & McKee, 2014).
As in the business literature, it seems that every health care writer has a list of the most important, or core, competencies for the health care manager. Many come from the personal experience and thoughts of the author, with little reliable empirical data to adequately distinguish, predict, or even to teach the most important competencies. For example, one study sought the most important competencies for physicians to become health care leaders. Most highly ranked were interpersonal communication skills, professional ethics, and social responsibility. Other desired competencies were influencing peers to adopt new approaches in medicine and administrative responsibility in a health care organization (McKenna, Gartland, & Pugno, 2004).
There is increasing interest in the empirical discovery and measurement of competencies for successful leaders (Day et al., 2014). Guo and Anderson (2005) and Guo (2009) promoted a paradigm that identified four essential dimensions: conceptual, participation, interpersonal, and leadership. They subsequently identified the following core competencies: health care system and environment competencies, organization competencies, and interpersonal competencies (Guo, 2009). Stoller (2008) outlined six more specific key leadership competency domains: (a) technical skills and knowledge (operational, financial, information systems, human resources, and strategic planning), (b) industry knowledge (clinical processes, regulation, and health care trends), (c) problem-solving skills, (d) emotional intelligence, (e) communication, and (f) commitment to lifelong learning.
Another list includes planning, organizing, leading, and controlling (Anderson & Pulich, 2002). Still another cluster includes teamwork, negotiation, interpersonal skills, communication, vision, customer service, and business operations (Finstuen & Mangelsdorff, 2006). And yet another model outlines 52 competencies in four domains: (a) technical skills (operations, finance, information resources, human resources, and strategic planning/external affairs), (b) industry knowledge (clinical process and health care institutions), (c) analytical and conceptual reasoning, and (d) interpersonal and emotional intelligence (Robbins, Bradley, & Spicer, 2001). Intuitively, the list seems to be comprehensive and useful. Each of the competencies has been defined theoretically and operationally. Nevertheless, it is daunting to the aspiring leader who might ask, “Where do I begin?”
One group of competencies that has been extensively researched originates from the National Center for Healthcare Leadership (NCHL) in Chicago, Illinois. Its Health Leadership Competency Model (NCHL, 2015) was developed from extensive academic and clinical study. The model comprises three domains of transformation, execution, and people. Under each domain is a list of the following competencies:
1.Transformation competencies: achievement orientation, analytical thinking, community orientation, financial skills, information seeking, innovative thinking, and strategic orientation
2.Execution competencies: accountability, change leadership, collaboration, communication skills, impact and influence, information technology management, initiative, organizational awareness, performance measurement, process management/organizational design, and project management
3.People competencies: human resources management, interpersonal understanding, professionalism, relationship building, self-confidence, self-development, talent development, and team leadership (Calhoun et al., 2004; NCHL, 2015)
The Healthcare Leadership Alliance Competency Directory (Evans, 2005; Healthcare Leadership Alliance [HLA], 2013; Stefl, 2008) lists 300 competences under the five domains of leadership, communications and relationship management, professionalism, business knowledge and skills, and knowledge of the health care environment. If leadership performance could be learned from a dictionary, this would be the one of choice. It is a large classification system of knowledge and skill areas searchable by an elaborate system of key words. Sponsored by the American College of Healthcare Executives, the American College of Physician Executives, the American Organization of Nurse Executives (AONE), the Healthcare Financial Management Association, the Healthcare Information and Management Systems Society, and the Medical Group Management Association, it provides an impressive inventory of leadership concepts that can enable managers and leaders to meet the challenges of navigating and leading through the complexities of today’s current health care environment (HLA, 2013). Unfortunately, it does not provide mentorship, role models, personal experience, or inspiration for the soul of the aspiring leader. For nurse leaders, these supports must be found through the many available leadership academies, conferences, short intensive courses, and other similar options.
Each new list or model (which may or may not be grounded in evidence) announces something along these lines: “The model of leadership competencies presented … [here] will become an essential tool for organizations in their pursuit of leaders to implement and drive successful change. This leadership competency model … will ensure that essential steps of change are followed and provide organizations with a blueprint for success” (Hall, 2004). If nothing else, current experts appear to be confident in their competency paradigms.
Nursing leaders also have their own lists of competencies. These include competencies specific to areas of practice, such as professionalism, network and team building, communication, problem solving and prioritizing, vision, awareness of nurse subordinates, and knowledge of policies and procedures of the unit and larger organization (Grossman, 2007). Most lists developed by nurses are not uniquely distinct from those of the management disciplines. A study using focus groups of nurses produced the following “essential nursing leadership competencies”: skills in listening and conflict resolution; the ability to communicate a vision, motivate, and inspire; and “technological adroitness, fiscal dexterity, and the courage to be proactive during rapid change” (Eddy et al., 2009, p. 1). Stichler (2006, pp. 256–257) asserted that creating and fostering a vision were most important, followed by 15 positive personal attributes, leadership skills that “ignite passion in others and influence them to make things happen,” clinical knowledge and skills, and business competencies. Sherman, Bishop, Eggenberger, and Karden (2007) developed a competency model from a list of six competency categories. The categories were systems thinking, personal mastery, financial management, human resource management, interpersonal effectiveness, and caring.
Huston (2008, p. 906) outlined eight “essential” leadership competencies for the nurse leader of 2020:
1.A global perspective of health care and professional nursing issues
2.Technology skills that facilitate mobility and portability of relationships, interactions, and operational processes
3.Expert decision-making skills rooted in empirical science
4.The ability to create organization cultures that permeate quality health care and patient/worker safety
5.Understanding and appropriately intervening in political processes
6.Collaborative and team-building skills
7.The ability to balance authenticity and performance expectations
8.Being able to envision and proactively adapt to a health care system characterized by rapid change and chaos
Whew! The list is as daunting as the health care system itself.
In health care organizations, one of the frequently referenced models of competencies is that produced by the AONE (2016). They provide an assessment tool that emerging leaders can use to examine their own competencies and where they are in their leadership journey. Nurse educators can also use the tool to help guide curricular development. The AONE noted the need to delineate differences in leadership competencies among leaders of health care systems, leaders working outside of traditional hospital or inpatient settings, and those who are nurse managers.
The current emphasis on competencies and competency measurement appears to be in direct response to economic and social pressures of health care organizations for performance as well as the fact that “rapid change in the organization, financing, and provision of health care services … demand greater efficiencies and better clinical and organizational performance” (Shewchuk et al., 2005, p. 33). With the proliferation of competency-based leadership evaluation that targets efficiencies and safety, caution seems prudent regarding the potential return to traditional mechanistic, industrial efficiency models of providing health care.
Despite our tongue-in-cheek journey through the world of competencies, it may be helpful to know the specific competencies on which nurse leaders might focus. Some observers say that there is a need for greater business acumen (Kleinman, 2003); others promote the need for more “caring competencies” (O’Connor, 2008). The Center for Nursing Leadership outlined nine dimensions of leadership that reflect unique caring competencies: holding the truth, intellectual and emotional self, discovery of potential, quest for the adventure toward knowing, diversity as a vehicle to wholeness, appreciation of ambiguity, knowing something of life, holding multiple perspectives without judgment, and keeping commitments to one’s self (O’Connor, 2008). Again, there is little evidence of empirical testing. Some models from nursing include specific characteristics of transformational leadership, but most fall short of identifying clinical applications, and many borrow from models in business and health care management.
Competencies are necessary, of course, to provide a framework to document and assure performance, especially in areas of productivity, accuracy, and efficiency, but it is difficult to inspire workers or even endear clients or patients with catalogs of expectations. Without vision, competencies are only chore lists for managers. Porter-O’Grady and Malloch (2007, p. 421) reminded that “Leadership is not simply as set of skills [and competencies], but a whole discipline.” Wear (2008, p. 625) warned that while competencies are important, turning every measure of practice into a competency “is an ill-advised leap that transforms a complex educational [clinical, and leadership] mission into a bottom-line venture.” It is important that we broaden the focus to include “ongoing reflective processes and humility that mark the lifelong development of skilled, empathic” clinicians and leaders (Wear, 2008, p. 625).
As you consider new roles or simply a new perspective for an existing clinical leadership role with advanced preparation at the highest level of clinical practice, it would be most unfortunate if you were to attempt to reinvent the entire concept of competency. This review confirms the abundance of work on health care leadership competencies It is the responsibility of the next generation of leaders to sort, identify, test, and apply most effective competencies that will support the vision of the transformational leader.
REFLECTION QUESTIONS
1.What habits, skills, and competencies must the next generation of leaders in nursing in practice and academe possess?
2.Is health care leadership only about competencies or skills?
3.What are common assumptions and expectations related to leadership style and competencies? What needs might be uniquely met by a leader rooted in clinical practice?
4.If you are a leader with responsibilities across both academe and practice, what leadership skills must you possess?
5.Who and where are your role models for leadership? What knowledge, skills, and competencies do you see in them that you admire and would seek to emulate? What are the gaps in skill you see?
6.If you interview one of your role models what three questions would you ask them to help you understand how they developed their leadership skills?
VISION: PERSPECTIVE AND CRITICAL ANALYSIS
Vision is probably one of the most discussed and commonly accepted attributes of leaders. Vision is their habit. Visionary leaders do not stop at simply holding workers accountable to competencies. They make it their habit to look up and beyond, foreseeing next steps and future challenges, opportunities, and accountabilities. Their own personal vision enlivens formal vision statements and integrates the meaning of the statements into their very beings. Vision releases forces that attract commitment and energize people to create meaning in the lives of others, to establish standards of excellence, and to bridge the present and the future (Kouzes & Posner, 2010; Nanus, 1992). If you have no vision of where you are going, why should anyone follow you? Followers expect leaders to know where they are going and to strike the path toward a vision. Kouzes and Posner (2007, 2010) are credited with the well-known statement, “There’s nothing more demoralizing than a leader who can’t clearly articulate why we’re doing what we’re doing.” By the same token, to spare themselves their own personal demoralizing sense of daily drudgery and burden, visionary leaders take the larger perspective, beyond day-to-day tasks and operations.
What is vision and how do you cultivate the habit of sustaining your vision? Vision is the image of the future you want to create. It is your picture of what is possible. Vision requires a dream and a perspective that set a direction that others want to follow. Heathfield (2015) proposed the following fundamental requirements for vision to actually make a difference: The vision must clearly set a direction and purpose for the entire organization. It must inspire a commitment, loyalty, caring, and genuine interest in personal involvement in the enterprise. The vision should reflect the unique culture, values, beliefs, strengths, and the direction of the organization. It must “fit.” The vision always promotes the feeling among followers that they are part of something greater than themselves, that their daily work is more than operational, but part of some greater future. Such a vision challenges others to stretch, to reach, and to produce beyond their own expectations.
The leader who sets such a vision will have the larger perspective not only of the official vision statement or strategic plan but also beyond. Nevertheless, the effective visionary leader does not only see the big picture of the vision, but also is able to sensitively support others in the daily work of all members of the organization. To the perceptive leader, the vision is more than a rallying cheer. It represents a substantive direction for action and achievement. The vision is only one aspect of a strategic plan for action, but it is the vital life force of that plan. Inspiring leaders have the courage and the drive to dream. In times of near despair, confusion, chaos, or even routine and boredom, we need dreams. As a leader, you must believe in your dream; you must believe that it can happen. Kouzes and Posner (2007, p. 17) observed:
Every organization, every social movement, begins with a dream. The dream of vision is the force that invents the future…. Leaders gaze across the horizon of time, imagining the attractive opportunities that are in store…. They envision exciting and ennobling possibilities. Leaders have a desire to make something happen, to change the way things are, to create something that no one else has ever created before.
Dreams that actually become fulfilled are shared among members of a critical mass. A leader must have followers. Solitary vision that is not shared is only daydreaming. Transformational leaders must be vigilant that they do not follow their own light so far into the distance that followers are left in the dark. Shared dreams “fit,” and they grow in the hearts of those committed to the organization. Stichler (2006, pp. 255–256) stated:
The nurse leader is responsible for creating a vision for the organization and clearly articulating that vision to others. The vision must be so compelling that others can feel passionately enough about it to direct their efforts toward achieving the vision. The vision must be viewed as being for the “common good,” and the [leader] must foster that sense of common commitment so that others are willing to follow on the quest toward the vision …
Along with the vision, the [leader] is responsible for defining the philosophy of care and translating that philosophy with others into care delivery models…. [The leader] directs the care delivery process and accomplishes the mission and goals of the organization through others in a manner that empowers nurses and other professional providers to achieve autonomy in their practice.
BOX 6.1. VISION EXERCISE
Think of a team you are working with on a specific project. Even projects have a vision- that is a desired end state-a common goal—a place where the group wants to end up. It is a helpful exercise to engage people in creating a vision statement. This activity should take no longer than 1 hour of a meeting.
•When brainstorming to develop the vision statement, be bold to use metaphor, poetry, images, stories, and emotion. People need to truly experience the image. Ask each member of the group to draw a picture, image or a word that describes where they want to project look like when completed.
•Now ask each participant to take 1 minute and vividly describe it, discuss it, and encourage all to share in that person’s their view of it.
•As the last person is done, ask the group to write down a clear, succinct statement that captures what the common theme was across everyone’s “vision” or preferred end state.
•At the end there will be two to three different themes if 10 to 12 people are in the group. So next step is to come to one understanding that is so clear that the only response is, “Yes! That’s who we are. That’s what we want to be. That’s where we are going!”
A vision statement is a helpful way to articulate the dream. The most effective vision statements are short (two to three sentences), reflect the values of the organization, and provide a picture of what the organization is about to become (see Box 6.1).
A shared vision for any project or organization gives perspective. It allows everyone to look up from many lists of competencies and the daily grind that hovers over nearly every team or organization at one time or another. As a leader with a vision in your heart, you are the guardian of perspective. You are able to critically appraise what is important and what simply appears to be urgent at the time. You help people cut through the daily lists of “stuff” that must be done to see what really might be done for a better future. Sometimes, it involves just a moment of reflection, a reminder; sometimes, a change of schedule or procedure; sometimes, a different use of language. Language is important, particularly in the vision statement. It must be beautiful so that it clearly reflects the image of where you are going, the picture of the desired future.
The leader who believes and constantly carries the vision is able to critically analyze decisions, solve problems, and effectively predict next steps. The vision is not about you, your career goals, or your personal desires. It is about the organization as a living organism, as a community, perhaps even as a family. You are the steward of the vision of the organization. For your vision to be authentic, you must love the place, the people, and the work you are doing.
Because the vision is integrated into your being as the leader, many plans and decisions will seem to automatically flow in the direction of the vision. Opportunities will appear, or you will suddenly see opportunities in a new way to allow you to move toward the vision. The vision becomes your habit. It will not be easy, but a clear vision allows purposeful critical analysis and helps to winnow away issues that cloud direction. It allows you to better trust your decisions because you know where you are going, and your actions are more likely to be trusted because you have the creditability of a clear direction. Critical analysis becomes easier, almost second nature, because you have set your own benchmark. You know where you are going.
USING EVIDENCE TO MAKE A DIFFERENCE
Vision is only dreaming without the use of evidence to make decisions that make it happen. The use of evidence in health care is no longer an option (Malloch & Melnyk, 2013). It must become the intellectual and practice habit of all leaders and clinicians. If use of evidence, or empirical research data, is truly to make a difference, it must be embraced at all levels, from point of contact to the broadest systems perspective. Furthermore, evidence must be implemented and evaluated from the perspective of all aspects of leader, clinician, and patient experiences. The effects or outcomes of evidence cannot be evaluated from any sole viewpoint. Evidence must be integrated and synthesized into the practice experience, into the patient response, into the entire caregiving or healing event. “Evidence of making a difference is … evidence of collaboration, integration, and systemization of all the related contribution” (Porter-O’Grady & Malloch, 2007, p. 54).
The recent sweeping movement toward evidence-based practice has been largely promoted by academics and targeted to clinicians in direct patient care. Nurse leaders have long been accustomed to the challenges of promoting research utilization within health care organizations. Current care settings are often laden with practices of habit, tradition, and routine. Nevertheless, Porter-O’Grady and Malloch (2008, pp. 185–186) warned against joining “the evidence-based practice fad,” that the current surge toward use of evidence should “not exclude other non-quantitative sources of evidence,” and cautioned not to oversimplify clinical nursing knowledge. It is important as we embrace evidence-based practice that we not lose, but rather empirically document, other significant ways of knowing and practice such as clinical intuition, attention to individual differences, the art of practice based on clinical expertise, and professional autonomy (Tracy, Dantas, & Upshur, 2003). Indeed, Råholm (2009, p. 168) “challenged the wisdom of basing the practice of leadership on a narrow, reductionist understanding” of evidence and defended the meaning of context in the definition of evidence. With the emerging focus on implications of genetic testing and genomics, health care practice is poised to move from the application of evidence-based protocols to a focus on individualized or customized care.
Although the development, discovery, and use of evidence for clinical practice continue to mount, there is a continuing need to close the gap between evidence and practice (Hay et al., 2008). In most clinical settings, truly integrated evidence-based practice is still not second nature. In the past several years much emphasis has been placed on the role of leadership for implementation of evidence-based practice. Aarons, Farahnak, Ehrhart, and Sklar (2014) discussed the critical importance of the leader in shaping a culture in which all clinicians value evidence versus tradition-based practices in their work. The leader’s mandate is to expect, support, and reward those who demonstrate that value through their work. Examples of clinicians who demonstrate these behaviors include:
•The nurse who consults the pharmacist on the unit after a patient mentions that his wife brought his antinausea drug from home, and a check of the medication triggers an alert when entered into the electronic health record
•The new graduate who questions the use of 48-hour dressing changes in the manager’s staff meeting after reading a related research study in a journal on the unit
•An experienced nurse who suggests a new procedure for communicating physician messages to nurses who are administering medications after reading new evidence on the relationship between information overload and medication errors
A movement is under way to emphasize the role of the nurse manager and leader in executing the appropriate use of evidence into practice. Unfortunately, we are only just beginning to compile adequate evidence for how this is best accomplished. Gifford, Davies, Edwards, Griffin, and Lybanon (2007) reviewed the literature on what may constitute effective nursing leadership in leading the charge toward evidence-based practice. They found the following leadership activities that influenced nurses’ use of research: managerial support, policy revisions, and auditing. They also found that, often, organizational practice structures impose barriers to both leaders’ and nurses’ access to, promotion of, and ultimate use of evidence. They concluded that “both facilitative and regulatory” measures for leaders are necessary and recognized the need for research to confirm the role of leadership in promoting evidence-based practice to improve patient outcomes. DeSmedt, Buyl, and Nyssen (2006) found that implementation of evidence-based practice is best facilitated by clear communication, summaries of evidence, easily understood protocols, and web-based databases accessible within the work environment, as well as by leaders whose practice is grounded more thoroughly in evidence and less by personal experience.
It is the role of the leader to remove barriers and provide resources for clinicians to access the best research evidence. Such practice often represents a change of culture and total integration of use of evidence in clinical communications (Aarons et al., 2014). And all leaders throughout the nursing department, from nurse manager to nurse executive, must be aligned in their expectations about implementation of innovative approaches (O’Reilly, Caldwell, Chatman, Lapiz, & Self, 2010). If they are not engaged and aligned, nurses at the bedside may revert to become tradition and trial-and-error bound in their practices caring for patients.
It continues to be largely the responsibility of the leader to break the path, to facilitate the culture for evidence-based practice to be comprehensive throughout all systems. Use of evidence must simply become a way of doing and being in clinical practice. Indeed, leadership and operational structures must align to “place clinical practice at the center of the organization’s purpose and build the structures and processes necessary to support it” (Goad, 2002; Porter-O’Grady & Malloch, 2008, p. 177). The entire organizational culture, especially its leadership, must support the ongoing practice of evidence-based decision making, actions, and evaluation of outcomes.
Holloway, Nesbit, Bordley, and Noyes (2004) and Quinlan (2006) pointed out that although the literature may offer methods to teach evidence-based practice, traditional teaching methods for integrating such practice do not lead to sustained, integrated change. This can be accomplished only by setting standards, clearly outlining role expectations, and supporting practices that instill and promote the wise use of evidence. Leaders must incorporate the language and concepts of evidence-based practice into the organizational mission and strategic plans, establish clear performance expectations related to the use of evidence, integrate the work of evidence-based practice into the governance structures of the system, and recognize and reward performance and outcomes based on the use of evidence (Titler, Cullen, & Ardery, 2002). The transformational leader coaches and promotes collaboration among clinicians, patients, and researchers to create a “professional culture and transformed environment of care in which decisions are made on the basis of best evidence, patient preferences and needs, and expert clinical judgment” (Worral, 2006, p. 339).
Thus, it is well established that evidence-based practice will not thrive without leadership support (Aarons et al, 2014; Berwick, 2003; Everett & Titler, 2006; Stetler, 2003). Leaders must provide access to evidence, authority to change practice, an environment of collaboration, and policies that support evidence-based practice (Everett & Titler, 2006; Malloch & Melnyk, 2013; Titler, 2004).
Although we have become more careful to seek and use research for aspects of patient care, with all of our attention on the trend of the past decade toward evidence-based practice we have largely neglected the need to generate and use evidence specifically related to leadership practices. A growing body of clinical guidelines are in use internationally (Hutchinson, McIntosh, Anderson, Gilbert, & Field, 2003; Mäkelä & Kunnamo, 2001), but we are just beginning to assemble an empirically tested knowledge base for best practices in leadership. Vance and Larson (2002) reviewed nearly 20 years of research on leadership outcomes in health care. Of 6,628 articles, only 4% were data based, and 41% were purely descriptive of the demographic characteristics or traits of leaders. Thus, we know little about either what actually works for leaders or what or how to teach effective leadership (Welton, 2004). Day et al. (2014) recently reviewed 25 years of research on leadership development and called for a continuing focus on gathering data that support the effectiveness of certain leadership strategies and education/training programs. In health care we are just beginning to document and promote models for evidence-based decision making in leadership (Aarons et al., 2014; Nicklin & Stipich, 2005). Effective leaders pay attention to the need to recruit nurses who enjoy innovative approaches to old challenges, support those nurses who can influence others using positive evidence-based strategies for change in policies and procedures, and provide vision and time to teams who invest in the work culture. The next generation of transformational leaders must continue the task of discovering and utilizing best evidence for successful leadership. Valid use of evidence for leadership will define and strengthen the entire concept of power to leaders of the future.
USING POWER EFFECTIVELY
Leadership, authority, and power are often confused. Leadership may be formal or informal and is always characterized by the ability to influence others toward the attainment of some task or goal. We have already described transformational leadership as value driven and grounded from an ethical foundation. It includes the personal qualities and behaviors of the leader. Authority is a formally designated or organizationally endowed ability, accountability, or right to act and make decisions. Power is the ability to exert influence, but may or may not be rooted in an ethical value system. It may also be formal or informal. Gardner is said to have defined power as “the basic energy needed to initiate and sustain action or … the capacity to translate intention into reality and sustain it” (National Defense University [NDU], n.d., p. 2). Positional power “confers the ability to influence decisions about who gets what resources, what goals are pursued, what philosophy the organization adopts, what actions are taken, who succeeds and who fails” (NDU, n.d., p. 4). The source and use of power by world leaders has been a fascination throughout the centuries.
Power is key to leadership. It is its underlying energy. To become an effective leader, you must become comfortable with power. It takes many forms. There is power of position, power of personality, power in presence or of charisma, power of informal authority, and power by relationships with others of greater power. Power is the ability to move others, to move causes forward, and to extend both energy and assurance or confidence. No matter what the external source of authority, power is eventually ineffective if some sense of personal power does not burn from within. It emanates from conviction, drive, and confidence in self; from a greater self; and from the direction of the organization.
The use of power can be subtle and positive or cunning and ruthless. History has long shown that seeking or using power for its own sake or for personal satisfaction reflects an unfortunate level of professional immaturity that undermines ethics and effectiveness and can do damage to the organization in the long run.
To lead with power, you must build a power base. The power base is both a process and a structure of connecting to personal attributes, skills, organizations, and people to contribute to the creation and control of strategic goals, direction, and resources. A power base is built by engaging in communication, information, and personal networks; reaching out to influential others for mentorship; acquiring your own reputation as powerful; and reflecting the influence and reputation of your own organization (NDU, n.d.).
Pfeffer (1992) outlined the following attributes of a leader to acquire and sustain a strategic power base:
•High energy and physical endurance, including the ability and motivation to personally contribute long and sometimes grueling hours to the work of the organization
•Directing energy to focus on clear strategic objectives, with attention to logistical details embedded with the objectives
•Successfully reading the behavior of others to understand key players, including the ability to assess willingness and resistance to following the leader’s direction
•Adaptability and flexibility to redirect energy, abandon a course of action that is not working, and manage emotional responses to such situations
•Motivation to confront conflict, willingness to face difficult issues, and the ability to challenge difficult people to execute a successful strategic decision
•Subordinating the personal ego to the collective good of the organization, by exercising discipline, restraint, and humility
Authentic, transforming power emanates from values and principles. Such principles carry their own form of power to be expanded by the person who carries them forward. Principle-based power is not self-aggrandizement or self-advancement. Rather, the more one empowers others, the more power is generated.
Power is not control; indeed, it is often enhanced by letting go of control. In new paradigms of self-organization and transformational leadership, power is generated from sharing, enhanced by a shared vision, and becomes the amplified energy for change when understood and used as the secret treasure of the leader who shares it strategically within the organization. In fact, the judicious and other-centered use of power and influence are often defined as empowerment of others (MacPhee, Skelton-Green, Bouthillette, & Suryaprakash, 2012). Giving the gift of power actually expands the power of the giver. When people feel that power is being taken from them, they engage in actions to “hoard” power: sabotage, passive resistance, withdrawal, or outright rebellion. But a sense of having power frees energy and promotes a sense of self-efficacy, positive influence, commitment, and greater willingness to give. Conflict is reduced as influence becomes more positive and shared. This discussion makes the process sound reasonable and easy. It is not easy. But it is worth the effort to cultivate skills in sharing power and influence, and empowering others.
THINKING AS AN ENTREPRENEUR
Appropriate use of power releases freedom to innovate and tap into your entrepreneurial leanings. Yet, preparation as a health care professional is not rooted in entrepreneurial thinking. Entrepreneurship is largely absent in American professional clinical curricula. Indeed, a review of entrepreneurial activities of nurses and other health care workers revealed that most of the studies have been done in Scandinavia and the United Kingdom (Austin, Luker, & Roland, 2006; Exton, 2008; Mackintosh, 2006; Sankelo & Akerblad, 2008, 2009; Traynor et al., 2008). Marshall remembers when a creative, nonconformist nurse asked, while they were at work years ago, “Do you ever think of your entrepreneurial self?”
I did not have a clue what she was talking about. I have often wondered what happened to her. I always imagined that she started her own care business or consulting firm. I have always assumed that entrepreneurs either had patrons to support their inventive habits or put their family fortunes at risks on whimsical new business ideas. I was wrong. Entrepreneurial habits are ways of thinking, creating, and solving problems.
Never have there been more opportunities for entrepreneurial thinking in health care. The U.S. system cries out for innovative answers to difficult, complex problems. It may be a new kind of independent practice; it may be a consultation service to solve unique problems (Shirey, 2006; Tumolo, 2006; Zaccagnini, 2012); it may be a new kind of business relationship between the practitioner and the agency. But we need more independent, creative approaches to solve problems. Some outstanding examples of entrepreneurial nurses who developed businesses to improve health are highlighted by the American Academy of Nursing (AAN, 2016).
You can be a system employee and still be an entrepreneur. Synonyms for entrepreneur include adventurer, promoter, producer, explorer, hero, opportunist, voyager, and risk taker. Our health care systems need entrepreneurial thinkers. We need those willing to risk a new idea, to provide evidence for its value, to take the responsibility for its implementation and evaluation, and to nurture teams to risk innovative practices for positive outcomes. An entrepreneurial thinker resists habits of “stuck” thinking and forms new habits of looking at old problems in new ways. If such approaches are done within the system effectively, the entrepreneur may become even more valued by the system. When you see a problem, before lamenting its existence, reflect on the problem, let it simmer, then brainstorm at least three ways to solve it. Search for evidence on the problem. Think some more. Create a plan to address the problem, marshal the team to commit, implement the new idea, and then test the outcomes. The process is as old and familiar as practice, but it is the reframing of problems and search for ideas and solutions that calls for some adventure.
Given the pioneering roots of professional nursing, in general, and of advanced practice nursing, in particular, it is ironic that the entrepreneurial spirit seems so foreign to current daily practice. Lillian Wald dared to envision, champion, and create public health nursing. Following the loss of her own two children and the heartache of observing the lack of health care in rural America, Mary Breckinridge did not hesitate to nearly single-handedly bring the independent practice of nurse-midwifery to the United States. And Loretta Ford legitimized the primary care practice of public health nurses by establishing the first nurse practitioner program. Why, then, is entrepreneurial nursing not evident in the everyday practice of every nurse leader today? Several authors have pointed out that worldwide, although expertise among nurses is increasingly recognized, traditional organizational bureaucratic and hierarchical mechanisms, ingrained cultures, and ambivalence and ambiguity among practitioners in shaping “new” identities and practices continue to restrain entrepreneurial activities that might improve health care (Aranda & Jones, 2008; Austin et al., 2006; Exton, 2008).
Entrepreneurial habits need to be fed. Ideas are not born of nothing. They come from watching, listening, and reading widely. Begin today with the habit of reading within and outside the health care literature. Read business magazines and newspapers. Notice how chiefs of other industries are solving problems. Drucker (2004, p. 59) chided:
Ask what needs to be done. Note that the question is not, “What do I want to do?” Asking what has to be done, and taking the question seriously, is crucial for managerial success. Failure to ask this question will render even the ablest executive ineffectual.
Is there a policy that must be changed? What is your idea to change it? Are you willing to give the time and commitment to see it through (Traynor et al., 2008; Whitehead, 2003)?
Once you are committed to a new idea, passion alone is not enough for success. Nurses are generally not prepared to face the challenges of an entrepreneurial practice. You must commit to becoming an expert in securing resources and relationships to help with legal issues, financial management, marketing strategies, payment plans, defining your role and niche, time management (Caffrey, 2005), and outcomes measurement. It takes courage and the willingness to risk, but the world needs more nurses willing to break new paths in health care leadership in entrepreneurial ways.
CARING FOR OTHERS: WHAT SERVANT LEADERSHIP REALLY MEANS
Unlike some entrepreneurs in the general marketplace who creatively feed self-interest, effective entrepreneurial leaders in health care foster some aspect of altruism. At the root of health care leadership is caring for and about others. No industry is more appropriate for servant leadership.
“Leadership is giving. Leadership is an ethic, a gift of oneself to a common cause, a higher calling” (Bolman & Deal, 2001, p. 106). The unique power and prerogative of a leader is the freedom to share yourself, your style, your values, and your influence for a better future. Bolman and Deal (2001, p. 106) stated:
The essence of leadership is not giving things or even providing visions. It is offering oneself and one’s spirit. Material gifts are not unimportant. We need both bread and roses. Soul and spirit are no substitute for wages and working conditions. But … the most important thing about a gift is the spirit behind it…. The gifts of authorship, love, power, and significance work only when they are freely given and freely received. Leaders cannot give what they do not have…. When they try, they breed disappointment and cynicism. When their gifts are genuine and the spirit is right, their giving transforms an organization from a mere place of work to a shared way of life.
The concept of servant leadership was introduced by Robert Greenleaf in the 1970s (1977, 1998) and has been further developed by Spears (1995). Servant leadership releases powerful energy and proposes skills that are particularly effective in health care disciplines, at the heart of which is some degree of altruism. It resonates in special ways within the discipline of nursing (Howatson-Jones, 2004; Swearingen & Liberman, 2004). It encourages the professional growth of the leader and clinician and promotes positive health outcomes. It facilitates collaboration, teamwork, shared decision making, values, and ethical behavior (Barbuto & Wheeler, 2007).
Eleven characteristics of servant leadership include having a sense of calling, listening, empathy, healing, awareness, persuasion, conceptualization, foresight, stewardship, growth, and building community. Senge (1990, 2006) suggested the following five elements of the servant-leader: (a) personal mastery, or “continually clarifying and deepening personal vision … focusing energies, developing patience, and seeing reality objectively” (1990, p. 7); (b) mental models, or deep assumptions, generalizations, or images “that influence how we understand the world and how we take action” (1990, p. 8); (c) building shared vision, or sharing the image we create of the future; (d) team learning, or fundamental learning as a team unit rather than as individuals; and (e) systems thinking.
Some people are natural servant-leaders. You know who they are in your own life. But more important, one can learn to become a servant-leader. It begins with commitment to and practice of lifelong personal and professional learning. Personal mastery is the first step. It means to commit to continual engagement in redefining and clarifying your own personal mission. It means that you cultivate exquisite self-knowledge and personal growth, that you set personal goals related more to the advancement of others than to self-aggrandizement, and that you take time for reflection and feeding your inner self. You come to see your work with a sense of calling.
To be aware of mental models means that you are sensitive to your own personal biases, viewpoints, history, and style and that you strive to use your best self to promote the effective work of others to achieve organizational goals. You examine your own thinking and strive to create a clear vision that you can valiantly communicate and defend. You cultivate exquisite sensitivity in listening, awareness, and empathy. You approach your work and relationships from a perspective of healing.
The shared vision is the common and persuasive image of the future. As the leader, you conceptualize and facilitate that picture with foresight and empower others to share the dream and focus energies to make the changes and do the work to achieve shared goals.
Team learning reflects your ability to suspend your personal assumptions and pace in order to bring the team together to listen to each other and to work in synchrony or harmony. It means that your focus is on the needs and strengths of the team and that you create ways to develop the team to foster collaboration and effectiveness. You lead the team with a sense of stewardship and interest in the growth of its members and help them build a community together. Systems thinking allows you to see the whole as a synergistic concept rather than simply as parts put together. It allows you to see the influence of your own actions and the work of the team on the entire system.
Secretan (2016a) identified the following five “shifts” in servant leadership: (a) from self to other, (b) from things to people, (c) from breakthrough to “kaizen” (celebration of doing things differently rather than simply doing things better), (d) from weakness to strength, (e) and from competition and fear to love. He reminded leaders to ask how we use our gifts to serve. He further outlined six values or principles for Higher Ground Leadership®:
1.Courage: Being brave enough to reach beyond the boundaries created by our existing, often deeply held, limitations, fears, and beliefs. Initiating change in our lives—of any kind—happens only when we are courageous enough to take the necessary action.
2.Authenticity: Committing oneself to show up and be fully present in all aspects of life, removing the mask and becoming a real, vulnerable, and intimate human being, a person without self-absorption who is genuine and emotionally and spiritually connected to others.
3.Service: Focusing on the needs of others by listening to them, identifying their needs, and meeting them. Being inspiring, rather than following a self-focused, competitive, fear-based approach.
4.Truthfulness: Listening openly to the truth of others and refusing to compromise integrity or to deny universal truths—even when avoiding the truth might, on the face of it, especially in testing times, seem easier.
5.Love: Embracing the underlying oneness with others and life. Relating to, and inspiring, others and touching their hearts in ways that add to who you both are as persons.
6.Effectiveness: Being capable of, and successful in, achieving the physical, material, intellectual, emotional, and spiritual goals we set in life. (Secretan, 2016b)
When a leader adopts the transformational stance, along with efforts to transform the organization is a tacit promise to transform others. This is an unspoken covenant to promote and model integrity, respect, and good works of others. This can be achieved in myriad ways. Create traditions replete with ceremonies and rituals that provide a sense of community and belonging, and reinforce the message that significant things are happening and that the people involved are important. Celebrate successes, and rejoice in the achievements of others. Find ways to distinguish good work and reward it. Create an environment of high standards to which people are drawn with assurance that their work is appreciated. Servant leadership is based on the assumption that people are more important than the task and that authentic service to people gets the task done.
GENERATIVITY: PREPARING THE NEXT GENERATION
The transformational leader in health care has an eye on and a heart for the next generation of leaders. Leadership development, coaching, and mentoring are integrated into the very life of the transformational leader. This is the only hope of society for a better future. It is how you leave a living legacy. As the number of experienced managers and leaders in health care continues to diminish at the same time that demand for competent and visionary leaders is increasing, entire organizations are now beginning to integrate leadership development into the everyday life of clinical practice (Spallina, 2002). Unfortunately, too many disciplines in professional health care have histories of a kind of professional hazing (as in, “If I did it, so should you”), including long hours with assigned shift work; sink-or-swim approaches to practice; see-one, teach-one, do-one; “probie” approaches to learning; or even condescending bullying. Such traditions simply will not work in a more competitive environment that must focus on quality improvement, patient outcomes, cost containment, and professional recruitment and retention. A study in Belgium attempted to identify the impact of a specific clinical leadership development program on the clinical nursing leader, the nursing team, and the caregiving process. Although the study uncovered insights related to the leader’s progress toward a transformational style and its effects on nursing staff, effects on care processes were more challenging (Dierckx de Casterlé, Willemse, Verschueren, & Milisen, 2008). Another exploration in England demonstrated the value of structured planning and programs in professional development and coaching for future leaders (Alleyne & Jumaa, 2007). There is certainly room for more study in this area.
Drucker (2000) proposed four ways to motivate and develop future leaders: (a) know people’s strengths, (b) place them where they can make the greatest contributions, (c) treat them as associates, and (d) expose them to challenges. Wells and Hijna (2009) proposed five key elements to develop new talent for leadership in health care: (a) identification of leader competencies; (b) effective job design; (c) a strong focus on leadership recruitment, development, and retention; (d) leadership training and development throughout all levels of the organization; and (e) ongoing leadership assessment and performance management. Of course, this is common-sense jargon, but how do we do it in a way that inspires the dreams and hopes of new leadership?
One way to inspire the next generation for leadership is to tell your own story. Some research has demonstrated that storytelling, especially directly related to the aspiring leader, is effective in developing managers with high potential for success (Ready, 2002). Stories need to be related to the context of current situations and at the level understood by the potential leader. Effective stories are told by respected role models. Share the passion and drama of your experiences, how you failed and learned from the failure, what your successes were, and how you learned to survive. And listen to the stories of aspiring leaders. What is their context and where are they going? How can you help them get there?
Stichler (2006, p. 256) advised that the leader “must consider a logical succession plan in developing tomorrow’s nurse leaders and demonstrate competencies and skills as a mentor, coach, role model, and preceptor. The [leader] teaches by example and fosters continual growth” and extends increasing responsibilities to those to assume future leadership. One nurse leader suggested specific steps to approach succession management as a professional obligation, calling it a “migration risk assessment” (Ponti, 2009). First, assess potential attrition and emerging leaders within the organization, establish core competencies for leadership positions, and develop individual plans while identifying critical success factors for upcoming leaders. Then prioritize, coach, and mentor aspiring leaders.
The transformational leader with a constant eye on developing others for leadership is investing in the future. Generativity is a characteristic of leaders with passion for what they do, a vision for a better future, and a genuine interest in helping others to grow. By enabling the next generation, you extend a living legacy of your own efforts, you enliven our own experiences, and you contribute to a positive human investment in making the world a better place.
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