Leadership and Management in Nursing

Porter-O’Grady (2003) defined leadership as a versatile process of identifying a target, motivating others, and providing the necessary support to achieve mutually negotiated goals. In the context of nursing, leadership involves coordinating the day or night shifts, a team of nurses, and supporting on duty. The successful operation of the shift, staff morale, and managing challenging situations depend mainly on the nurse’s leadership skills. Consequently, appreciating those leadership roles differs from management functions. According to Middleton (2009), management is about tasks, while “leadership is about perception, judgment, skill and philosophy” (p. 3). Therefore, it is much harder to be an effective leader than an effective manager (Middleton 2009). Specifically, there are different leadership styles, including transactional and transformational leadership styles. 

Transactional versus transformational leadership styles

According to Joe (2012), transactional leadership is a style of leading an organization where a leader inspires his or her followers to achieve a goal by using routine transactions, including rewards and punishments. It is wholly based on transactions conducted between the nurse leader and subordinate staff, since it is grounded on the theory that rewards and punishment motivate and deter workers, respectively. However, Ingram (n.d.) argues that this form of leadership does not consider the future in guiding an organization to a position of market leadership, as it is primarily focused on ensuring that everything flows smoothly at the moment. Joe (2012) points out four focal points of transactional leadership. First, the nurse leader has ultimate authority over the nursing staff members. Secondly, employees must comply with and follow directives. Thirdly, rewards include compensation in the form of paychecks. Fourthly, punishments integrate progressive discipline, including termination.

Transformational leadership differs from transactional leadership in that it focuses on team-building, collaboration, and motivation with followers at various levels of the organization to achieve change for the better (Ingram, n.d.). Joe (2012) observes that transformational leadership, unlike transactional leadership, focuses on inspiring subordinate members to give their most by acting as examples and showing an optimistic personality. Based on Joe (2012), transformational leadership works on the assumption that subordinate employees obtain motivation to perform their tasks through positive incentives but not negative incentives. Based on Joe (2012), the focal points of transformational leadership are four. First, staff will easily copy the example of a model nurse leader. Second, priorities include promoting innovation and creative thinking. Thirdly, the optimism of a nurse leader is sufficient to transform the staff members. Fourth, enthusiasm creates the drive to get the job done.

Both forms of leadership have pros and cons and suit specific situations. For example, transactional leadership may function well with from line supervision of low-skilled staff, including Registered Nurse (RN) or License Practical Nurse (LPN) charge nurses supervising Certified Nursing Assistants (CNAs) in the long-term care setting. According to Joe (2012), this form of leadership may lead to compliant workers; however, this style of leadership can frustrate autonomy and creativity in more skilled employees.

Transformational leadership, on the other hand, works well, because it operates based on self-motivation. Joe (2012) argues that self-directed employees usually want to get the job done without any form of incentive. As a result, transformational leadership can be very effective. Nevertheless, this form of leadership will fail if the nurse leader is deficient in the ideal personality traits, mission, or enthusiasm to bring out the best in people (Joe, 2012). In this regard, nurse leaders should master the art of winning the trust of followers and helping them develop confidence in themselves. Without special people skills, all the attempts of a nurse leader would be futile.

Facilitating professional development through supervision

         Gilmartin and D’Aunno (2007) reviewed leadership in healthcare settings and underscored that the majority of research studies targeted nurses and nurse managers. Gilmartin and D’Aunno (2007) observed a strong relationship between managerial style and the subordinate staff’s satisfaction with their jobs, retention, and turnover. The review revealed that nurses preferred managers who were facilitative, participative, and emotionally intelligent. These characteristics promoted team cohesion, reduced stress, and heightened staff empowerment and self-efficacy (Gilmartin and D’Aunno, 2007). The reviewed research characterized successful nurse leaders as flexible, collaborative, and delegating responsibility on top of using personal values to enhance high-quality performance. 

         Studies also investigated the effects of the environment of nursing and burnout on quality of care and patient outcomes (Van Bogaert et al., 2010). Nursing management was positively related to perceived quality of care and staff satisfaction (Van Bogaert et al. 2010), correlation with medication errors (Van Bogaert et al., 2014), and staff levels of well-being, burnout as well as turnover intention (Weber, 2010). Furthermore, a relationship between nurses’ relational leadership styles and lower levels of mortality rates and medication errors was found (Wong, Cummings, and Ducharme, 2013).

Karilnli et al. (2008) showed that when nurse leaders gave nursing staff opportunities to participate in decision-making, they not only indicated increased job performance but also expressed high levels of organizational identification.  According to West et al. (2015), the empowerment of nurses to bring about quality improvement emerges from the literature as a possible key factor of nurse motivation toward achieving organizational and team goals. Specifically, Wong and Laschinger (2013) described the mechanism by which authentic leadership can facilitate job satisfaction and patient outcomes through empowerment. West et al. (2015) observed that leaders who understand, openly express their core values, and model ethical standards seem to communicate integrity and transparency to subordinate staff.

According to Middleton (2009), nurse leaders should be able to develop other staff by facilitating them to translate theory into practice and encouraging the staff to translate theory into practice. In addition, leaders should spur subordinates to test new skills in a safe and supportive environment. Middleton (2009) argues that this relationship serves as an example of where leadership activities mix with developmental ones to build competence in nurse practitioners via practice-based learning. The target nurses should adopt, therefore, a supportive leadership style with coaching, mentorship, and supervision as core values. An earlier study indicated that heightened support from supervisors alleviated emotional fatigue and cushioned the subordinate staff from negative influences of the work setting (see. Constable & Russell, 1986). Bakker et al. (2000) propose that it would be beneficial for supervisors to offer emotional support to nurses and provide them with adequate feedback about performance to promote their self-esteem. Nurse leaders should also apply leadership skills in promoting staff to apply critical reflection to facilitate new understanding.

Role of Nurse Leaders in Risk Management

According to an online lecture on patient safety research, risk management is a common practice in many industries. It has traditionally been associated with reducing litigation costs. Many organizations try to circumvent financial loss, fraud, or failure to achieve production targets by implementing strategies to avoid these events (“Patient Safety Research”). Based on Reason (2001), health organizations use various methods to manage risks. Nonetheless, the success of a risk management tool depends on developing and maintaining safe care systems, designed to mitigate adverse events and boost human performance. The vast majority of health facilities have well-established structures for reporting undesirable events, such as medication errors, patient falls, retained swabs, and patient misidentification. However, hospitals and other health facilities have begun to focus on all dimensions of clinical care to find opportunities for mitigating risks to patients (“Patient Safety Research” n.d.).

All staff in healthcare facilities have a responsibility to make appropriate decisions when they perceive an unsafe environment or circumstance (“Patient Safety Research” n.d.). For example, taking steps to dry thoroughly a slippery floor and averting a patient from falling over is equally crucial as ensuring that the medication administered to the patient is the correct one. Subordinates should report all incidences of patients being administered the wrong medication or falling on a slippery floor so that the necessary precautions can be taken to avoid a repeat of the same in the future (“Patient Safety Research” n.d.).

According to the “Patient Safety Research” (n.d.) successful risk management involves all levels of the health service. Therefore, all healthcare staff must appreciate the goals and relevance of the strategies for managing risk and their relevance to their workplace. Nevertheless, despite hospitals and other health facilities having policies for reporting adverse incidents, the actual reporting of them is usually erratic. Nurses can start to practice reporting by discussing with nurse leaders or healthcare teams about medication errors and the available strategies for managing and avoiding them.

All in all, research indicates that nurses are more likely to report an adverse event than other healthcare providers including doctors (“Patient Safety Research” n.d.). Based on “Patient Safety Research” (n.d.), the low reporting rate of adverse events is attributed to blame culture in medicine. Presently, many risk management programs have been put in place to enhance safety and quality besides reducing risks of litigation as well as other undesirable consequences, including diminished morale, high turnover, and loss of business due to poor reputation. Worth noting, that the extent of the success of such programs depends on a combination of factors.

The PDSA cycle

         Quality Improvement (QI) strategies have been incorporated into healthcare to facilitate timely, safe, effective, efficient, equitable, and cost-effective delivery of care (Reed & Card 2016). Among the various QI tools and procedures, the Plan-Do-Study-Act (PDSA) cycle is amongst the few that targets the root of change, the conversion of ideas and intentions into acts. Hence, the PSDA cycle alongside iterative tests of change are core to various QI frameworks, such as the model for improvement (Langley, Moen & Nolan, 2009), lean Six Sigma (Toussaint & Berry, 2013), and total quality management (Brannan, 1998). It provides a structured experimental learning perspective to testing changes.

According to Reed and Card (2016), the PDSA model aims to learn as fast as possible if an intervention is effective in a specific setting besides making adjustments to increase opportunities for delivering and sustaining the desired change. Converse to controlled trials, this model enables new learning to be integrated into the experimental process (Reed et al., 2016). Suppose a nurse leader detects a problem with the original plan. In that case, he or she can revise the theory to improve on the learning and a subsequent experiment done to see whether it has resolved the problem, and to determine if any further issues need to be resolved. On this note, Reed and colleagues assert that the flexibility and adaptability of PDSA are crucial characteristics that support the adaptation of interventions to operate in local settings.

 References

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