Senior nurses are likely to engage in a range of leadership activities in their daily routine. Some will naturally adopt an effective leadership style, while others may find the concept of leadership or seeing themselves as leaders difficult to understand. Effective leadership is critical in delivering high-quality care, ensuring patient safety and facilitating positive staff development.
Frankel, A. (2008) What leadership styles should senior nurses develop? This is an extended version of the article published in Nursing Times; 104: 35, 23-24.
Andrew Frankel, MSc, BA, PGCMS, RNM, DipN, is hospital director, Churchill Gisburn Clinic, Lancashire.
This article outlines the characteristics of an effective leader, the political context and various leadership activities for senior nurses. It also discusses mentorship, different leadership models and the process of professional socialisation.
For the purposes of this article, senior nurses are defined as practitioners with additional post-qualification education, skills and experience who work within the nursing team providing a day-to-day, hands-on, visible presence.
Leadership can be defined as a multifaceted process of identifying a goal or target, motivating other people to act, and providing support and motivation to achieve mutually negotiated goals (Porter-O’Grady, 2003). In the daily life of a senior nurse, this could refer to coordinating the day/night shift and the team of nurses and support staff on duty under the direction of that nurse. The successful operation of the shift, staff morale and managing difficult or challenging situations depends largely on the senior nurse’s leadership skills.
It is important to appreciate that leadership roles are different from management functions. In Stephen Covey’s (1999) book The Seven Habits of Highly Effective People, he quoted Peter Drucker as saying: ‘Management is doing things right; leadership is doing the right things. Management is efficiency in climbing the ladder of success; leadership is about determining whether the ladder is leaning against the right wall.’ This suggests that management is about tasks, whereas leadership is about perception, judgement, skill and philosophy. We could infer from this that it is much more difficult to be an effective leader than an effective manager.
Characteristics of an effective leader
Leaders are often described as being visionary, equipped with strategies, a plan and desire to direct their teams and services to a future goal (Mahoney, 2001). Effective leaders are required to use problem-solving processes, maintain group effectiveness and develop group identification. They should also be dynamic, passionate, have a motivational influence on other people, be solution-focused and seek to inspire others.
Senior nurses must apply these characteristics to their work in order to win the respect and trust of team members and lead the development of clinical practice. By demonstrating an effective leadership style, these nurses will be in a powerful position to influence the successful development of other staff, ensuring that professional standards are maintained and enabling the growth of competent practitioners. In a study by Bondas (2006), leaders who were described as driving forces were admired. They were regarded as a source for inspiration and role models for future nurse leaders.
Leadership for senior nurses is primarily about the following: making decisions; delegating appropriately; resolving conflict; and acting with integrity. The role also involves nurturing others and being aware of how people in the team are feeling by being emotionally in tune with staff.
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The above functions are the core elements necessary to connect leadership with the effective development of other team members. This is largely achieved by working alongside them in a mentoring and coaching role. A good and successful leader will seek to develop other staff through their leadership. Saarikoski and Leino-Kilpi (2002) found the one-to-one supervisory relationship was the most important element in clinical instruction. Research also suggests that mentorship facilitates learning opportunities, helping to supervise and assess staff in the practice setting. Terminology frequently used to describe a mentor includes: teacher; supporter; coach; facilitator; assessor; role model; and supervisor (Hughes, 2004; Chow and Suen, 2001).
Within my own organisation we often refer to the phrase ‘don’t just tell me - show me’, which illustrates the need for management instructions to be supported by clear leadership and supervision. It is recommended that staff are first shown how to perform a task and then supported to complete it.
A culture based on continual learning through support and best-practice methods will empower and motivate staff. Dynamic clinical leaders and supportive clinical environments are essential in the development and achievement of best practice models.
Key factors described as effective in nurturing transformational clinical leaders are: provision and access to effective role models; mechanisms for mentoring and clinical supervision; provision of career pathways; intentional succession planning; organisations that value clinical competence; and promotion of centres of excellence (Borbasi and Gaston, 2002).
Nurse leaders need to be able to respond to an ever-changing healthcare environment, including organisational expectations and changes to local and national policy. I do not know of any clinician or manager who would dispute that nursing roles are changing. These roles have become more specialist, autonomous, accountable and focused on outcome, with both positive and negative consequences for the profession. Consumers and purchasers of healthcare services have greater expectations of higher standards, particularly in relation to nursing care.
Nurse leaders must demonstrate resilience in responding to change and supporting others to embrace this in a positive way. Effective leaders should be capable of reframing the thinking of those whom they are leading, enabling them to see that changes are not only imperative but achievable.
Senior nurses need to find ways of becoming involved in organisational decision-making on issues impacting on clinical care such as: developing policy; workforce planning; departmental business planning; and clinical and corporate governance. Sorensen et al (2008) advocate that senior nurses must develop constructive processes through which they become accepted as equal team members. They also need to design workplace systems that underpin good patient outcomes, evaluate nursing expertise and represent nursing interests in corporate decision-making forums.
Leadership activities of senior nurses
Senior nurses should be able to develop other staff by enabling them to apply theory to practice and encouraging them to test new skills in a safe and supportive environment. This, again, is an example of where leadership activities combine with developmental ones to create competent practitioners through practice-based learning.
These nurses should adopt a supportive leadership style with mentorship, coaching and supervision as core values. Constable and Russell (1986) showed that high levels of support from supervisors reduced emotional exhaustion and buffered negative effects of the job environment. Consequently, it would be particularly beneficial for supervisors to provide emotional support to nurses and give them adequate feedback about performance to increase self-esteem (Bakker et al, 2000). Senior nurses should also apply leadership skills in encouraging staff to use critical reflection to facilitate new understanding.
In the ward environment, there can be tensions between professional disciplines. Resolving these and building effective relationships between multidisciplinary team members is a test of senior nurses’ leadership abilities. With nurses becoming more autonomous decision-makers, this must inevitably lead to revising the relationship between professional roles.
Senior nurses also have a leadership role in facilitating their organisation’s staff support and development programme, which should aim to reduce stress, burnout, sickness and absenteeism among colleagues. Supervisors have a significant influence on employees’ personal and professional outcomes. Bakker et al (2000) reported that senior nurses can buffer the effects of a demanding work environment on staff nurses by thoughtfully maintaining a leadership style that supports staff needs.
A successful leader will see each person as an individual, recognising their unique set of needs, as not everyone will perform at the same level or respond in the same way to environmental stressors or workplace pressure. Leaders need to support staff in ways in which individuals recognise as being useful.
In the same way, staff will be motivated by different factors. Leaders must focus on the needs of individual staff and use motivational strategies appropriate to each person and situation. They must seek to inspire demotivated staff and maintain the motivation of those who are already motivated. Leadership seeks to produce necessary changes in demotivated staff by developing a vision of the future and inspiring staff to attain this. Leadership is the driving force of the work environment and directly affects staff motivation and morale. West-Burnham (1997) argued that leaders should seek to improve on current practice, and use their influence to achieve this. This includes working within the team to develop goals and a feeling of shared ownership to achieve excellence in clinical practice.
Different people are motivated in different ways. Therefore, leaders must use strategies that individuals find motivating to empower them and highlight the importance of the nursing role.
One method of achieving this is through the process of structured mentorship. I believe that mentorship should foster ongoing role development and be based on the acquisition and mastery of new skills.
Senior nurses should take time on every shift (between five and 30 minutes) to be involved in some form of mentoring activity, which should then be recorded in staff members’ ‘learning log’.
The learning log is a simple, task-specific recording method used as documented evidence that mentorship has been given on a particular area of work activity. The staff member participates in the completion of their log, which briefly records:
The nature of the activity being coached;
Strengths and weaknesses in performing the activity;
It is important that staff members do not feel micromanaged. Learning logs must be viewed as a mentorship tool, rather than a management one. The log is merely used to remind and refresh the mentor and staff member about what has been achieved between the last formal clinical supervision session and the next. The learning log will be used for reflection purposes to form the basis of a more comprehensive supervision discussion.
Leaders, in their capacity as mentors, must ensure that more junior staff have the freedom to seek information, through an open exchange of opinions and ideas. Staff should also be given the opportunity to show initiative, thus promoting confidence in decision-making and underpinning knowledge and competence in their own skills. The goal of mentorship should be to create a stable and supportive environment which encourages professional growth through effective role modelling. Murray and Main (2005) argued that the notion of role modelling is seen as a traditional expectation of less experienced nurses learning from more experienced ones.
There are a number of useful models to help to guide senior nurses in leading other staff. The two most common are transformational and transactional models (Bass, 1985; Burns, 1978).
The effects of transactional leadership are short-lived, episodic and task based, with the transactional leader only intervening with negative feedback when something goes wrong. This form of leadership would have a place where there is a specific short-term directed project or piece of work to be completed.
In a ward, it is more desirable to identify a leadership model that offers longevity in the relationship between senior nurses and junior colleagues. The transformational model is more complex but has a more positive effect on communication and teambuilding than the transactional model (Thyer, 2003). Transformational leadership shapes and alters the goals and values of other staff to achieve a collective purpose to benefit the nursing profession and the employing organisation. Bass (1985) found that transformational leadership factors were more highly correlated with perceived group effectiveness and job satisfaction, and contributed more to individual performance and motivation, than transactional leaders.
Adair (2002) proposed a different model. This is the three-circle model of strategic leadership, with the circles being the needs of the task, the individual and the team (Fig 1).
Adair believes that knowledge or expertise alone is not enough to lead; however, without it, leadership is impossible. Leaders should be aware of both group and individual needs, and should harmonise them to support common goals.
Each of the three needs in the model interacts with the others. One must always be seen in relation to the other two (Adair, 2003). This is a democratic model of leadership, in which there is consideration for the opinions of those who have to carry out the task. Individuals and groups are involved in decision-making processes concerning their work. The valuing of people, their knowledge, experience and skills is central to this model.
Leadership models are a useful tool for senior nurses and help to put the function of leadership activity into perspective. These nurses should not be concerned about using concepts from various models and developing an eclectic strategy. The models should be used as a framework on which to build an effective leadership style which suits the individual leader and those whom they are leading.
Supervised learning in clinical practice fosters emotional intelligence, responsibility, motivation and a deeper understanding of patient relationships and nurses’ identity and role (Allan et al, 2008).
For care standards to improve, attention must be paid to improving post-registration education and practice development. This should include clarifying role expectation and developing a professional identity. Professional socialisation is a learning process that takes place in a work environment, of which junior nurses are an integral part. Effective leaders will generate opportunities which create potential for professional self-development for junior staff. It is during this socialisation period that junior nurses develop opinions, attitudes and beliefs about their role which form the basis of professional growth. The role-modelling behaviour of senior nurses during this process is critical in transmitting appropriate professional values from one generation of nurses to the next.
The role of senior nurses is dynamic and multifaceted. Nurse leaders in practice settings have unique opportunities to influence and even create the environment in which professional nursing practice can flourish. Marriner-Tomey (1993) suggested that, in this highly influential role, nurse leaders have a major responsibility to change behaviour to provide an environment that supports the preparation of competent and expert practitioners. It is part of nurse leaders’ role to serve as a model in providing effective socialisation experiences that impart the appropriate values, beliefs, behaviours and skills to staff.
Better outcomes for patient care
Ultimately, a goal of any healthcare organisation should be to influence the quality of patient care through good nursing leadership. Good leaders should encourage junior staff to gain a better understanding of patients and their needs and values. Overall, these strategies will lead to increased patient satisfaction, more effective nurse-patient relationships and quicker recovery times.
Empowered nurses are eager to implement evidence-based practice. They are highly motivated, well informed and committed to organisational goals, and thus deliver patient care with greater effectiveness (Kuokkanen and Leino-Kilpi, 2000).
Good leadership could produce better patient outcomes by promoting greater nursing expertise through increased staff ability and a new level of competence. Aiken et al (2001) argued the hospital practice environment has a significant effect on patient outcomes. Junior nurses should be encouraged to seek maximum rather than minimum standards, and be expected to achieve and maintain high-quality benchmarks.
This article has highlighted the essential leadership role that senior nurses have in developing skilled and competent staff. Leadership behaviour has a great impact on staff. Senior nurses must acknowledge the importance of their role, recognising that junior staff rely on their leadership in developing their own professional skills and capability.
These nurses must use their leadership behaviour to positively influence organisational outcomes and need to appreciate the inter-relationship between developing nursing practice, improving quality of care and optimising patient outcomes. Healthcare organisations need nurse leaders who can develop nursing care, are an advocate for the nursing profession and have a positive effect on healthcare through leadership.
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