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Examining transformational approaches to effective leadership in healthcare settings

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Exploring the three core ‘constants’ that can be used to develop effective leadership as nurses deliver care in an increasingly challenging environment


Govier, I., Nash, S. (2009) Examining transformational approaches to effective leadership in healthcare settings. Nursing Times; 105: 18, early online publication.

This is the first article in a two-part series on leadership. It outlines three core ‘constants’ that can be used to develop effective leadership, and describes the principles that underpin transformational leadership to enable nurses to adopt this approach in healthcare settings.

  • This article has been double-blind peer-reviewed

Keywords: Leadership, Change, Choice, Principles



Ian Govier, MSc, PGCE, BN, DipN, RNT, RGN, is development manager – nursing leadership, NationalLeadership and Innovation Agency for Healthcare, Llanharan, Wales, and runs CTR Training and Consultancy; SueNash, MBA, BSc, RGN, is facilitator of individual, team and service development, Action Learning Teams Consultancy; both are associates of the RCN Consultancy Service.


Practice points

  • Leadership exists at all levels of an organisation, especially as people share in a vision that moves them towards achieving the goal of providing safe and quality health care.
  • Recognising the value of proactive choice when faced with difficult decisions about healthcare organisation and delivery is critical when leading, responding and adapting to change.
  • The core values and principles that underpin nursing and the act of caring provide an internal compass that facilitates authentic and transformational healthcare leadership.


Healthcare services are constantly adapting to trends and policy, with healthcare professionals, especially nurses, having to lead, organise and deliver care in an increasingly challenging and changing environment.

Traditional values about care are being challenged and often come into conflict with the business environment that appears to dominate healthcare management (Shaw, 2007). This challenging and changing environment is not unique to health care; it is considered to be universal and appears to be increasing in intensity and complexity.

Vaill (1996) described this often frenetic and unpredictable environment as ‘permanent white water’ – an environment that frequently puts people in the position of doing things they have little experience of or have never done before. He also argued that, although good management skills are still essential for day-to-day operations, navigating permanent white water successfully must begin with effective leadership.

Kotter (1996) suggested that management is concerned mainly with order and consistency, while leadership is centred on change and movement. Management focuses on controlling complex processes, whereas leadership is about challenging existing ways of doing things and setting new directions for organisations.

It could be argued that management is about ‘doing things right’ and leadership is about ‘doing the right things’. Covey (2006) supported this view, asserting that yesterday’s methods do not work in the permanent white-water world, where managers traditionally manage within the system and focus on doing things according to the rules.

Like Vaill, Covey agreed that, while the managerial role is essential and performs a vital function, leadership must come first to make managing more effective. If management is efficiency in climbing the ladder, then it is leadership that determines whether the ladder is leaning against the right wall. The story in Box 1 may help to illustrate this point of view.

To help individuals, teams and organisations to navigate the permanent white-water environment safely, Covey (2006) suggested that there are three constants that provide stability in times of great uncertainty. These are change, choice and principles.

This article considers each of these three constants, focusing mainly on the principles that underpin transformational and effective leadership in healthcare settings.


Box 1.  Leadership and management

A group of workers and their managers are set a task of clearing a road through a dense jungle on a remote island to reach the coast, where an estuary provides a perfect site for a port.

The leaders organise the labour into efficient units and monitor the distribution and use of capital assets. Progress is excellent.

The managers continue to monitor and evaluate progress, making adjustments along the way to ensure that progress is maintained and efficiency increased wherever possible.

Then, one day amidst all the hustle and bustle and activity, one person climbs up a nearby tree. The person surveys the scene from the top of the tree and shouts down to the assembled group below: ‘Wrong direction!’

Source: Adapted from Covey (2004)


The constants


When it comes to responding and adapting to change, Yoder-Wise (2006) stated there are two choices. We can either ‘get organised’ or ‘go with the flow’.

In a permanent white-water environment, going with the flow is fraught with uncertainty and danger, whereas organising ourselves allows us to achieve greater stability and safety.

Covey (2006) argued that, in a constantly changing environment, when times are difficult and uncertain, there is a need to develop a solid, unwavering core. He asserted that, when we adopt changeless and timeless principles – such as trust, fairness, service, courage, humility, integrity, human dignity, contribution, growth and empowerment – as core values, we anchor and enable ourselves to adapt and respond to forces of change.

George (2007) also recognised the constancy of change, and challenged people to discover their ‘true north’ to enable them not only to cope with change but also to navigate successfully the permanent white water that often accompanies change.

In the same way in which a compass points towards a magnetic field, our true north is the internal compass that guides us successfully through life. It represents, at the deepest levels, who we are as human beings. It is based on what is most important to us, our most cherished values, our passions and motivations, and the sources of satisfaction in our lives.

When we follow our internal compass as nurses, clinical leadership will be authentic and transformational. We will also be more likely to reflect the core values that underpin nursing and the act of caring. This ensures we choose the ‘care of people’ as our main concern, treating them as individuals, respecting their dignity and providing them with high standards of practice at all times (NMC, 2008).

Alimo-Metcalfe and Alban-Metcalfe (2005) suggested the one thing that characterises organisational life is that change is inevitable. They also maintained that in organisations that constantly drive for improved efficiency and results, greater pressures are placed on their employees.

So, in organisations such as the NHS and large professional groups such as nurses, these pressures can often lead to increased stress and lower performance. This can be potentially harmful in terms of providing safe and effective patient care.

Acknowledging these pressures and the associated risks is especially important in light of Lord Darzi’s (2008) report. This heralds a significant change for the NHS in England, mainly because it has made quality of care a central organising principle alongside access, volume and cost of healthcare services.

The RCN is being proactive in asserting nursing’s key role in contributing to the quality-of-care agenda. It recently published a report (RCN, 2009) outlining a series of recommended actions (for England only) to achieve this. These are designed to gain recognition and acknowledgement of the value and impact of the ward sister/charge nurse role for high-quality care, and put in place the necessary measures to strengthen and support this role for care quality.

Other home countries, such as Wales, have also introduced initiatives that place more emphasis on the ward sister/charge nurse role to lead and manage changing environments and so directly influence and enhance patient care (Welsh Assembly Government, 2008). There is also evidence that links the impact of this role to standards of patient care. For example, the Hay Group (2006) showed that effective ward management has a significant impact on resource use as well as on performance indicators such as:

  • Patient satisfaction;
  • Absenteeism rates;
  • Amount and nature of complaints;
  • Number of drug errors and levels of severity;
  • Staff turnover rates.

Reaffirming ward sisters’ and charge nurses’ key clinical leadership role and ensuring they have the capacity, time, resources and authority to coordinate and deliver patient care, is a top priority.

Leading, responding and adapting to change is everyone’s business. Although ward sisters/charge nurses play a key role in leading health care in acute settings, it should also be recognised that leadership support and development must occur at all levels and settings of healthcare organisations. A major challenge for nurses is how we ‘take the bedside to the boardroom’. Executive nurses in particular are challenged with balancing the leadership of business with the leadership of caring. These senior nurse leaders will recognise more than others that failure to deliver the fundamental components of care can bring down an NHS board faster than either financial or performance failures (Machell et al, 2009).


A unique ability that sets us apart as human beings is that of self-awareness and the ability to choose how we respond to any given stimulus. While conditioning can have a strong impact on our lives, we are not ultimately determined by it. Covey (2004) suggested that between what happens to us and our response is a space, and within this space is the ability to choose our response – ‘response-ability’. He quoted the account of the eminent Austrian psychiatrist Viktor Frankl, who was incarcerated in a Nazi death camp in the Second World War. Frankl, like so many others, endured unimaginable experiences and hardships and was one of the few who survived.

Frankl (2004) said: ‘We who lived in concentration camps can remember the men and women who walked through the huts comforting others, giving away their last piece of bread. They may have been few in number, but they offer sufficient proof that everything can be taken from a man but one thing: the last of human freedoms, to choose one’s attitude in any given set of circumstances – to choose one’s own way.’

During his time in the death camp, Frankl realised that he alone had the ability to determine his response to the horror of his situation. He exercised the only freedom he had in the environment by imagining himself teaching students after his release. He became an inspiration to others around him and realised that within the middle of the stimulus-response model, humans have the freedom to choose.

Although Frankl’s understanding was realised in a harsh and inhumane environment, we too can learn lessons that can be applied in far more favourable situations that, nevertheless, present challenges. We can choose to be reactive to our environment. For example, if the weather is good we feel happy and if the weather is bad we will be unhappy. If people treat us well, we feel well; if they do not, we may feel bad and become defensive or even aggressive. We can, however, choose to be proactive and not let our situation determine how we feel. It is also liberating to know that even when we are faced with decisions that appear to be lacking in preferable choices, we can still choose our attitude.

Regarding choice, proactive leaders are driven by values that are independent of the weather or how others treat them. Mahatma Gandhi said: ‘They cannot take away our self-respect if we do not give it to them.’ Being proactive means assessing the situation and developing a positive response. Proactive leaders use their resourcefulness and initiative to find solutions rather than just reporting problems and waiting for other people to solve them. Such leaders are also more likely to view leadership as a choice, not a position; they will be nurses who are concerned with making things happen and making a positive difference to patient care.

Nurses sometimes find themselves disempowered and consider their choices are limited when faced with policies and directives calling for increased efficiency that appear to compromise quality of patient care. Once we decide to become more proactive, where we focus our efforts becomes more important. Our response to what happened to us will often affect us more than what actually happened, and we will choose to use difficult situations to build our character and develop the ability to better handle such situations in future.


Covey (2009) also subscribes to the view of connecting with our internal compass and discovering and following our ‘true north’. He asserts boldly that principles govern growth and prosperity in both people and organisations, claiming that principles draw the highest and best from people because they reflect the whole person: body, mind, heart and spirit. Equally significant, these people then choose to influence and inspire others to find their voice through these principles.

Influencing and inspiring others are key components of transformational leadership. They not only allow us to increase leadership skills and abilities, but also help us to navigate the permanent white-water environment of healthcare. Through the power of transformational leadership, leaders and followers raise one another to new heights of achievement and development. They are also able to sustain one another in a life-long effort to define and construct meaning in their work lives (Sashkin and Sashkin, 2003). This approach to leadership not only improves performance and productivity, but also makes a positive difference in the lives of organisation members. Transformational leaders achieve superior results because of their ability to motivate and transform people from dutiful followers into self-directed leaders who go beyond simply doing what is expected of them.

Bass and Riggio (2006) supported these benefits of transformational leadership, arguing that people who embrace the principles of such leadership have staff with higher levels of satisfaction, motivation and performance, as well as lower levels of stress and burnout. They also maintained that such teams are more innovative, collaborative and effective, which results in their organisations being able to respond more quickly and productively to change. In addition, these organisations possess effective, healthier and more humane cultures.

Alimo-Metcalfe and Alban-Metcalfe (2008) showed similar outcomes in their comprehensive research to investigate the impact of transformational (or engaging) leadership on organisational performance in the NHS. They discovered that a culture of transformational or ‘engaging’ leadership significantly predicts increased levels of staff motivation, satisfaction and commitment. This combines with reduced stress and emotional exhaustion and increased general team effectiveness and productivity.

There are a number of transformational leadership models or frameworks that may prove helpful to nurses working in modern healthcare settings. One that has already been referred to, and is rapidly gaining recognition within the NHS and other sectors, is that of ‘engaging leadership’ (Alimo-Metcalfe and Alban-Metcalfe, 2008). The structure of this model is represented by four clusters of dimensions: ‘engaging individuals’; ‘engaging the organisation’ (or team); ‘moving forward together’ (which relates to working with a range of internal and external stakeholders); and ‘personal qualities and core values’. Fig 1 shows the various dimensions in each cluster.

The emphasis of engaging leadership is on serving and enabling others to display leadership themselves. It is not about being an extraordinary person, but rather a somewhat ordinary, vulnerable and humble – or at least a very open, accessible and transparent – person. This approach to leadership complements other viewpoints such as Collins (2001), who described highly successful, or ‘level 5’, leaders as people who channel their ego needs away from themselves and into the larger goal of building a great organisation. These leaders have a tremendous will to get things done, yet have a level of humility that sets them apart from others. They rarely talk about themselves, yet delight in talking about the organisation and the contribution of others.

Engaging leadership focuses on the critical importance of teamworking and emphasises the benefits of collaboration that create a culture where dialogue is open and new ways of thinking and doing are encouraged, listened to and truly appreciated. It stresses that leadership exists at all levels of an organisation, especially as people share in a vision that moves them towards achieving goals of providing safe and quality health care.


Effective and transformational leadership is pivotal to the success of healthcare organisations, as front-line clinicians, such as nurses, lead teams to provide quality care and deliver service improvement.

As nurses lead, respond and adapt to change, they will recognise the value of proactive choice when faced with difficult decisions about healthcare organisation and delivery. They will also be guided by an internal compass that points to their ‘true north’ and reflects the core values and principles of transformational healthcare leadership – an authentic approach that both recognises and affirms that in a permanent white-water environment, the things that matter most must never be at the mercy of things that matter least.

  • The second article in this series examines how to lead effective teams
  • For further information, please contact Ian Govier or Sue Nash


  • 1 Comment

Readers' comments (1)

  • really interesting article, I was wondering if you have any journals about empowering persons with type 2 diabetic through transformational or transactional leadership.

    thank you

    Barbara Dunn.

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