This essay explores how the nursing profession has evolved since Nightingale and to understand how quality patient care today, requires effective leadership rather than autocratic management. Nurse managers still perform a valuable function; however, management activities are thought to compliment rather than replace the leadership role. As the nursing profession has evolved, nurses have adapted and developed skills that are complimentary for the society and times they are functioning in. One example of this has been the development of competency standards for the registered nurse [Australian Nursing Council (ANC) 2002].
Modern health care settings are complex and the registered nurse’s ability to perform a multitude of roles and responsibilities requires highly developed skills in decision making, critical thinking, and adherence to professional, ethical, moral and legal standards. In addition to these skills, leadership and management abilities are considered essential for professional practice; all are included in the ANC National Competency Standards (ANC 2002) and are required for competent practice. The ability of registered nurses to be effective leaders will impact on staff, resources, and the setting and achieving of goals. This will, in turn, have implications for the quality of patient care.
I examined the role of the registered nurse to understand how practise and client safety can be maintained by adhering to competency standards. In addition, transformational leadership was examined to understand how this style of leadership functions and to determine how it could benefit the nursing profession. Professional competencies and transformational leadership theories were then combined to reflect on a scenario to see how, when used together, an improved outcome could be achieved for all involved, especially the client.
Transformational Leadership could be one answer to the question; How do you transform organisations or the staff within them to work in a more effective or efficient fashion? Those who support transformational leadership believe it to be much more than a passing fad. Embracing this style of Leadership has been described as ‘the key to future nursing development’ (Cook 2001:41) Covey (1992, cited in Wieck;Evans 2003:22), describes the goal of the transformational leader as:
…to transform people and organisations in a literal sense, to change them in mind and heart; enlarge vision, insight and understanding; clarify purposes; make behaviour congruent with beliefs, principles or values; and bring about changes that are permanent, self perpetuating and momentum building.
The five principles of transformational leadership include;
1) Challenging the process
2) Inspiring a vision
3) Enabling others to act
4) Modelling the way
5) Encouraging the heart
Used together these principles can help to develop trust and communication between staff (Kouzesand Posner (1997,cited in Weick ; Evans 2003:22)
From this exploration I concluded that patients, staff and organisations could all benefit if a transformational leadership approach were to be introduced into healthcare situations. Communication, trust between staff, stress levels, absenteeism and staff turnover levels could all be improved and if that were the outcome the primary goal of quality patient care would also benefit greatly.
What is Transformational Leadership?
Nightingale nurses of the 19th Century were managed by experienced nurses ‘who were usually used to managing servants’ (Fedoruk 2000:16) Todays nurses are graduates who have been described as knowledge workers who want to be led not managed (Drucker1999, cited in Weick; Evans 2003) Transformational leadership has the potential to transform the nursing profession so that it is up to date with the needs of the current society and in order for nurses to have a stimulating and rewarding professional career. (Weick ; Evans 2003)
The role of management in the time of Nightingale was authoritarian and focused on rules, control, hierarchy and systems of punishment or reward to motivate workers (McCallin 2003). This role to oversee working conditions may have been appropriate for directing servants, nurses and factory workers in the 19th century but today it no longer reflects the needs or values of professional nurses. Nurses who are managers have a vital function in the nursing profession. Nursing managers perform duties that are necessary, such as the organisation of staff rosters, looking after budgets, ensuring the safety of the work environment and the organising of materials and resources. These duties ensure the smooth operation of the nursing environment. This role is described by Huber (2000:77) as: ‘the coordination and integration of nursing resources by applying the management process to accomplish nursing care and service goals and objectives’. Modern nurse managers are integrators and facilitators, not watchdogs and interventionists’ (Huber 2000:19)
It is desirable that nurse managers are leaders but this is not always necessary or achievable. (Weick & Evans 2003). Effective leaders are important to the profession as they set the tone of the working environment and inspire others to perform at their highest level (Weick & Evans 2003). Bowles and Bowles (200:70) define leadership as:
‘…an interpersonal relationship of influence, the product of personal characteristics rather than mere occupation of managerial positions. It is these personal characteristics which attract, enthuse and motivate followers towards organizational goals…’
Various leadership styles have been discussed and debated over time. The transformational leadership style appears to be well suited to the nursing profession (Bowles & Bowles 2000; Sofarelli & Brown 1998). A leader of this type works well in a team situation, which is beneficial in a busy healthcare setting (Weick & Evans 2003, Thyer 2003). A leader who promotes collaboration between staff to set goals and make decisions will achieve efficient outcomes and a more supportive atmosphere (Weick& Evans 2003). Dunham-Taylor (200, cited in Chambers 2002:127) state that a transformational leader has the following attributes:
The ability to identify and communicate a vision for the future: articulate and gain commitment to shared values, and empower colleagues to work towards achieving organizational goals…
Kouzes and Posner (1997, cited in Weick & Evans 2003:22) describe five behavioural attributes which contribut to the ability to be a transformational leader. These are the ability to:
1. Challenge the process-creative problem solving, question procedures and solicit new ideas. Encourage colleagues to share new information and to participate in new learning experiences.
2. Inspire a shared vision-ensure goals are shared, desirable, and achievable.
3. Enable others to act-support and encourage others, let them know that extra effort is appreciated.
4. Model the way-active participation engenders trust and encourages others to participate.
5. Encourage the heart-show appreciation when others make an effort. Active listening is a necessity.
Traditional managers were appointed to positions of authority and were given the power to delegate and control the work process (Sofarelli & Brown 1998). As Spence (1996, cited in Thyer 2003:221) identifies, leadership does not have to be tied to a position of authority. Leadership can be seen as an ‘innate’ quality based on ‘the ability to care, to dream, to think, to imagine, and to speak up’. It has also been said however that anyone can be a leader with the right motivation, encouragement and practise. (Bowles & Bowles 2000). Leadership, according to Weick and Evans (2003:23), ‘is an earned right and a privilege’.
Weick and Evans (2003:26) say ‘the key to leadership is to believe in the vision and enjoy the journey.’ The following suggestions for the successful integration of transformational leadership are also given:
1. They suggest that you should learn not to waste time, the consequences of wasted time are frustration and work left undone.
2. They warn the would-be leader that they must learn to be self-motivated-others are quick to criticise and slow to praise. You just cannot let a lack of positive support get you down, maybe find a mentor or friend to talk to when the going is tough.
3. Self-confidence is important as confidence and success are often closely related.
4. They warn potential leaders of the possibility of becoming arrogant and note that it is difficult to remain confident when setbacks occur.
5. Active listening. If you ask relevant questions this is one way to let others know that you are interested in them and their ideas.
6. It is important to take risks and make decisions after considering facts. If you say you will do something, better make sure you do or get back to the other person to explain what went wrong.
7. It is important to remember that ‘attitude is vital to leadership success…and attitude is a choice, not a forgone conclusion’. Positive thinking and positive messages are important to focus on to be a successful leader, Weick and Evans (2003:27)
Transformational leadership and the registered nurse
Registered nurses work not only in many different environments but also in a range of different specialities and they must all perform their work to a high standard. The Australian Nursing Council (ANC) has developed national standards for professional conduct, these ensure the community that the standard of care provided will be both safe and effective (ANC 2002). Registered nurses are responsible for their own actions and may be held accountable under civil or criminal law if they do not perform their duties according to the prescribed standards (Mair 2000). ANC national standards are outlined in three documents; these include (ANC 2002):
* The ANC National Competency Standards for Registered and Enrolled Nurses
* The Code of Ethics for Nurses in Australia
* The Code of Professional Conduct for Nurses in Australia
The National Competency Standards outline ‘the various roles and functions nurses fulfil and identify a combination of the attributes a competent nurse must have’ (ANC 2002). These standards are included in 14 competency units that cover such areas as legal and ethical requirements, assessment of patient needs, abilities to use knowledge and reasoning skills, access and application of research findings to practice, and skills such as collaboration, communication, and education.
As a newly registered nurse these standards of practice have to be adhered to and kept in the forefront of ones’ mind. This will be challenging. The novice registered nurse must deal with time management issues, completion of tasks, attending to accurate written documentation, communication with other healthcare professionals, other nurses and patients, often in difficult circumstances. Adopting the positive attitude and skills required of a ‘transformational’ leader, will enable the newly registered nurse to integrate new experiences and achieve confidence in their abilities, whilst continually aiming to provide quality patient care. Performing the role of the registered nurse can be a rewarding experience or can lead to stress, exhaustion, and eventually burnout (Olofsson, Bengtsson, ; Brinke 2003). These negative effects result in nurses leaving the profession altogether. As a student registered nurse we are taught that with a positive attitude we can see ourselves as part of the solution to making the workplace one in which the experiences for staff and patients are positive ones. This appears to be a very tall order! Transformational leadership offers us some strategies in the hope that we will be able to achieve this goal.