Leadership in Nursing.

Definitions, Theories, and Styles of Leadership

Developing future nurse leaders is one of the greatest challenges faced by the nursing
profession (Mahoney, 2001). Powerful leadership skills are needed by all nurses—those
providing direct care to those in top management positions. Anyone who is looked to as
an authority (e.g., a nurse taking care of a patient) or who is responsible for giving
assistance to others is considered a leader (Mahoney, 2001).

A clinical nursing leader is one who is involved in direct patient care and who
continuously improves care by influencing others (Cook, 2001). Leadership is not
merely a series of skills or tasks; rather, it is an attitude that informs behavior (Cook,
2001). In addition, good leadership is consistent superior performance with long term
benefit to all involved. Leaders are not merely those who control others, but they act as
visionaries who help employees to plan, lead, control, and organize their activities
(Jooste, 2004).

Leadership has been defined many ways in the literature. However, several features are
common to most definitions of leadership. For example, leadership is a process, involves
influence, usually occurs in a group setting, involves the attainment of a goal, and
leadership exists at all levels (Faugier & Woolnough, 2002). There are several
recognized leadership styles. Autocratic leaders set an end goal without allowing others
to participate in the decision-making process (Faugier & Woolnough, 2002).
Bureaucratic leadership occurs when a leader rigidly adheres to rules, regulations, and
policies. Participative leaders allow staff to participate in decision-making and actively
seek out the participation of those involved. This type of leadership allows team
members to feel more committed to the goals they were involved with formulating
(Faugier & Woolnough, 2002). Laissez faire leadership leaves employees to their own
devices in meeting goals, and is a highly risky form of leadership. A more effective form
of leadership may be situational leadership. This is where the leader switches between
the above styles depending upon the situation at hand and upon the competence of the
followers (Faugier & Woolnough, 2002).

There is a difference between theory and style of leadership. According to Moiden

(2002), theory represents reality, while style of leadership is the various ways one can
implement a theory of leadership—the way in which something is said or done.
Organizations should aim for a leadership style that allows for high levels of work
performance, with few disruptions, in a wide variety of situational circumstances, in an
efficient manner (Moiden, 2002). Similarly, there is a difference between management
and leadership. Managers plan, organize and control, while leaders communicate vision,
motivate, inspire and empower in order to create organizational change (Faugier &
Woolnough, 2002).

Transactional versus Translational Leadership

Outhwaite (2003) cites definitions of transactional and transformational leadership as
posited by Bass in 1990. Transactional leadership involves the skills required in the
effective day to day running of a team. However, transformational leadership involves
how an integrated team works together and the innovativeness of their approach to the
work (Outhwaite, 2003). For example, a leader can empower team members by allowing
individuals to lead certain aspects of a project based on their areas of expertise. This will
encourage the development of individual leadership skills. In addition, leaders should
explore barriers and identify conflicts when they arise, and then work collaboratively
with the team to resolve these (Outhwaite, 2003). Furthermore, the leader should remain
a part of the team, sharing in the work, thus remaining close to operations and being able
to understand the employee’s perspective (Outhwaite, 2003).

Transactional leadership focuses on providing day-to-day care, while transformational

leadership is more focused on processes that motivate followers to perform to their full
potential by influencing change and providing a sense of direction (Cook, 2001). The
ability of a leader to articulate a shared vision is an important aspect of transformational
leadership (Faugier & Woolnough, 2002). Transactional leadership is most concerned
with managing predictability and order, while transformational leaders recognize the
importance of challenging the status quo (Faugier & Woolnough, 2002).

One group of authors described the use of transformational leadership by Magnet

hospitals (De Geest, Claessens, Longerich, & Schubert, 2003). This leadership style
allows for instilling faith and respect, treating of employees as individuals, innovation in
problem solving, transmission of values and ethical principles, and provision of
challenging goals while communicating a vision for the future (De Geest, et al., 2003).
Transformational leadership is especially well-suited to today’s fast-changing health care
environment where adaptation is extremely important. The author cites findings that this
leadership style is positively associated with higher employee satisfaction and better
performance. These, in turn, correlate positively with higher patient satisfaction (De
Geest, et al., 2003). One way to facilitate change using transformational leadership
involves the use of action learning (De Geest, et al., 2003). Leaders use directive,
supportive, democratic, and enabling methods to implement and sustain change. The
effects of such leadership will radiate to better outcomes for both nurses and patients.
Transformational leadership focuses on the interpersonal processes between leaders and
followers and is encouraged by empowerment (Hyett, 2003). Empowered nurses are able
to believe in their own ability to create and adapt to change. When using a team
approach to leadership, it is important to set boundaries, goals, accountability, and
supports for team members (Hyett, 2003). Transformational leadership is seen as
empowering, but the nurse manager must balance the use of power in a democratic
fashion to avoid the appearance of abuse of power (Welford, 2002). Respect and trust of
staff by the leader is essential.

Clinical or Shared Governance

Clinical governance is a new way of working in which National Health Service (NHS)
organizations are accountable for continuous quality improvement, safeguarding
standards of care, and creating an environment for clinical excellence (Moiden, 2002).
Requirements of several recent UK government policies require that new forms of
leadership better reflecting the diversity of the workforce and the community be
developed (Scott & Caress, 2005). Leadership needs to be strengthened and needs to
involve all staff in clinical leadership. Shared governance is one method of allowing for
this. This form of leadership empowers all staff for decision making processes, and
allows staff to work together to develop multi-professional care (Scott & Caress, 2005).
Shared governance is a decentralized style of management in which all team members
have responsibility and managers are facilitative, rather than using a hierarchical
management style where managers are controlling and staff are not involved in decision-
making (Scott & Caress, 2005). Scott and Caress (2005) contend that this type of
leadership will lead to increased morale and job satisfaction, increased motivation and
staff contribution, encouragement of creativity, and increased sense of worth.

Knowledge, Attitudes, and Skills of an Effective Nurse Leader

A clinical nursing leader is one who is involved in direct patient care and who
continuously improves care by influencing others (Cook, 2001). Leadership is not
merely a series of skills or tasks; rather, it is an attitude that informs behavior (Cook,
2001). Several important functions of a nurse leader are: acting as a role model,
collaboration to provide optimum care, provision of information and support, providing
care based on theory and research, and being an advocate for patients and the health care
organization (Mahoney, 2001). In addition, nurse leaders should have knowledge of
management, communication, and teamwork skills, as well as some background in health
economics, finance, and evidence-based outcomes (Mahoney, 2001). Personal qualities
desirable in a nurse leader include competence, confidence, courage, collaboration, and
creativity. Nurse leaders should be aware of the changing environment and make
changes proactively. Leaders who show concern for the needs and objectives of staff
members and are cognizant of the conditions affecting the work environment will
encourage productivity (Moiden, 2003). In doing this, it is important that a philosophy of
productivity is established.

According to Jooste (2004), three things that are essential to leadership are authority,
power, and influence. Effective leaders of today should use more influence and less
authority and power. It is more important to be able to motivate, persuade, appreciate,
and negotiate than to merely wield power. The author cites three categories of influence
for nurse leaders to use in creating a supportive care environment. These include
modeling by example, building caring relationships, and mentoring by instruction
(Jooste, 2004). In addition, Jooste lists five practices fundamental to good leadership
including inspiring a shared vision, enabling others to act, challenging processes,
modeling, and encouraging. For example, a leader may challenge others to act by
recognizing contributions and by fostering collaboration. Recognizing contributions also
serves to encourage employees in their work. Team leadership moves the focus away
from the leader towards the team as a whole (Jooste, 2004).
Applications to Practice Settings

Hyett described several barriers to health visitors taking on a leadership role (2003). For
example, health visitors usually work in a self-led environment, yet there may be no
mechanism for self control or decision-making at the point of service—thus stifling
innovation (Hyett, 2003). Furthermore, if nurses who do try to initiate change are not
supported, they lose confidence and assertiveness and may feel disempowered and unable
to support one another (Hyett, 2003). Management often focuses on the volume of
services provided, leading to loss self-esteem and dependence—causing workers to
become disruptive, or to leave the organization (Hyett, 2003).

Focus group data from a study of implementing change in a nursing home suggests that
nurses want a leader with drive, enthusiasm, and credibility—not mere superiority
(Rycroft-Malone, et al., 2004). Further, focus group members identified qualities desired
in a leader facilitating change. This person should have knowledge of the collaborative
project, should have status with the team, should be able to manage others, take a positive
approach to management, and possess good management skills (Rycroft-Malone, et al.,
2004).

Applications to the Wider Health and Social Context

Nurse leaders function at all levels of nursing from the ward through top nursing
management. Over time, the function of leadership has changed from one of authority
and power to one of being powerful without being overpowering (Jooste, 2004).
Boundaries between upper, middle, and lower level leaders are becoming blurred, and
responsibilities are becoming less static and more flexible in nature. In other words, there
is a trend toward decentralization of responsibility and authority from upper to the lower
levels of health care delivery (Jooste, 2004).
An ongoing program of political leadership at the Royal College of Nursing describes a
multi-step model for political influencing (Thomas, Billington & Getliffe, 2004). Some
steps include: identifying the issue to be changed, turning the issue into a proposal for
change, find and speak with supporters and stakeholders to develop a collective voice,
identification of desired policy change outcomes, and construction of messages to get the
issue across (Thomas et al., 2004).

Education for Leadership

In order for nursing practice to improve, an investment must be made in educating nurses
to be effective leaders (Cook, 2001). Cook contends that leadership should be introduced
in initial nursing preparation curricula, and mentoring should be available for aspiring
nurse leaders (2001). For example, the use of evidence-based practice requires nurses to
be able to evaluate evidence and formulate solutions based upon the best available
evidence (Cook, 2001). In order for these things to occur, it is important that nurses have
educational preparation for leadership during training to prepare them to have greater
understanding and control of events that may occur during work situations (Moiden,
2002).
The NHS has adopted the Leading an Empowered Organization (LEO) project in order to
encourage the use of transformational leadership (Moiden, 2002). By doing so, the goal
is to enable professionals to empower themselves and others through responsibility,
authority, and accountability. The program also aims to help professionals develop
autonomy, take risks, solve problems, and articulate responsibility (Moiden, 2002).
Strategies such as the Leading and Empowered Organization (LEO) programme and the
RCN Clinical Leaders Programme are designed to produce leaders in nursing who are
aware of the benefits of transformational leadership (Faugier & Woolnough, 2002).

Challenges and Opportunities to Stimulate Change

The health care environment is constantly changing and producing new challenges that
the nurse leader must work within (Jooste, 2004). Leadership involves enabling people
to produce extraordinary things while being faced with challenge and change (Jooste,
2004). While management in the past took a direct, hierarchical approach to leadership,
the time has come for a better leadership style that includes encouragement, listening, and
facilitating (Hyett, 2003). Hyett (2003, p. 231) cites Yoder-Wise (1999) as defining
leadership as “the ability to create new systems and methods to accomplish a desired
vision”. Today, the belief is that anyone can be a leader—leadership is a learnable set of
skills and practices (Hyett, 2003). All nurses must display leadership skills such as
adaptability, self-confidence, and judgment in the provision of health care (Hyett, 2003).
The expectation is that nurses lead care, and that they be able to move between leading
and following frequently (Hyett, 2003).

Empowering Patients to Participate in the Decision-Making Process

Only when health care services are well-led will they be well-organized in meeting the
needs of patients (Fradd, 2004). Nurses have considerable influence on the patient’s
experience as patient involvement in care is most often nurse-led (Fradd, 2004). Today,
patients are more aware of their own health care needs and better informed about
treatments and practice. This requires nurses to be better equipped with analytical and
assertiveness skills (Welford, 2002). Transformational leadership is ideal for today’s
nursing practice as it seeks to satisfy needs, and involves both the leader and the follower
in meeting needs (Welford, 2002). It is also flexible—allowing the leader to adapt in
varied situations. The leader accepts that things will change often, and followers will
enjoy this flexibility. Thus both nurses and patients will benefit. The avoidance of
hierarchy and the ability to work in new ways helps organizations put resources together
to create added value for both employees and consumers (Welford, 2002). Further, use
of transformational leadership allows team nurses to enhance their role as teacher or
advocate (Welford, 2002).

References
Cook, M. (2001). The renaissance of clinical leadership.
International nursing review, 48: 38-46.
De Geest, S., Claessens, P., Longerich, H. and Schubert, M. (2003). Transformational
leadership: Worthwhile the investment! European Journal of Cardiovascular Nursing,
2: 3-5.

Faugier, J. and Woolnough, H. (2002). National nursing leadership programme. Mental

Health Practice, 6 (3): 28-34.

Fradd, L. (2004). Political leadership in action. Journal of Nursing Management, 12:

242-245.

Hyett, E. (2003). What blocks health visitors from taking on a leadership role? Journal
of Nursing Management, 11: 229-33.

Jooste, K. (2004). Leadership: A new perspective. Journal of Nursing Management, 12:

217-223.

Mahoney, J. (2001). Leadership skills for the 21st century. Journal of Nursing
Management, 9: 269-71.

Moiden, N. (2003). A framework for leadership. Nursing Management, 9: 19-23.

Moiden, M. (2002). Evolution of leadership in nursing. Nursing Management, 9: 20-25.

Outhwaite, S. (2003). The importance of leadership in the development of an integrated

team. Journal of Nursing Management, 11: 371-76.

Rycroft-Malone, J., Harvey, G., Seers, K., Kitson, A., MCormack, B, and Titchen, A.
(2004). An exploration of the factors that influence the implementation of evidence into
practice. Journal of Clinical Nursing, 13: 913-24.

Scott, L. and Caress, A-L. (2005). Shared governance and shared leadership: Meeting the
challenges of implementation. Journal of Nursing Management, 13: 4-12.

Thomas, S., Billington, A. and Getliffe, K. (2004). Journal of Nursing Management, 12:
252-57.

Parish Nursing: a speciality practice and professional model of health ministry. A

Parish Nurse is an experienced registered nurse in good standing with the Professional
governing body or association. A Parish Nurse links faith and health to combine
professional nursing with Christian ministry. The Christian Church mandate is to preach,
to teach and to heal.
I believe there are also some Jewish Parish Nurses as well although I haven't met any as
of yet.
Hope this is helpful. Do a internet seach and you will find hundreds of entries.
arish nursing is the intentional integration of the practice of nursing with the beliefs of a
religious community. A parish nurse is a registered nurse (RN) specialist who encourages
physical and spiritual health and wholeness by developing and leading programs within
faith communities. If you are person of faith, parish nursing can be an exciting way to
integrate body, mind, spirit and community into your nursing practice.

Parish Nurse Career Overview

The American Nurses Association (ANA) uses the term Faith Community Nursing
(FCN) to define the nursing specialty of parish nursing, also known as congregational
nursing or church nursing. ANA defines FCN as "the specialized practice of professional
nursing that focuses on the intentional care of the spirit as part of the process of
promoting holistic health and preventing or minimizing illness in a faith community."

Rather than dealing primarily with sickness in a faith community, parish nurses focus on
wellness, disease prevention and health promotion. Responsibilities may include:

• Health education and teaching

• Personal health counseling for faith community members
• Coordinating with community health resources and acting as a church liaison
• Training and coordinating volunteers in support services
• Organizing health support groups
• Assessing congregational and community health needs
• Responding to health-related issues such as substance abuse, addictions and
violence within congregational families or the surrounding community

Parish nurses may work exclusively with a single large congregation or divide their time
between multiple smaller congregations. A number of faith denominations coordinate
national or international parish nursing programs.

Parish Nurse Education

To become a parish nurse, you must first become a licensed registered nurse (RN) by one
of three educational paths:

• Getting a bachelor's degree in nursing

• Getting an associate's degree in nursing
• Getting a diploma from an approved nursing school program
You may then choose from a variety of specialized educational programs specific to
parish nursing or faith community nursing. These include the following programs:

• Short parish nurse preparation courses

• A master's program that integrates nursing and faith ministry
• A doctoral program that integrates nursing and faith ministry

If you already have a Master's Degree in Nursing (MSN), you can pursue a post-master's
certificate.

For more information, visit the International Parish Nurse Resource Center.

Parish Nurse Salary

According to the Bureau of Labor Statistics, registered nurses earned a median annual
salary of $57,280 in May 2006. The middle 50 percent earned between $47,710 and
$69,850.

However, average RN salaries within the specialty of parish nursing are often
significantly lower. In fact, many parish nurses are volunteers. A lot of churches cannot
afford to offer competitive nursing salaries, so parish nurses work part-time and
supplement their incomes with other nursing jobs. You may earn more if you work for a
community agency or a more established denominational nursing program, but it is
unusual to earn wages comparable to what you could earn in a hospital or other health
care focused setting. To be satisfied in a parish nursing career, you will need to be
motivated by the non-monetary rewards of your work—the daily opportunities to
improve physical and spiritual wellness within your community of faith.

Parish Nurse Career Outlook

Parish nursing is a growing international movement of over 10,000 registered nurses. The
specialty has gained prominence only recently and was recognized by the American
Nurses Association in 2005. More and more faith communities are acknowledging the
need for trained medical professionals to help them address the full spectrum of needs in
their congregations, particularly in light of the current health care crisis. Faith
communities are also under increasing pressure to "pick up the pieces" in terms of health-
related social problems such as addiction, mental illness and violence.
In addition, the demand for all types of nurses is expected to increase significantly over
the next ten years. Job demand positively affects salaries, schedules, job openings, and
the availability of training institutions and government grants for education.

Sources:
University of Maryland, 2007
National Health Ministries, 2008