The Health Care Manager

Volume 39, Number 3, pp. 117–121

Copyright © 2020 Wolters Kluwer Health, Inc.
All rights reserved.

Transformational Leadership in
Health Care Today
Beverly Robbins, RN, BSN; Ruth Davidhizar, RN, DNS, ARNP, BC, FAAN
Management in nursing is in a state of revolution based on positive transformational changes. Effective
leadership on individual nursing units directly affects nursing staff satisfaction. Employees are inter-
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ested in managers who can lead in a positive and encouraging manner. Nurses who are content in
their positions correlate to a reduction in staff turnover and improve retention. When the nursing staff
are satisfied with their employment, patient satisfaction rises. Health care organizations can see this
trickle-down effect through increases in patient satisfaction scores over time. The promotion of effec-
tive communication and positive attitudes enhances a healthy environment for all employees and staff.
Health care organizations should evaluate individual nurse managers on units to promote transforma-
tional leadership qualities; this will directly result in staff satisfaction, staff retention, and
patient satisfaction. Key words: change, leadership, nursing, patient satisfaction, staff retention

CHANGES NEEDED IN LEADERSHIP making positive strides toward changing the en-
vironment of individual nursing units.
In today’s corporate environment, the health The management of nursing is on the edge
care system lags behind the times as the provider of change and is positioned to positively trans-
of a product to a diverse group of consumers. Be- form the hospital environment by catapulting the
cause of the encumbrances resulting from fed- dinosaur into a new age of leadership strategies.
eral, state, and local bureaucracy, regulation, Transformational leadership affects all levels within
and endless procedures and policies, it could the health care system. Management tasks and be-
be said that the health care system resembles a haviors are different from leadership pro-
prehistoric dinosaur. According to Thyer,1 “The cesses; however, it is reasonable to anticipate
changing face of the workplace has required that management will strive to promote good
the use of effective and appropriate communica- leadership.2 For example, the strategies used
tion strategies. However, the health care sector by leaders in the health care arena directly affect
has been a lot slower to implement new initia- staff satisfaction, which in turn affects patient satis-
tives in nursing management.” At the core of faction. There is a direct link between nursing
changing the health care system are those who care and patient satisfaction. The significance of
provide direct care to patients. Involvement at nursing care to overall patient satisfaction actually
this level is essential if the health care system is increases the likelihood of the patient returning to
the provider or recommending the provider to
Reprinted from Robbins B, Davidhizar R.
friends and relatives.3 This chain of events would
Transformational leadership in health care today. Health cascade into an increase of revenue for the health
Care Manag. 2007;26(3):234-239. doi:10.1097/01. care institution. Al-Mailam notes, “The financial
HCM.0000285014.26397.e7.
implications of these relationships are substantial
Author Affiliations: Lakeland Regional Health System, as more repeat customers would bring in addi-
Saint Joseph, Michigan (Ms Robbins) and School of tional revenues.”3(p119) Hospital executive man-
Nursing, Bethel College, Mishawaka, Indiana (Dr
Davidhizar).
agement must focus on the correct selection of
personnel for the positions of leadership for indi-
The authors have no conflicts of interest. vidual nursing units to achieve greater success
Corresponding author: Ruth Davidhizar, RN, DNS, ARNP, with staff satisfaction, staff retention, and patient
BC, FAAN, 1001 W. McKinley Ave, Mishawaka, IN 46545 satisfaction. When staff satisfaction and retention
([email protected]).
and patient satisfaction are achieved, hospital
DOI: 10.1097/HCM.0000000000000296 revenues will increase.
117

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118 THE HEALTH CARE MANAGER/JULY–SEPTEMBER 2020

TRANSFORMATIONAL LEADERSHIP THE MISSION OF EDUCATING

NURSING LEADERS
Communication is at the core of effective
management and leadership. Historically, 2 Managers need to be educated in transforma-
clearly different types of leadership have been tional leadership qualities. While some hospital
identified, transactional and transformational.4 organizations continue to promote from within, it
The transactional thought process involves a is important to remember that education in
style of reward and punishment, with a focus techniques that can transform the health care
on day-to-day functioning. The goals are set system is crucial. Among the many challenges
by the manager, and staff must comply. For ex- that result from the current nursing shortage
ample, a nursing unit may have a rule requiring is the expectation that a nurse who performs
an employee who calls in sick on a weekend well at the bedside will also do well in manage-
shift to work a shift on the following weekend. ment. Without formal training, this can create
The manager of the unit will schedule the em- devastation in the health care organization.7
ployee to this makeup shift without talking Top-level administrators must be looking at
with the employee about the missed shift. This specialized training for their nurse managers.
is the rule, and it will be followed. As Wieck8 states, “The manager and leadership
On the other hand, the transformational role must be brought back to nursing academic
thought process involves working in a team graduate programs and must be compensated
with the manager as a transformational leader. at a level equal to others who hold similar posi-
This leader has a vision of what and how the tions of responsibility.”
unit should function. The team has a say in Nursing organizations must promote in-
how to achieve this vision. Transformational creasing educational qualifications if nursing
thinking is more work, but in the end, the staff leaders and managers must be educationally
are involved, and there is a sense of belong- prepared at a level commensurate with other
ing and acceptance of responsibility to make disciplines. Nursing leaders should hold a min-
the goals a reality. Burns4 emphasized that imum of a master’s degree to hold top level
transformational leadership is a commitment management positions.
to a vision and empowers others to achieve However, because many managers already
the vision. occupying these positions do not hold gradu-
The transformational leader must have a ate degrees, it is important that educational of-
vision and must be able to communicate this ferings be provided for managers already in the
vision to the followers. If a leader is deficient health care system. Focused leadership train-
in the ability to communicate this vision, the ing is a cost-effective strategy for developing ef-
leader will be unsuccessful in leading the fective leadership characteristics in nurse
group.5 Equally important is allowing the en- managers as opposed to the investment in
tire group to have a say in specifying the de- graduate education.9 Associate and baccalaure-
sired outcome. According to Bujak,6 by letting ate degree nurses who have reached a nursing
go of the consequences of leading to a tran- management position should require addi-
scendent vision, the leader inspires followers tional education from their organizations.
and encourages the followers to reconnect Nurse managers who do not possess higher
to the main purpose in their work. Bujak6 level degrees or have not received additional
also notes that the administrative side of educational offerings cannot provide the trans-
health care has removed the focus from pa- formational leadership needed to maintain staff
tient care, ultimately resulting in the neglect job satisfaction.
of vision and mission. The mission of The author’s health care agency, which is lo-
modern-day nursing is about providing excel- cated in Saint Joseph, Michigan, provides excel-
lent patient care. Nurse managers need a lent educational benefits to its employees. The
well-honed critical thinking process to achieve benefits offered include tuition reimbursement
transformational leadership. programs, associate degree to bachelor’s degree

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 Transformational Leadership in Health Care 119

nursing loan program, health care scholarship foster growth, motivation, and excellence in
programs, and collaborative educational programs communication is evident in turnover rates,
with Lake Michigan College in Benton Harbor, lower profitability, and diminished employee
Michigan, and Bethel College in Mishawaka, concern for quality.”2(p45)
Indiana. The collaborative program is scheduled Strong correlations have been shown between
to allow employees maximum opportunity to at- poor leadership on a nursing unit and unhappy,
tend classes. The classes are offered 1 night a unmotivated, and less dedicated staff.
week, so work schedules can be easily adjusted.
Bethel College professors are traveling the 1-hour LEADERSHIP STYLE AFFECTS
distance from the campus to meet with their stu- STAFF RETENTION
dents in Lakeland’s educational classrooms. This
collaborative arrangement between the health Leadership style also relates to staff reten-
care agency and the college has provided im- tion. Retaining experienced staff is critical.
proved flexibility for the employees of Lakeland. According to Runy, “The nursing shortage is
In the first year, 14 associate degree nurses likely to get worse before it gets better.”13(p60)
signed up for the program, filling all the spaces In 2000, the shortage of registered nurses was
in the class, making the baccalaureate degrees 110,000 according to the Health Resources
2 years away and within reach. and Services Administration. By 2010, it will
grow to 275,220, and by 2020, to 808,416.13
LEADERSHIP STYLE AFFECTS With such bleak numbers forecasted for
STAFF SATISFACTION the future, now is the time to be evaluating what
is being accomplished on individual nursing
Traditionally, employees were to be seen and units. Because it is estimated that it costs US
not heard.10 Over the last decade, this has $46,000 to replace a medical/ surgical nurse,
changed. Today, all-personnel employee sur- the cost of staff turnover is phenomenal.14
veys seek guidance for improving the satisfac- These financial figures, compounded with the
tion of employees. Although these surveys are nursing shortage figures, illustrate how vital
helpful information, hospital administrators currently employed experienced nurses are
need to focus on how middle managers are to each health care institution.
leading their staff. Only then will they be able Although new ideas and pilot projects are time
to improve staff retention and, in the long consuming and labor intensive, the development
run, improve patient satisfaction. of better care delivery methods is imperative. In-
Visionary managers focus on empowering novation and maintaining a satisfied workforce
staff.11,12 A content staff makes a nursing unit are mandatory for a high standard of care.8
run smoothly and aids individual nurses with New approaches by nurse managers will en-
a feeling of success. Kleinman9 notes that able each nursing unit to exercise its own inde-
while nurse administrators continue to strug- pendent and creative thinking in coming up
gle with staff nurse recruitment and retention, with ways on how to best deliver patient care
evidenced-based strategies can address leader and improve staff involvement. Job satisfaction
preparation and organizational structure. Fur- and retention are closely related.
thermore, studies indicate that when leadership Kleinman9 reported that nurse administra-
behaviors include support and consideration of tors who more frequently demonstrated transfor-
staff, high visibility, and willingness to share leader- mational behaviors compared with transactional
ship responsibilities, there is a positive influence on behaviors increased staff nurse job satisfaction
staff nurse retention.9 The nurse managers’ ability and reduced staff nurse turnover. Nursing staff
to interact with their staff is the key. retention is much higher when nursing manage-
As Pearman states, “Communication and ment is led by transformational leaders.
relationship-building habits are among the Bethune et al state that “the nurse manager’s
greatest challenges leaders have to face. The leadership and management style play an im-
fact that many fail to develop good habits that portant role in developing attractive work

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120 THE HEALTH CARE MANAGER/JULY–SEPTEMBER 2020

cultures.”15(p25) Professional nursing practice Services, “We are always striving to improve pa-
on a unit highlights each individual nurse’s abil- tient satisfaction in every area of the hospital”
ity to interact in an environment of autonomy.16 (E. Willits, personal communication, 2006). In the
Autonomy for nurses is essential to professional emergency department, Lakeland wanted to in-
practice because this enables nurses to partici- crease patient satisfaction scores and has shown a
pate in decisions made regarding daily patient consistent rise in patient satisfaction in nursing care
care.16 As nurse managers make their staff more for the same periods over the previous year. As
autonomous, they are drawing more participa- Willits states, “We are continuously looking for
tion from their employees, which in turn will in- ways to improve our delivery of health care and
crease retention in nursing units. have implemented many new processes to better
Employees want to feel a part of their nursing serve our patients in Lakeland’s emergency depart-
units and have a voice in the decisions being made. ment. Two key elements we have centered upon
Reilly states from an interview with Mary Sheahen, with our staff have been increasing effective com-
director of Signature Leadership Initiatives at the munication with our patients and their family and
University of Illinois at Chicago Nursing Institute, consistent positive attitudes by our staff” (E. Willits,
“The No. 1 reason people are leaving jobs is the re- personal communication, 2006).
lationships with managers...when you have strong Lakeland has implemented many process
leaders, people respond to them.”17(p20) If the staff changes in the emergency department, such as
do not feel valued or important, there can be dis- bedside registration, greeters who are in continu-
sention in the unit. Organizational commitment, ous communication with patients waiting for
empowerment, collegial relationships, and trust rooms, and development of a fast track process
in management are all reasons why a nurse may for less emergent visits where physician assistants
leave an employer.7 and nurse practitioners see patients, which re-
The foundation of leadership on a nursing duces overall patient wait time. Emergency de-
unit is solely based on the leader. According partment personnel have signed positive attitude
to McConnell, “One prominent feature of a commitment statements to show their dedication
well-led workforce is the absence of cynicism. to improving staff interaction with all patients.
Cynicism disappears when employees respect In today’s health care environment, consumers,
their leaders.”18(p153) This respect is formed as well as providers, are continuously searching for
when the leader shows high levels of compe- improvement on patient satisfaction. International
tency, effective decision making, compassion, accreditation agencies, such as the Joint Commis-
and trust. The leader forms a level of trust with sion on Accreditation of Healthcare Organizations
employees who then feel enriched and moti- and the National Committee on Quality Assurance,
vated to accomplish tasks. Employees feel a con- have included satisfaction as a quality indicator.
nection with their leader and are empowered
to deliver excellent patient care, resulting in in- NURSING SATISFACTION AND
creased patient satisfaction. RETENTION IMPACT PATIENT CARE

EVALUATION OF PATIENT SATISFACTION When nurses are satisfied, they stay in their po-
sitions. This impacts staff retention in a positive
There are many different ways to measure pa- way by reducing turnover on each nursing unit.
tient satisfaction. One of the ways hospital ad- This enables nursing units to continue with expe-
ministrators evaluate the extent to which they rienced staff, which positively impacts patient
are satisfying patients is through Press Ganey care. Workforce struggles, particularly the short-
surveys sent to their consumers after they have age of registered nurses, have a negative impact
left the hospital. Lakeland Regional Health Sys- on quality of care and public perception about
tem in Saint Joseph, Michigan, analyzes this in- the quality of care provided. Positions are re-
formation from discharged patients to improve placeable but people are not, and in health care,
their health care delivery processes. according positive people are what make the difference.
to Eileen Willits, vice president of Patient Care According to Bujak, “When we can put the soul

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

 Transformational Leadership in Health Care 121

back into health care, when those in health care delivered to patients and on the important people
can reconnect what they do with what they who are delivering that care; only then will the
most care about, then the joy will return, and tan- health care organization succeed.
gible results will show up at the front door.”6(p40)
Executive management of health care organi-
zations needs to reevaluate how to successfully SUMMARY
provide positive patient care with satisfied em-
ployees while maintaining an economical structure. Health care organizations will discover that
Because of the high costs of replacing staff, espe- transformational leadership is crucial in maintain-
cially registered nurses, administrators need to reas- ing and retaining nursing staff and in achieving
sess the way nursing managers are interacting with overall patient satisfaction. Focus and evalua-
staff. All levels of management should be involved tion must address how nursing managers are
in promoting a healthy environment. This process interacting with their staff. Relationships be-
will reduce hospital costs, empower employees, tween manager and staff require professionalism,
and improve staff attitudes, values, and commitment promotion of ideas, and effective communica-
to our facilities, which in turn affect improved tion. When the nursing staff are satisfied, patient
patient care. care improves. Encouragement and support of
Nurse managers are responsible for finding, employees by nursing managers are the ultimate
modifying, and executing a better way, not only key to enhancing staff harmony. A transforma-
for the staff but for the population relying on the tional leader can empower nursing staff, which
health care system. The nurse managers’ focus in turn promotes a healthy environment for the
needs to be on the quality care that is being entire health care organization.

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