Nursing Leadership Nursing CE Course

tions. The leadership style of a nurse manager or other nurse leaders on a unit or within an organization can play a large part in patient and staff satisfaction, affecting staff retention and patient outcomes. Having individuals leading the healthcare industry who exemplify the traits listed above can increase human relations and promote interdisciplinary communication (Durmus & Kirca, 2019).  

There is minimal research regarding the leadership styles of nurses specifically; however, most nursing leadership styles appear to fall within the broader categories of relational leadership or task-focused leadership. Within these broader categories are more defined leadership styles (Durmus & Kirca, 2019).

Relational Leadership

Relational leadership styles include transformational, resonance, and participatory leadership. These leadership styles are associated with increased staff satisfaction, which leads to a stronger commitment to an organization, reduced stress, increased job satisfaction, improved overall staff health and welfare, increased productivity, and positive patient outcomes (Durmus & Kirca, 2019).

Transformational Leadership

Transformational leadership is considered the gold standard of nursing leadership styles due to its focus on patient outcomes, employee satisfaction rates, and promoting a culture of safety within the organization. Nurses with a transformational leadership style can communicate effectively regardless of their audience. They can also perform nursing tasks and act as a role model to other nurses. These leaders motivate and empower their staff to meet organizational and personal goals (Durmus & Kirca, 2019). Transformational leaders commonly have four key characteristics:

• charismatic: this charisma is often associated with the leader's physical characteristics as well as their ability to communicate effectively and share their vision
• inspirational: transformational leaders can inspire and motivate others through the delivery of captivating speeches that encourages their followers during times of crisis or difficult situations
• intellectual thinkers: they can inspire others to think outside the box and come up with innovative ideas to solve problems
• able to provide individual attention to those around them and understand the individual needs of their employees: leaders understand that the needs and characteristics of employees can change and often depend on the style and influence of a particular leader (Durmus & Kirca, 2019)

Resonance Leadership 

Resonance leadership is based on the concepts included in emotional intelligence (EI), which are discussed later in this module. Resonance leaders have self-awareness, social awareness, the ability to self-manage, and relationship management skills. Due to these skills, resonance leaders can effectively manage individuals, including finding solutions to problems and providing conflict management (Durmus & Kirca, 2019).

Participatory Leadership 

Participatory leaders consider the group and individuals' views and opinions when making decisions. This decision-making process is based on group and individual knowledge, experience, skills, and innovation. In 2016, the World Health Organization (WHO) pushed for participatory leadership to take the place of hierarchical leadership in healthcare since hierarchical leadership is based on strict roles and a chain of command instead of collaboration. This was due to the inclusiveness and involvement of many individuals in decision-making, which is the basis of participatory leadership. This decision-making process can lead to a stronger healthcare workforce and interdisciplinary involvement (Durmus & Kirca, 2019).

Task-Focused Leadership Styles

Task-focused leadership styles consist of transactional (operational), autocratic, and laissez-faire. Task-focused leadership defines and clarifies roles within a team or group of individuals, sets a project's objectives, monitors individuals and the group for progress toward completion, and provides performance feedback. These leadership styles focus on the work and completion of tasks and deadlines to meet organizational directives (Durmus & Kirca, 2019).

Transactional and Autocratic Leadership 

Transactional leadership, also known as operational leadership, involves motivating individuals to reach short-term goals by fulfilling their needs. Transactional leadership comprises two sub-styles known as management with exceptions and conditional rewarding. Management with exceptions is further differentiated between active and passive leadership. An active leader monitors team performance and intervenes to correct errors or provide education. A passive leader expects the team members to recognize their errors; if they fail to recognize errors, a passive leader provides negative feedback. In conditional rewarding, a leader clearly explains everyone’s responsibilities and how they will be rewarded for tasks that are completed satisfactorily. Transactional leadership is preferred in a crisis or when critical events occur (Durmus & Kirca, 2019).

Another type of transactional leadership is autocratic leadership. Autocratic leaders follow defined directives and are described as controlling, power-seeking, and close-minded. Autocratic leaders stress the importance of obedience, loyalty, and strict rule adherence to their followers. This type of leadership may be beneficial in emergent or chaotic situations when decisions must be made quickly, as an autocratic leader makes all the decisions, and the rest of the staff follow directions. Outside of emergent situations, these leaders view information as power and often withhold information from their staff, promoting a culture without transparency. Autocratic leaders do not tolerate mistakes being made; when mistakes do happen, individuals are often accused and reprimanded publicly. When individuals comply with directives, rewards are given; however, disobedience or questioning the leader's decision-making is punished. Autocratic leaders are often disliked by their staff but can be appreciated if positive results of their leadership style are noticed (Durmus & Kirca, 2019).

Laissez-Faire Leadership 

This leadership style follows the definition of laissez-faire: letting them do it. Laissez-faire leaders do not participate in a collaborative process but encourage and give complete freedom to their followers to generate ideas and critically think to come up with a solution or process on their own. If needed, laissez-faire leaders will provide opinions and offer suggestions; however, with this leadership style, a leader's primary purpose is to provide staff with the resources they need to succeed. This leadership style is often used by those who are inexperienced or are leaving their position and stepping back to leave their followers on their own. A positive to this type of leadership is that everyone is motivated to train themselves and learn to be well-equipped to find solutions to problems. When an individual finds a need, they are free to create small groups with like-minded people to solve problems and implement new ideas. Giving complete freedom to individuals also has adverse effects. With this leadership style, turmoil can emerge within an organization due to differing views on how problems should be solved, and which are most important. These differing viewpoints can hinder organizational success (Durmus & Kirca, 2019).

Emotional Intelligence

Consistent themes among the different leadership styles include authenticity, self-awareness, insight into situations, and the ability to communicate effectively. EI is a term that describes these personal characteristics. EI is demonstrated by an individual who has awareness, examination, and management of their emotions and recognizes how their emotions impact interpersonal relationships, particularly in the workplace. Having EI is essential for personal and professional success. Nurse leaders can utilize EI to develop and foster effective relationships and facilitate effective communication and teamwork across healthcare disciplines. This skill can help individuals with time management, decision-making, accountability, stress tolerance, and communication. Individual, team, or organizational growth can culminate from a culture of transparent communication and insight into emotions by leadership. Empathy, mindfulness, happiness, compassion, and a forgiving nature emerge from individuals with a high EI. Those with a high EI have a positive impact on interpersonal relationships. Team building among members with high EI and emotionally competent behaviors (i.e., self-awareness, self-regulation, motivation, empathy, and social skills) provides a strong foundation. An EI leader can cultivate a spirit of mutual respect, maintain integrity, and facilitate collaboration while proactively managing conflict. In healthcare, effective communication is essential for improving patient care and outcomes (Khademi et al., 2021; Porter-O'Grady & Malloch, 2022).

Impact of Leadership Styles on Patient Outcomes

Effective healthcare leadership is essential for improving the quality of nursing care and patient outcomes. Effective leadership retains experienced staff and supports them as leaders and mentors to newer employees, promotes staff satisfaction, and increases productivity, leading to a reduction in medication errors, restraint use, fall rates, pressure ulcer development, hospital-acquired urinary tract infections, and mortality rates. Leadership is considered a core element for providing patient care regardless of the setting (i.e., inpatient units, clinics, long-term care units, and home health care). Poor leadership can lead to unintentional injuries resulting in disability, increased hospital stay, or death. Studies have shown that out of all the styles of leadership commonly seen in nursing, transformational leadership has the most significant positive impact on quality measures (Sfantou et al., 2017).

 

Leadership Opportunities

Nurses have many opportunities for leadership in healthcare organizations and academic institutions. Most nurses begin their careers as staff nurses in a clinical setting. Nurses can function as informal or formal leaders even in these early roles. Many nurses will move into unit-level management positions or may remain mentors or informal leaders as part of the healthcare team within their units. Other nurses will leave the clinical setting and move into other roles as leaders (Denker et al., 2015). Below are some examples of nursing leadership opportunities within healthcare organizations:

• Nurse Manager
• Nurse Administrator
• Nurse Supervisor
• Director of Nursing (DON)
• Vice President of Nursing
• Chief Nursing Officer (CNO; Denker et al., 2015)

Unique challenges accompany each of these roles. Nurse Managers are responsible for oversight of first-level nursing services and the utilization of resources within their units. Nurse Supervisors or DONs may be responsible for overseeing and managing several units within a hospital or clinical setting. Vice Presidents of Nursing or CNOs are nurse executives who drive healthcare delivery within a facility or healthcare system. Within these roles, a leader must know the accreditation requirements of the Joint Commission or other facility-specific accrediting bodies. State and federal laws must also be understood, and policies and procedures should reflect compliance. Application of evidence-based practice (EBP), collaboration with other healthcare professionals, and budgetary maintenance are additional responsibilities of nurse leaders in clinical settings (Denker et al., 2015).

Educational leadership requires a high level of clinical knowledge and extensive understanding of the educational system, accrediting agencies for higher education institutions, individual program accreditor(s), state and federal laws protecting students, human resource standards, and teaching and curriculum experience. Higher education has different budgetary considerations and staffing barriers compared to leadership in a clinical setting. Experienced and well-trained leadership in higher education is also linked to the success of students enrolled in the program. An experienced leader can form partnerships with local healthcare organizations to promote student learning. A strong educational leader brings clinical practice and the educational system together, and many academic leaders voice their need to be clinical and educational experts. There are unique challenges within the educational system, as leaders must advocate for the needed resources and faculty that are required to establish and effectively deliver a nursing or healthcare program. Additionally, program leadership must build strong clinical relationships that allow clinical opportunities for students (AACN, 2022b; Tagliareni & Brewington, 2018). Examples of nursing leadership opportunities within educational institutions include:

• Program Director
• Assistant Dean
• Dean
• Provost
• President
• Chief Academic Officer
• Vice President of Academic Affairs (Denker et al., 2015)

 

Becoming a Nurse Leader

Nurses can seek leadership positions or opportunities within their organizations. Leadership competencies involve the knowledge, skills, and attitudes (KSAs) needed to lead within an organization effectively. KSAs include EI, effective communication, self-awareness, and authenticity. KSAs for leadership can be defined through the American Organization for Nursing Leadership (AONL, previously the American Organization of Nurse Executives [AONE]) core competencies for nurse leaders across specific practice areas. Competency statements address KSAs for nursing leadership roles in various care settings, including the Nurse Executive (AONL, 2022b). The AONL (2015) identified core competencies for nurse executives as communication, knowledge, leadership, professionalism, and business skills.

Nurses in a formal leadership role can use the AONL competencies as a guideline or professional standard of practice. Before seeking a leadership position, an individual must perform a self-assessment of KSAs to identify and develop weak areas. The Authentic Leadership Questionnaire (ALQ) is often used as a self-assessment for leadership skills. This tool can identify areas of strength and weakness in 4 areas: self-awareness, relational transparency, balanced processing, and internalized moral perspective. There are 16 statements that the respondent answers using a Likert scale, with 1 indicating strong disagreement and 5 indicating strong agreement. The self-assessment is outlined in Table 1 (Northouse, 2022).

Table 1

Authentic Leadership Questionnaire: Areas of Authentic Leadership 

                                                                                                                                                             (Northouse, 2022)

After completing a self-assessment, the individual's scores for each question are totaled to determine their authentic leadership score:

• very high 64-80
• high 48-64
• low 32-48
• very low 16-32 (Northouse, 2022)

Additional types of leadership-style quizzes are available online and can help future or current leaders determine their current style or avenues of growth. These quizzes ask questions to help identify strengths, weaknesses, beliefs, or bias and enables prospective leaders to adopt the correct traits for a specific leadership style and work on the areas that may demonstrate weakness. Most only take a few minutes to complete, and many are free to use (MindTools, 2022).

Required Competencies for Nurse Leaders

Leadership competencies require building and sustaining strong, positive, and effective relationships that promote safe and high-quality care or outcomes within the organization. Communication and EI skills that cultivate interpersonal relationships are fundamental concepts for solid leadership. Other essential skills for leaders are understanding, appreciating, and using power and influence to promote positive change. Leadership in healthcare or nursing education should include cultural humility, professional identity formation, person-centered care, and holistic health principles (IOM, 2011; Porter-O'Grady & Malloch, 2022).

Ethical leadership is foundational since the profession of nursing is grounded in the welfare of others. Each nurse leader is responsible for patients, their families, coworkers, colleagues across the healthcare system, and community members. Ethical practices involve advocating for the well-being of individuals and society and upholding the innate value of all people. Competencies grounded in ethical behaviors can contribute to trust and stronger interpersonal relationships. Transformational and authentic leadership styles reflect ethical practice, including the principles of truth, loyalty, equality, respect for others, doing good, and doing no harm (Yoder-Wise, 2019). 

In today's healthcare environment, a culture of excellence must exist in tandem with ethical leadership. To deliver safe and effective care, nurse leaders must create and maintain organizational cultures that emphasize high performance and develop processes that maintain quality, safety, and organizational mission alignment. Leaders can translate principles into practice and deliver positive outcomes by intentionally modeling behaviors and practices that reflect the overall organizational culture and expectations (Cochrane, 2017). Developing and maintaining a culture of excellence requires a commitment to pursue excellence each day personally and collectively as an organization. Lynch and colleagues (2018) define knowing oneself as a prerequisite to delivering person-centered nursing care, noting that knowing oneself impacts the overall work environment. Leaders across the healthcare industry have identified the need for teamwork and collaboration to deliver safe, high-quality care (Lynch et al., 2018). Fostering strong teams also builds the following:

• increased productivity
• mutual respect among coworkers
• increased employee satisfaction
• enhanced loyalty to the organization
• improvement in the quality of care delivered
• reduced employee turnover
• cost savings through staff retention (Interprofessional Education Collaborative [IPEC], 2016; Quality and Safety Education for Nurses Institute [QSEN], 2020)

Effective healthcare organizations or educational systems integrate leadership, monitor situations, offer mutual support, and implement intentional communication. According to the Agency for Healthcare Research and Quality (AHRQ), outcomes for effective teams include:

• utilization of resources to optimize outcomes
• increased awareness of team roles and responsibilities
• constructive conflict resolution
• elimination of barriers to quality and safety (AHRQ, 2021)

Leaders are positioned to cultivate a culture of excellence through their day-to-day work practices that focus on the organization's mission, vision, and values. Competent interpersonal skills that focus on a culture of mutual respect and civility within the organization promote safe, high-quality healthcare delivery (AHRQ, 2021).

 

Communication Promoting Healthy Work Environments

While a leader may embrace or possess different leadership styles, there is a common theme among all: effective communication skills and interpersonal relationship building. Effective communication is a skill that is beneficial to everyone but is of utmost importance for a leader. Nurses learn the value of interpersonal communication with patients and peers, including verbal and non-verbal communication. Nurses perform a quick survey of a patient, evaluate any pertinent data, and make quick decisions based on the available evidence. The leader role is no different. A leader must interact with their team, develop quick assessments of the climate of interactions, and choose how to proceed with communication—both verbal and non-verbal—that will develop a healthy work environment. According to the American Nurses Association (ANA, n.d.-a), a healthy work environment is "safe, empowering, and satisfying . . . a place of physical, mental, and social well-being" (para. 3). Through effective communication, leaders, workers, and managers can share a feeling of mental and social well-being (ANA, n.d.-a).

A leader should always communicate with a respectful and professional tone. Nonverbal communication is articulated through facial expressions and body language (Porter-O'Grady & Malloch, 2022). Effective non-verbal communication can be displayed by:

• maintaining eye-contact
• respecting personal space
• providing a firm handshake
• maintaining relaxed movements
• using open-arm gestures
• showing the palms of the hands, signaling candor and credibility
• nodding when people talk to indicate agreement or understanding (Porter-O'Grady & Malloch, 2022)

Non-verbal communication that is ineffective can include:

• sighing
• finger-pointing
• arm-crossing
• eye-rolling (Porter-O'Grady & Malloch, 2022)

Nurse leaders count on their verbal and non-verbal foundational skills and enhanced communication skills to establish an atmosphere of integrity and trust, develop interpersonal relationships, and engage others in their daily work. Advanced communication skills include critical questioning, critical thinking, and critical listening. Critical questioning involves asking specific questions to clarify, validate perceptions, and understand any information being shared. Critical listening involves intentionally listening to another person unbiasedly, demonstrating authentic presence with the other person, and valuing the other person's perspective. Critical thinking is a skill most nurses begin to develop during nursing school education; however, it is especially vital for nurse leaders. Critical thinking takes place once listening and questioning have been completed, at which time careful analysis of the information and perceptions shared is used to develop a conclusion. Giving and receiving feedback in a professional manner comprise another competency for a leader (Porter-O'Grady & Malloch, 2022). When providing feedback to another person, the following tips can be helpful:

• ensure that privacy and confidentiality are provided
• sandwich opportunities for improvement between positive feedback
• remove bias and personal feelings from feedback
• when addressing subjective feelings, use "I" statements to avoid placing blame; there are four parts to an "I" statement: I feel [insert emotion] when you [insert behavior] because [insert impact]. I would prefer [insert desired behavior/action].
• ensure that feedback is timely after an incident and give the individual an opportunity to respond
• provide a future time for follow-up discussions (Porter-O'Grady & Malloch, 2022)

When receiving feedback from others, the following tips can be helpful:

• be receptive to feedback and maintain an open mind
• if the information is not clear, ask for specific examples or clarification
• summarize and validate the feedback to ensure the interpretation is accurate
• ask the person giving feedback for direction if new information is provided or suggestions on different directions to consider
• seek an opportunity for future follow-up discussions as appropriate (Porter-O'Grady & Malloch, 2022)

Interprofessional collaborative practice has evolved from increased awareness of patient safety and positive outcomes. With a shift in healthcare delivery models to person-centered care, nursing leaders must develop strong interprofessional and interpersonal relationships to foster partnerships with patients, families, and populations (QSEN, 2020). IPEC (2016) established competencies for interprofessional practice in 4 domains: values and ethics, roles and responsibilities, interprofessional communication, and teams and teamwork, as outlined in Table 2.  

 

Table 2

IPEC Core Competencies for Interprofessional Practice

Competency 1 Values and Ethics	Work with individuals of other professions to maintain a climate of mutual respect and shared values.
Competency 2 Roles and Responsibilities	Use the knowledge of one's role and those of other professions to assess and address the healthcare needs of patients appropriately and to promote and advance the health of populations.
Competency 3 Interprofessional Communication	Communicate with patients, families, communities, and professionals in health and other fields responsively and responsibly to support a team approach to promoting and maintaining health and preventing and treating disease.
Competency 4 Teams and Teamwork	Apply relationship-building values and the principles of team dynamics to perform effectively in different team roles to plan, deliver, and evaluate patient/population-centered care and population health programs and policies that are safe, timely, efficient, effective, and equitable.

                                                                                                                                               (IPEC, 2016)

Healthcare leaders are uniquely positioned to foster teamwork and interprofessional collaboration in various clinical and academic settings. Effective teamwork can produce positive outcomes in all settings but requires leaders who can facilitate emotionally competent interactions. An emotionally intelligent leader can achieve the best outcomes for an organization (IPEC, 2016). 

Challenges for Nurse Leaders

Regardless of the quality and expertise of communication, leaders will be presented with conflict and must develop skills for conflict resolution within an organization. Conflict can be constructive or destructive, based on each event's management and resolution. Conflict will occur at all levels of an organization, and nurse leaders may experience varying levels of conflict, ranging from their subordinates to lateral leadership. Since healthcare involves collaboration with many stakeholders and caring for diverse populations, working in healthcare can lead to even more opportunities for conflict. A leader should recognize and initiate strategies to offset conflict quickly to impact positive resolution. The Thomas-Kilmann Conflict Management Model offers approaches to conflict management. This model was developed by psychologists Kenneth Thomas and Ralph Kilmann in 2002 and is the gold standard in corporate and workplace training. The five options to resolve conflict within this model are competing, accommodating, avoiding, compromising, and collaborating, as described in Table 3 (Thomas, 2002).

 

Table 3

Thomas-Kilmann Conflict Management Model Approaches

Competing	This method attempts to meet one's own needs without concern or regard for the needs of others.
Accommodating	This method puts another person's needs or concerns ahead of one's own. This option is useful when another person has the best solution. It is unassertive and highly cooperative.
Avoiding	This method attempts to avoid conflict and address the other party's concerns. It is a non-productive approach that is uncooperative and unassertive.
Compromising	This method involves both assertiveness and cooperativeness to find a solution that partially meets the concerns of all parties involved in the conflict.
Collaborating	This method involves assertiveness and cooperation and seeks a win-win for all involved.

(Thomas, 2002)

Self-assessment of one's current conflict management approach is crucial for the leader. Determining the current resolution method can help inform the choice of different methods and behaviors to enhance leadership competency (IPEC, 2016).

Critical conversations may become part of conflict management. These conversations address performance outcomes and professional behavior essential to maintaining organizational quality. Timely and intentional recognition of high performers is critical in retaining high-quality talent. Higher performers should be recognized with conversations expressing gratitude for their work and high performance, recognizing specific examples of achievement, and communicating their contributions to the organization. Individuals who may be performing in the middle should have critical conversations related to support and clear expectations to achieve their fullest potential. These conversations should include examples of things they are doing well, coaching in areas that need improvement with specific direction, and confirmation of the leader's confidence in them for meeting future expectations. Conversations with low performers can be the most difficult. They should include specific descriptions of the behaviors needing improvement, an explanation of their behavior's impact, specific direction on future expectations, and a clear definition of any consequences that may occur without improvement in their performance. Trust is essential to build within a team, and critical conversations can open the door to trust and confidence in the leadership and their guidance (Donohue, 2018).

A leader cannot overlook the importance of self-care. Often, the demands of fast-paced healthcare and educational systems and caring for others can lead to self-neglect. To lead others, a nurse should be at their best self. Adequate self-care cultivates the ability to have positive interpersonal relationships and a resilient nature that can influence and impact others (Whitehead et al., 2017). Steps to maintain mental and emotional wellness include:

• practice relaxation and stress management
• simplify life when possible
• limit unhealthy relationships
• maintain emotional connections to family and friends
• practice time management
• use emotional resources carefully, or risk feeling emotionally drained
• assess and reduce negative stressors or distractors when possible (Whitehead et al., 2017)

Physical wellness is equally important and can be maintained through the following actions:

• get adequate sleep and practice rest patterns
• maintain a healthy nutritional intake
• drink plenty of water and maintain hydration
• engage in regular, enjoyable physical activity
• eliminate unhealthy lifestyle choices
• spend time with positive people who support a healthy lifestyle (Whitehead et al., 2017)

Spiritual wellness is another opportunity for self-care, and the following suggestions can improve a leader's spiritual well-being:

• reflect on the connection to others
• spend time in meditation or prayer
• nurture a sense of gratitude
• respect personal values and beliefs while respecting the values and beliefs of others equally
• work to integrate kindness into everything (Whitehead et al., 2017)

Self-leadership is as essential as leading others, and self-care is the initial step in the journey. Self-leadership can be challenging and requires self-awareness. Beyond identifying personal bias and beliefs, nurses should also consider how they relate to others and how others perceive their interactions and strive to understand how they negatively and positively influence others. Self-reflection can be used to intentionally consider and fine-tune many of the competencies of a strong leader, including listening, collaborating with others, and communicating. Being able to self-lead is a form of self-discipline that will aid in recognizing areas of opportunity for improvement and taking actions to facilitate self-growth (Whitehead et al., 2017).

Self-leading and self-care can result in a happier leader with a better work-life balance. Ways to maintain a healthier work-life balance include:

• realizing the need for balance between work and personal life and pursuing it intentionally
• setting realistic goals for personal and work performance while considering time and energy, available resources, and personal passions
• engaging in purposeful outside-of-work activities and personal self-care by scheduling proactively
• monitoring progress toward goals and updating as needed to maintain work-life balance and self-care needs (Whitehead et al., 2017)

Managing change is another challenge for many leaders, especially in contexts as continuous and dynamic as those in healthcare. Change can occur for many reasons and may be due to quality improvement, problem-solving, changing needs, compliance with regulatory or accreditation standards, implementation of EBP, risk mitigation, a noted concern, or technological advancement. Leaders from all aspects of healthcare are faced with the challenges of change, such as implementing a new curriculum in an educational setting or initiating a new staffing model as a nurse executive (Whitehead et al., 2017).

Change management theories and models can provide a foundation to facilitate change. Typical models used in health care are Lewin's Theory of Planned Change or the Plan-Do-Study-Act (PDSA) model. Lewin's model has 3 phases: unfreezing, moving, and refreezing. The unfreezing phase is preparing for the change. Moving involves applying the change, and refreezing is the process of regaining stability as the changes are accepted and become the new norm (Whitehead et al., 2017). In the PDSA model, the planning stage is like the unfreezing step, followed by doing the change, which corresponds with Lewin's moving step. After the change is initiated, the information or outcome is studied to determine its effectiveness and establish any necessary modifications, followed by acting on what has been learned. This model is designed to be repeated in a continuous loop (Yoder-Wise, 2019).

Theories serve as foundational steps to keep leaders on track when implementing change or projects. Undoubtedly, the most significant barriers to change involve those being led. As quoted by John Maxwell in Developing the Leader in You 2.0, "he who thinketh he leadeth and hath no one following him is only taking a walk" (pg. 3). Leaders will encounter pessimists, optimists, and those in the middle when experiencing a change. Finding the cheerleaders or optimists will aid the leader in driving change and maintaining morale. While they may not change the pessimists' minds, a strong leader can communicate the positive aspects of change and convince them to follow (Maxwell, 2018).

Leaders must face change within complex systems and may drive change from the micro-, meso-, and macro-levels. A higher education microsystem represents a department within an organization, such as a college of nursing within a more prominent college or university. The clinical microsystem represents a unit where patient care delivery or direct services are provided in a clinical setting. A mesosystem represents the next level of an organization, such as a hospital or another community-based organization. A mesosystem is led by a nurse leader, such as a CNO of a single hospital and directors. A macrosystem is the highest level and represents an entire organization or community, like government entities, professional organizations, or regulatory agencies. This type of leader includes Vice Presidents of Nursing, Chief Executive Officers (CEOs), or other corporate or organizational leadership roles. In addition to these levels, each nurse leader must consider stakeholders, which can deliver support or resistance to change. Stakeholders are vital throughout the change process. Nurse leaders will interface with stakeholders within the micro-, meso-, and macro-system levels. Leaders should consider the impact on each of these levels with any change and proactively offset any issues that may be anticipated. CNOs and leaders at the meso- and macro-system levels manage the organization's higher-level needs, including compliance with accreditation requirements rather than staffing, unit budget concerns, or patient numbers on a given day (Yoder-Wise, 2019).

Changes should not occur for the sake of change; instead, they should be directed at impacting a particular system based on evidence and best practices. A nurse leader should differentiate current policies, procedures, standards of care, best practices, and regulatory guidelines that may support the change initiative from those that may hinder the process. Any change process should consider human, material, and financial resources, including the support needed at each level and any barriers encountered (Whitehead et al., 2017).

Finally, nurse leaders must practice self-care, build a strong team culture, and work to deliver ethical and quality care. Additionally, nurse leaders must develop a professional identity and an individual performance improvement plan to enhance leadership skills and self-improvement. The Future of Nursing (IOM, 2011) noted eight specific recommendations that ensure excellence in the profession of nursing. These recommendations include a call for nurses to pursue professional development and advanced education to practice at their fullest potential and scope of practice, partner with other healthcare leaders, and lead healthcare while simultaneously developing the nursing workforce. Engaging in self-reflection, intentionally planning for professional development, and seeking opportunities for personal growth are critical for professional identity development among all nurse leaders (IOM, 2011).

 

Leadership Training Opportunities

The AONL (2022a) offers a specialty certification that recognizes the excellence and expertise of a nurse executive. A review course is available with a focus on the AONL nurse executive competencies and their practical application. The AONL also offers membership and annual educational conferences, allowing nurse executives to share best practices, remain current within the field, and network with their peers. Additionally, an Emerging Nurse Leader Institute training offered by the AONL (2022a) has participants engage in a 2-day interactive program to develop their leadership competencies to improve their effectiveness.

The National League for Nursing (NLN, 2022) Leadership Institute is another program for emerging nurse leaders in clinical practice or education who have recently transitioned into leadership positions. This program focuses on developing excellence in leadership. Additionally, the NLN has an advanced version for nurse executive leaders in education or clinical practice who have held their positions for at least 6 years and desire to reshape their practice and how they think about leadership. Both programs incorporate a transformational leadership style (NLN, 2022). 

The ANA has an online, self-paced leadership course in addition to a Nurse Executive Certification, the NE-BC. This certification is obtained through a competency-based examination. It verifies that an individual holds expertise in managing the daily operations of a clinical unit or service area within a healthcare organization (ANA, n.d.-b).

Many opportunities exist for ongoing education and support for nurse executives and nurse leaders. Nurses must stay engaged and network with peers. A nurse leader can also participate in training other leaders, helping to build future leaders through mentoring and succession planning to ensure the ongoing success of an organization (Rosenthal et al., 2018).

References

Agency for Healthcare Research and Quality. (2021). Team STEPPS for office-based care. https://www.ahrq.gov/teamstepps/officebasedcare/index.html

American Association of Colleges of Nursing. (2011). The essentials of master's education in nursing. http://www.aacnnursing.org/portals/42/publications/mastersessentials11.pdf

American Association of Colleges of Nursing. (2022a). AACN leads effort to prepare new nurses with stronger skills in leadership, resilience, and well-being. https://www.aacnnursing.org/News-Information/Press-Releases/View/ArticleId/25176

American Association of Colleges of Nursing. (2022b). Vision and mission. https://www.aacnnursing.org/About-AACN/AACN-Governance/Vision-and-Mission

American Nurses Association. (n.d.-a). Healthy work environment. Retrieved September 27, 2022, from http://www.nursingworld.org/workenvironment

American Nurses Association. (n.d.-b). Nurse executive certification (NE-BC). Retrieved on September 27, 2022, from https://www.nursingworld.org/our-certifications/nurse-executive

American Organization for Nursing Leadership. (2015). Nurse executive competencies. https://www.aonl.org/system/files/media/file/2019/06/nec.pdf

American Organization for Nursing Leadership. (2022a). Emerging nurse leader institute. https://www.aonl.org/education/enli

American Organization for Nursing Leadership. (2022b). Nurse leader competencies. https://www.aonl.org/resources/nurse-leader-competencies

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