Compare two leadership theories.

Theories and Concepts in Leadership and ManagementBy Stacey Whitney

Essential Questions

· What qualities should a good leader have?

· Who are leaders in health care?

· What is the difference between a leader and a manager?

· What types of leadership styles are observed in the workplace?

Introduction

Nurse leaders are at the forefront of health care and set the standards for nursing practice in terms of delivering safe and efficient patient care. This chapter will review the need for both nursing leadership and nursing management and examine a broad range of theoretical viewpoints and concepts associated with each. Applying the skills necessary for leading and managing staff will be discussed. The process of becoming an effective leader-manager includes developing personal leadership and management preferences, styles, and characteristics. The integration of both leadership and management skills is vital to the long-term success of all health care organizations.

Leadership in Health Care 

The Health Care System

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Nurses have been challenged over time to adapt to the ever-changing health care system. Because of recent events, such as health care reform, decreased government funding, and a growing number of patients to serve, the need for quality patient care that is safe and effective has never been greater. Strong nurse leaders and managers are needed to meet challenges today, throughout the next decade, and beyond. As the nation continues to adjust to health care changes under the Affordable Care Act, nurse leaders must advocate for their patients and influence change in the health care system (Fackler, Chambers, & Bourbonniere, 2015).

The American Organization of Nurse Executives (AONE) has identified the knowledge, skills, and abilities that nurse leaders will need to guide their practice within the health care system today and in the future. Collectively, these competencies include professionalism, communication, relationship management, knowledge of the health care environment, and business skills and principles (American Organization of Nurse Executives [AONE], 2015). Furthermore, AONE outlines knowledge and skills required to meet each competency effectively (see Table 1.1).

Figure 1.1 

Nursing Leadership Competencies

Note. Adapted from AONE Nurse Executive Competencies, by the American Organization of Nurse Executives, 2015, p. 3.

Table 1.1 

Leadership Competencies Identified by American Organization of Nurse Executives

Communication and Relationship Management	Professionalism	Knowledge of Health Care Environment	Business Skills and Principles
Effective Communication	Personal and Professional Accountability	Clinical Practice Knowledge	Financial Management
Relationship Management	Career Planning	Delivery Models – Work Design	Human Resource Management
Influencing Behaviors	Ethics	Health Care Economics and Policy	Strategic Management
Diversity	Advocacy	Governance	Information Management and Technology
Community Involvement		Evidence-Based Practice/Outcome Measurement and Research
Medical/Staff Relationships		Patient Safety
Academic Relationships		Performance Improvements/Metrics
		Risk Management

Note. Adapted from AONE Nurse Executive Competencies, by the American Organization of Nurse Executives, 2015, pp. 4-11.

Leadership skills can be studied and learned in courses and seminars, but experience is vital for grasping the fundamentals of excellence in leadership. It is best to learn leadership skills early in one’s career, and then refine and practice those skills over time. Jayson DeMers (2015) identified basic lessons that should be learned early in the profession. When the lessons are applied over time in professional practice, an exceptional nurse leader can emerge:

1. Finding the right people is the ultimate priority.

2. Mutual trust is essential.

3. Adversity is a reality of leadership.

4. Ideas must be grounded in pragmatism.

5. No one has ever learned enough. (DeMers, 2015)

Contemporary Health Care Environments 

Contemporary health care environments are influenced by economic, political, and societal changes occurring in today’s world. As these factors and others impact the health care system, nurse leaders should be ready to guide the process with a clear understanding of the health care environment. “As we look ahead into the next century, leaders will be those who empower others.” — Bill Gates This is an ideal opportunity for the nurse leader, who is considered an expert in the health care field, to influence patient satisfaction and improve quality of care. Knowledge of clinical practice should include an understanding of current nursing practice and roles of health care team members. Compliance with the state Nurse Practice Act, state board of nursing, state and federal regulatory agency standards, federal labor standards, and organizational policies is required. The nurse leader should also follow professional association standards of nursing practice. It is best practice to review and update organizational clinical policies and procedures according to evidence-based practice. Bioethical and legal considerations should be included in clinical and management decision making as well. This includes protection of human subject rights and safety in clinical research and study (AONE, 2015).

Health care environment delivery models should demonstrate current knowledge of the patient-care delivery system. The nurse leader should have knowledge of the advantages and disadvantages of various health care delivery systems and the effectiveness of age appropriate patient care models. A nurse leader with this knowledge base should be willing to participate in developing and designing new patient care facilities.

It is vital that the nurse leader understand organizational finance, specifically regulations and payment issues, including the organization’s payer mix. When opportunities to adjust operations arise, the nurse leader should be equipped to respond effectively considering knowledge of federal and state laws and regulations related to patient care. Examples include reimbursement, tort reform, malpractice, and negligence.

Nurse leaders have the power to influence the political process and can make a positive impact by developing relationships with legislators. The nurse leader should be an active participant in the legislative process concerning health care issues and work with others in the profession toward common goals. By utilizing membership in professional nursing organizations, such as the American Nurses Association (ANA) or National League for Nursing (NLN), nurses can collectively have a voice and be recognized by legislators. The individual nurse can become involved as well, simply by writing letters to legislators regarding important issues, and by staying current on pending legislation that directly or indirectly relates to nursing. These issues could be important, as they could affect licensure, practice, and health care in general. Current legislation can be viewed on the U.S. Congress website (www.congress.gov) by using the search term “nurse” (Cardillo, 2016). An explanation of pending legislation should be shared with the health care team so members are well educated regarding how the health care environment might be impacted by proposed legislation (AONE, 2015).

The nurse leader should understand the credentialing and fiduciary responsibilities of the organization’s governing body or board. It may be necessary to represent patient care issues, participate in strategic planning, or represent nursing or other disciplines at board meetings. The nurse leader should be well educated on organizational structure and design when the opportunity presents itself to discuss the value of nursing care for the organization. For example, a nurse leader may present to the board requesting additional resources, such as staff or supplies, and would need to know the organization’s payer base to determine where possible funds may be available.

When decision making as a nurse leader, the use of evidence-based data is necessary for creating standards, protocols, policies, and patient care models within the organization. Supporting the organization’s safety program by monitoring clinical activities, for example, can help to identify risk factors and potential liabilities. The nurse leadership role can be vital in creating teams to improve systems and processes that effect patient safety (AONE, 2015; Marquis & Huston, 2017).

Service and Levels of Care 

The purpose of various nursing care delivery systems is to organize ways of providing a service to a select group of patients. Models of patient care vary to meet the needs of patients and nurses. Traditionally, models of care have included  total patient care ,  team nursing , and  primary nursing . One model is not superior to another, and all offer advantages and disadvantages to patient care.

Total patient care is an original model in which a registered nurse (RN) is responsible for all aspects of care or service to the patient. This is the oldest form of organized patient care still used in hospitals and home health agencies today (Marquis & Huston, 2017). Advantages include autonomy for the RN and holistic, unfragmented care for the patient. A disadvantage to this model is that it is not cost-effective for RNs to be performing tasks that could be performed by unlicensed assistive personnel (UAPs).

Team nursing, as the name implies, consists of a team of nursing staff that provides total patient care for a group of patients under the direction of a professional nurse. The team typically consists of RNs, licensed practical nurses (LPNs), and UAPs. To ensure duplication of services does not occur, strong communication skills are required for this model to be effective. As an advantage, team nursing allows the nurse leader to recognize the expertise and skills of individual team members and assign responsibilities to them to best utilize the skills of each. Disadvantages include potential confusion of roles and responsibilities resulting in fragmented care and possibly errors.

In primary nursing, the value of the role of the RN in professional practice is not simply as a performer of task-based sets of skills, but implemented so that all care is provided by RNs. In other words, primary nursing requires an all-RN staff. Because of the high cost of implementing this model, it is not operational in many hospitals today (Sullivan, 2012). This form of nursing typically produces high job satisfaction for RNs because they receive a feeling of satisfaction and reward. A disadvantage to this type of care can be seen if the RN providing care is inexperienced or incompetent and does not properly care for the patient with complex medical needs.

Other models of patient care include  practice partnership ,  case management , and  critical pathways . These models combine different modalities of care to meet patient care needs. The practice partnership was designed in 1989 by Marie Manthey (Sullivan, 2012). In this model, an RN joins forces with an LPN or UAP to practice as partners with the same schedules and groups of patients. Advantages of this model include efficiency of skill mix and varied levels of expertise (Sullivan, 2012). A disadvantage to the practice partnership would occur if the partners were not compatible or were not able to agree upon plans of care for patients.

 

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