Monday, May 7, 2012


Transformational Leadership

Carrie Nowatzke, BSN, RN
 Michelle Leinen, BSN, RN
                                                                                  Rick Perez, BSN, RN


           Many problems exist today in the way nurses are managed.  There are many different types of leaders and leadership styles.  Motivating staff is becoming harder and harder.  Transformational leadership was first brought up in the 1970’s.  It continues to be at the forefront of nursing issues.  It is a type of leadership style that “draws on leaders’ moral values and exploits their ability to set examples and articulate goals to instigate positive change within social structures and individuals’ behaviors (Thompson, p. 21).  It is focused on the relationship between leaders and staff.  It is not a surprise that in today’s nursing world there are complex nursing styles and along with that are complex leadership styles. Transformational leadership is meant to help the staff to thrive and decrease or eliminate the negative attitudes in the workplace.  It is meant to create a motivating environment where staff members want to work and want to do an excellent job.  This type of leadership fosters creativity and new opportunities.  Healthcare is ever changing and in order for the changes to be successful, it is imperative that leaders find a necessity in transformational leadership.

Many times in the nursing world, there are leaders who are satisfied with the same results day after day.  In transformational leadership, leaders want change and they aren’t afraid to make it happen.  They can be the most radical type of leaders.

The population affected by this issue is the staff and also the leaders themselves.  Leaders are not born, they are made therefore, and they must be on board with this type of change as well.  However, the staff is affected most.  They are the ones who will benefit from this type of leader.  Desired outcomes for this issue are as follows: staffing changes that will benefit the nurses, higher employee engagement, and increased self-efficacy for the nurse and increased job satisfaction.  It is amazing that one manager can do all of these things!  When the staff is motivated by their leader, they in turn will make a positive change for their patients.  Therefore, the patients will also benefit from this type of leadership.  It is safe to say that transformational leadership will cause positive outcomes for the patient as well as the staff.

“Nurse Managers will feel more comfortable and confident by adopting the qualities of a transformational leader when engaging in the development of healthcare policies and the ever-changing components of healthcare technology” (Smith, 2011, p.44).  Transformational leaders feel they are able to make changes and see the benefit of these changes.  They also are able to motivate their staff to see the good in these changes and assist them in smooth transition.  They are able to overcome resistance.

Variables that affect transformational leadership are broad and complex themselves!  Variables such as demographics and culture can be difficult to change.  However, it was a belief of Burns that transformational leaders will be able to effectively create change in different cultures because they are essentially working for the good of the people.  There will always be staff that will not accept change either.  However, the transformational leader, if effective, should be able to motivate a high percentage of those.   Institutional policies may also be a variable that the transformational leader will have to tackle.  Motivation and inspiration are key elements in this type of leadership.

Access to health care does not necessarily apply to this topic.  If anything, transformational leaders will change the way healthcare is administered to everyone.  There is no prejudice in this type of healthcare.  These leaders want change for the better that will benefit everyone.  Transformational leaders may be able to change policies and budget, therefore making healthcare more accessible to everyone.

Today’s health care environment is experiencing unprecedented, intense reform and it is becoming increasingly more complex. Hospital and healthcare systems have become much more complex than in years past. Trends for transformational leadership include the need to focus on the promotion of innovation and change (Carroll, 2006). The American Nurses Credentialing Center (2008) stated, Nurses are faced with increasing demands and today’s leaders are required to transform their organization’s values, beliefs, and behaviors. It is somewhat easy to lead people where they want to go, but the transformational leader must lead people to where they need to be in order to meet the demands of the future. This requires vision, influence, clinical knowledge, and a strong expertise relating to professional nursing practice.



Transformational leadership encompasses skills, behaviors and characteristics that are critical for transformational leaders to have a positive impact on followers (Rosebach, Sashkin and Harburg, 1996). Specifically, transformational leaders convey the connection between the organization’s philosophy and shared values, and embedded in those values in organizational rules and actions in order to communicate meaning and inspire (Bennis & Nanus, 1985).  



For the organization that is able to successfully implement and sustain transformational leadership, there will be immediate return on their investment simply with the ability to retain employees. There is such focus on first year turn-over in hospitals and new employees want to feel empowered, they want to be paid for their expertise, but what will initially attract people to the nursing profession is the chance to make a difference in people’s lives.  Effective leadership on individual nursing units directly affects nursing staff satisfaction. Employees are interested 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 is 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 effective 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 transformational leadership qualities; this will directly result in staff satisfaction, staff retention, and patient satisfaction (Robbins & Davidhizar, 2007). This will directly affect the bottom line of any organization.

In comparison to other aspects of leaders or leadership, relatively little discussion is devoted to the ethical responsibilities of those who lead or to the ethical aspects of the process of leadership, which makes it important to discuss possible ethical issues of leadership. First, professions have a duty to maintain and protect public trust. Society empowers professions such as nursing to meet its specialized needs. Such empowerment creates a moral bond between the professions and the members of society it serves.  Health care institutions are powerful organizations that influence the quantity and quality of available health care services. Leaders who understand the ethical dimensions of making such decisions are important in shaping the structure of health care organizations.

Nurses are continuously faced with constant ethical issues and dilemmas in their practice and leaders will need to assist them in addressing the ethical dimensions of their practice (Cassidy & Koroll, 1994). An example of these ethical issues would be caring for the chronically ill, older adult populations, health care rationing and resource allocation. Because transformational leaders are in a unique situation to motivate, and empower staff, they must function as moral agents for the staff fulfilling their role as leader being responsible for and assisting staff when ethical issues arise.   Transformational leaders can be instrumental in helping define he ethical standards of the profession in a changing healthcare environment (Cassidy & Koroll, 1994).

Effective leadership styles among nurse managers have been associated with staff job satisfaction and retention. There is evidence that transformation leadership style is linked to employee psychological well-being.  Despite transformational leadership styles have been described as effective, it is still unclear which nurse leadership behaviors contribute most to nurse retention or well-being. Transformational leadership could provide a new optimism in a changing health care environment. Through partnering efforts, sharing information and sharing power, the transformational leadership can increase staff satisfaction, alleviate the burden of staff shortages and resource constraints while creating work environments that benefit nurses and ultimately patients.

 Bass’s Transformational Leadership Theory

Bass (1985), defined transformational leadership in terms of how the leader affects followers, who are intended to trust, admire and respect the transformational leader.

He identified three ways in which leaders transform followers:

·       Increasing their awareness of task importance and value.

·       Getting them to focus first on team or organizational goals, rather than their own interests.

·       Activating their higher-order needs.

Bass noted that authentic transformational leadership is grounded in moral foundations that are based on four components:

·       Idealized influence

·       Inspirational motivation

·       Intellectual stimulation

·       Individualized consideration

...and three moral aspects:

·       The moral character of the leader.

·       The ethical values embedded in the leader’s vision, articulation, and program (which followers either embrace or reject).

·       The morality of the processes of social ethical choice and action that leaders and followers engage in and collectively pursue.




Model of Transformational Leadership



                                                                          (“Transformational”, 2008)



Bass saw these aspects of transformational leadership:

  1. Individual consideration, where there is an emphasis on what a group member needs. The leader acts as a role model, mentor, facilitator, or teacher to bring a follower into the group and be motivated to do tasks.
  2. Intellectual stimulation is provided by a leader in terms of challenge to the prevailing order, task, and individual. S/he seeks ideas from the group and encourages them to contribute. Learn, and be independent. The leader often becomes a teacher.
  3. Inspirational motivation by a leader means giving meaning to the follows of a task. This usually involves providing a vision or goal. The group is given a reason or purpose to do a task or even be in the organization. The leader will resort to charismatic approaches in exhorting the group to go forward.
  4. Idealized influenced refers to the leader becoming a full-fledged role model, acting out and displaying ideal traits of honesty, trust, enthusiasm, pride, and so forth.

Transformation is synonymous with change and we are concerned with how people participate in change.  A Transformational Leader can have a great effect on people’s casual effort to change but how can we encourage people to change from within? 

Barrett Power as Knowing Participation in Change Theory



© 2009 Dr. Elizabeth Ann Manhart Barrett. All rights reserved.


          Barrett’s Theory describes power as the capacity to participate knowingly in the nature of change.  There are four dimensions of power: 1. Awareness 2. Choices 3. Freedom to act intentionally 4. Involvement in creating change.  This mid-range theory is based on Martha E. Roger’s axiom that humans can participate knowingly in change. According to Rogers' Science of Unitary Human Beings, humans cannot participate in change unless their participation is of a knowing nature (Barrett, 2009).

To make change a reality, Barrett suggests people must knowingly participate in creating their experience by being aware of what one is choosing to do, making choices based on that awareness, feeling free to act, and acting intentionally to create change.

Barrett describes power-as-freedom not power-as-control.  She describes power-as-freedom where change is innovative, creative, and unpredictable. 

By applying Barrett’s theory, a transformational leader can promote change and encourage adoption of evidence-based practice in individual staff, units, and hospital systems.

Analysis of Barrett’s Theory

Clarity/ Simplicity

Concepts in Barrett’s theory are given simple operational and theoretical definitions to describe how they are being used. Concepts in the theory are related to each other, are clearly stated, and a simple diagram is used to illustrate relationships between the concepts. Since there are only four dimensions, there are not too many interacting factors to confuse the concept.

Generality

Barrett’s power theory and/or the Power as Knowing Participation in Change Tool (PKPCT) has been validated cross culturally via its use in the United States, Germany, Korea and Brazil. It has been used in the homeless, cardiac rehab, breast cancer survivors, and critical care nurses. The theory is not limiting, it can be applied to numerous aspects of nursing and to diverse patient populations.

Empirical Precision

Barrett’s power theory and/or the PKPCT have been used as conceptual, theoretical, and empirical structure for research in more than 50 (qualitative and quantitative) studies (Kim, 2009).  Concepts are operationally defined and the use of the PKPCT helps measure the four dimensions of power.  It generates theoretical hypotheses and adds to the body of nursing knowledge.

Barbara W. Wright RN PhD FAAN (2010) cites, “In over 20 years of serving in elected office … and member of the legislature, I expressed my power as I participated knowingly in the process of change. The lens through which I participated was influenced by the science of unitary human beings, and more specifically by my research on trust and power.”  Barrett’s influence on Wright’s practice demonstrates and supports the theory’s empirical precision and its ability to affect change even in the political arena.

Derivable Consequences

The theory has implications for education, practice, and administration. Barrett’s theory can be readily adopted by transformational leaders. It has been shown in practice among critical care nurses to help create a nurse-to-nurse caring environment.  France, Byers, Kearney, & Myatt, (2011) indicate that to create environments for healing, administrators must be open to empowering the registered nurse (RN) and encourage RNs to be accountable and responsible to design quality nursing care.

Findings in this study include, trust, respect and empowerment/power are essential structures to create a healing environment for nurses, patients, families, and healthcare team members. The RNs who participated in this study made choices, which influenced and transformed their environment.  Implications from this study address the need for nurse educators to create positive nurse-to-nurse relationships. The study indicates that education on empowerment and nurse-to-nurse caring is imperative to break the cycle of nurses eating their young (France, Byers, Kearney, & Myatt, 2011).


                                     Evaluation of Outcomes in Relation to Theory

Transformational leaders can make staff aware of issues, ask for input and allow staff to make choices regarding solutions for managing issues, allow staff freedom to act, and encourage staff to be actively involved in creating change.  Just by applying, the simple principles of transformational leadership and Barrett’s Power theory leaders may see increased employee engagement, increased nurse self-efficacy, increased job satisfaction, and quality patient outcomes.  In a sense, a leader can empower and transform an individual, a unit, or whole hospital system to meet the complex needs of staff and patients in today’s ever changing healthcare system.



                                                                               References



Barrett, E.M. (2009). Summary of the Barrett Power as Knowing Participation in Change Theory. Retrieved from http://www.drelizabethbarrett.com/background/power-knowing-participation-change-theory

              Bennis, W., & Nanus, B. (1985). Leaders: The strategies for taking charge. New York: Harper & Row.

Carroll, P. L. (2006). Nursing Leadership and management: A practical guide. New York, NY: Thomson Delmar Learning.

Cassidy, V. R., & Koroll, C. J. (1994). Ethical aspects of transformational leadership. Nurse Management, 9(1), 41-47.

Farren, A. T. (2010). Power in breast cancer survivors: A secondary analysis. Visions: The Journal of Rogerian Nursing Science, 17(1), 29-43. doi:10.1177/0894318404263303

France, N., Byers, D., Kearney, B., & Myatt, S. (2011). Creating a healing environment: nurse-to-nurse caring in the critical care unit. International Journal for Human Caring, 15(1), 44-48.

              Kim, T.S. (2009). The theory of power as knowing participation in change: A literature review       update.        Visions: The Journal of Rogerian Nursing Science, 16(1), 19-39. Retrieved from     http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=2010713200&site=nrc-live

Robbins, B., & Davidhizar, R. (2007). Transformational Leadership in Healthcare Today. Health Care Manager, 26(3), 234-239. doi: 10.1097/01.HCM.0000285014.e7

Rosenbach, W., Sashkin, M., & Harburg, F. (1996). The leadership profile. Seabrook, MD: Ducochon Press.

             Smith, M.K. (2011).  Are you a transformational leader?  Nursing Management, 42(9), 44-50.

             Thompson, J. (2012).  Transformational leadership can improve workflow      competencies. Nursing Management-UK, 18(10), 21-24.              



Trofino, J. (1995). Transformational Leadership in Healthcare. Nurse Management, 26(8), 42-47.

Wright, B. W. (2010). Power, Trust, and Science of Unitary Human Beings Influence Political Leadership: A Celebration of Barrett's Power Theory. Nursing Science Quarterly, 23(1), 60-62. doi: 10.1177/0894318409353794


1 comment:

  1. Leaders develop tight systems to monitor and evaluate all parts of the system to ensure that they are efficient and effective.
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