Nursing Leadership: Two Paradigms
In its earliest incarnation as a profession, nurses were often conceptualized as attendants and helpers to physicians and patients, not as leaders. However, nurses over the years have attempted to eke out a unique sphere for themselves within the healthcare profession in the manner in which they integrate a patient's physical, social, psychological, and environmental needs. Today nurses are increasingly called forth to take on leadership positions within organizations, often as a result of cost-cutting efforts that shift responsibilities to nurse leaders that were once relegated to doctors and administrators.
The current available leadership models offered to nurses and to the leaders of healthcare organizations are numerous, and often draw from the literature of the business world as well as healthcare. "Now more than ever nursing needs vibrant and dedicated leaders…Leadership does not rest merely with administrators and high-level managers, but also can be developed and implemented at the bedside" (Valentine 2002). Nursing leadership must take place on every level of administering care -- nurses must fulfill new leadership positions, particularly when mentoring new nurses and other healthcare leaders must be more responsive to the needs of nurses.
Review of existing literature
One of the most radical, paradigm-shifting models of leadership is that of a learning organization, a participatory model which suggests parity between all members of an organization at every level in terms of how they can make a contribution. Rather than conceptualize leadership as a top-down model, leadership is seen as a dialogue. All members of the organization make a contribution with the information and ideas they offer. Learning organizations are defined as providing "continuous learning opportunities; use learning to reach their goals; link individual performance with organizational performance; foster inquiry and dialogue, making it safe for people to share openly and take risks; embrace creative tension as a source of energy" and respond to the environment (Smith 2001). A good example of this occurs when new nurses are mentored by other nurses. In the stressful environment of healthcare, there is some evidence in the literature that nurses have a tendency to 'eat their young' or to be hostile or nasty to new nurses. Experienced nurses must ask themselves: "Were you supportive? Did you encourage that person to gain and develop new skills and offer learning experiences to help the person grow as a nurse? Or did you create an environment that was infected with horizontal violence" to counteract this tendency (Roy 2007). Learning organizations both learn from and respect employees and encourage employees to respect and teach one another.
Mentorship programs specifically designed to foster ties between old and new nurses has the potential to reduce horizontal violence. Additionally, learning organization supports the desire of current nurses to add to their credentials and to expand their knowledge. In a constantly-changing healthcare environment, where new technology is always being incorporated into systems and processes, this is essential. In "today's changing environment that very rapid changes are seen in different areas of science and technology and the increasing complexity and dynamics of environmental factors, the only organizations that can survive and remain capable of growth are those with active adaptation (dynamic equilibrium). [A] learning organization is an organization where people constantly increase their capabilities. The new patterns of thinking develop and staffs learn how to learn together" (Yaghoubi et al. 2010). Rather...
When nurses are stressed and overscheduled and management does not listen to the unique concerns of nurses, patient care is inevitably compromised. The conception of a learning organization suggests that nurses in the field can provide invaluable sources of information about patient needs and why care deficits are occurring For example, organizational metrics might show high rates of patients with diabetes -- nurses may have insight as to why this is the case, such as patient culture and economic influences upon the eating and exercise habits, a lack patient literacy, or language barriers inhibiting communication. Nurses can offer insights as well as direct how to enact real changes that address the root of health-related issues.
Another theory of organizational leadership slightly different than that of a learning organization is that of situational leadership, or responding to the organization's needs on a situation-by-situation basis. Three commonly-designated types of leadership approaches, according to Lewin (1939) are that of an authoritative, participative, and delegative leadership style (Schein 2011). None of these styles are necessary superior, but rather must be suited to the needs of the situation in Lewin's analysis. For example, an authoritarian style might be appropriate when training a nervous new nurse, provided the leader is compassionate and competent in his or her mentorship. A participative style, however, is most appropriate when the employee is already competent and taking an authoritative style would seem patronizing and also not use the employee's knowledge to its maximum potential. A delegative or 'hands off' style should be used when the worker is more knowledgeable than the manager. In other words, managers should take this approach when nurses inform them of the procedures necessary to reduce medication errors and not 'tell' nurses what to do base upon financial data that is not contextualized by medical evidence and anecdotal observations from the field (Schein 2011). The notion of a learning organization, can be integrated into the situational leadership model, given that learning can take place in an authoritative, participatory, and delegative framework -- subordinates can learn from more experienced mentors, nurses can learn from one another, and individuals higher up on the organizational hierarchy can learn from subordinates.
Application of clinical example
To facilitate the creation of a learning organization and to reduce the 'nurses eating their young' phenomenon, many organizations have instituted formal mentorship programs. In such programs, older nurses can teach younger nurses, creating dialogue and learning between the two generations of nurses (Domrose 2002). As well as first-year neophytes, some programs also pair nurses currently within the organization with new hires returning from time off from the profession or nurses who have worked in other hospitals. This demonstrates an investment in new nurses which is at the heart of learning organizational theory.
Such programs have a certain authoritarian model in the sense that there is a clear leader and follower, but they are fundamentally grounded in learning organization principles because they invest considerable time and effort in the training of employees. New employees are also free to ask questions and to learn from others. They are given the tools to become independent workers, and are given the opportunities to challenge themselves and take on new tasks in a 'safe space' where they can receive guidance while trying out new things and adding to their skill set.
However, such mentorship programs would not have been instated without a different leadership type in operation. That leadership type is the democratic model, where the organizational leaders learn from subordinates. The informal mentorship of nurses that may have taken place in the past was no longer functioning, given the added demands that nurses were facing in addition to their duties and nurses needed to give feedback about their experiences as new and experienced nurses for the organization to be willing to enact real changes.
Healthcare organizations must be flexible and responsive to the changing environment. As more and more nurses will be retiring within the coming years, it is essential to prepare a new generation of nurses to the challenges they will face. Training and retention and creating a positive experience for new nurses can be facilitated through mentorship. Mentorship programs should be created based upon…
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