This paper examines how leadership theory can be applied to key nursing practice issues facing staff nurses in the contemporary healthcare environment. Drawing on four frameworks — situational leadership, path-goal theory, role theory, and transformational leadership theory — the paper demonstrates how nurse leaders can address problems including inadequate nurse staffing, the authority gradient, and changing models of care. The analysis argues that effective leadership not only improves patient outcomes but also sustains staff morale, job satisfaction, and nurses' sense of meaning in their work. Practical strategies are outlined for each leadership theory as applied to each practice issue.
The modern-day staff nurse faces a variety of challenges in the work environment. These include inadequate staffing, the authority gradient, and issues related to changing models of care. The nurse leader has a duty to aid staff nurses in addressing the challenges posed by these and other issues facing the nursing profession. Leadership theories provide effective guidelines by which nurse leaders can address issues inherent in the nursing profession. In so doing, they accord staff nurses adequate opportunities to make meaning out of their lives.
Leadership theories such as situational leadership theory, transformational leadership theory, role theory, and path-goal theory offer crucial insights from which nurse leaders can draw when seeking solutions to problems facing subordinate staff nurses. This paper explores how leadership theory can be applied to nursing practice issues, and the implications of such application on the work attitudes and morale of staff nurses.
Nurse leaders empower themselves and others to aid in the realization of organizational goals. They are in key positions to participate in decision-making that affects client care. Effective leaders use leadership theories and principles to guide their decisions, actions, and visions. These theories provide a framework for defining nursing practice, supporting the quality of client care, and providing solutions to nursing practice issues. Theory can be used to address nursing practice issues in research and education, in direct patient care situations, as well as in the management and administration of nursing care services.
Nursing staff will often thrive when they perceive strong and effective leadership from their nurse leaders, managers, and supervisors. The leadership style and overall morale set by the nursing leader has a direct correlation with the outcomes and attitudes of their staff. Leadership theories are varied; however, some theories resonate better with a given team than others. William Harman, a futurist, states that there is no need as compelling as that felt for one's life to have some meaning (Souba, 2006). People tend to give their best when accorded opportunities to give meaning to their lives (Souba, 2006). As a leader, the best one can do to get the most out of their team is to provide opportunities for staff to acquire meaning from their work. Four theories stand out as particularly effective in allowing a leader to accomplish this: situational leadership theory, path-goal theory, role theory, and transformational leadership theory.
This theory was advanced by Paul Hersey and Ken Blanchard in the 1970s and early 1980s (Barker, 1992). It draws its views from contingency thinking, asserting that no single leadership style can be identified as the best — different leadership styles work best in different situations (Barker, 1992). The theory suggests that tasks differ, and each type of task requires a different style of leadership. As such, a good leader is one who is able to adapt their leadership style to the objectives and goals to be achieved. The theory emphasizes follower maturity: a leader ought to choose the most appropriate style of leadership based on their followers' experience and level of maturity (Barker, 1992). The highest level of maturity exists when followers are ready, willing, and able to do the task. The most appropriate leadership approach in this case is delegation. However, when followers are less experienced or mature, the telling, selling, and participative approaches to leadership may be more effective (Barker, 1992).
The path-goal theory was introduced by Martin Evans in 1970 and further developed by House in 1971 (Barker, 1992). It is based on selecting specific leader behaviors that effectively guide followers along the path toward the accomplishment of their daily work goals (Barker, 1992). In this theory, a leader identifies the goals to be achieved, eliminates the roadblocks preventing followers from achieving them, and increases favorable elements such as rewards to support followers in goal achievement (Barker, 1992). This helps to ensure that followers have the best opportunities to make meaning out of their lives (Barker, 1992).
Role theory is based on the assumption that human behavior is influenced by expectations held by the individual and by other people. Role theory in the context of organizational leadership relates to how a leader defines their own roles and those of others, how people act within their specific roles, and how people expect others to act in their roles (Early, 2005). The theory draws on social role theory, suggesting that leaders define their roles as well as those of their followers through reading and social learning (Early, 2005). Leaders then form expectations about the roles that everyone — including themselves — will play, and encourage their followers to act within those role expectations (Early, 2005). At the same time, the leader strives to act within their own role expectations.
In an organizational setting, leaders and followers both have designated roles. Social theory suggests that leaders hold role expectations about their followers, just as followers hold expectations about their leaders. Followers consciously or unconsciously communicate these expectations to their leaders — for instance, forwarding a customer escalation to the leader for guidance even when the employee already knows the appropriate course of action. By balancing which decisions to take upon themselves and which to pass to the leader, employees signal their expectations. The leader is in turn influenced by these expectations, fulfilling the leadership role placed upon them and striving to improve through leadership values training and mentoring from senior leaders. The organization is able to function effectively because both the leader and the followers understand their roles and role expectations and strive to operate within them.
The transformational leadership theory was introduced by McGregor Burns. Transformational leadership is a process in which followers and leaders raise each other to higher levels of motivation and morality (Barker, 1992). The theory suggests that leaders should not focus solely on managing managerial challenges; they should also strive to change the nursing environment through a transformational process (Barker, 1992). The theory is based on two core assumptions:
(i) People will often follow a leader who motivates and inspires them.
(ii) The best way to get things done is by injecting energy and enthusiasm into the effort.
Nurse leaders can transform the work environment for their followers by:
(i) Establishing the organization as a learning organization
(ii) Involving staff in the decision-making process
(iii) Managing the change process
(iv) Building and sustaining trust throughout the organization
(v) Balancing the tension between efficiency and production
Decreasing the number of staff nurses is often seen as the most logical way of combating rising healthcare costs (McHugh, 2010). Failure to ensure sufficient numbers of staff nurses results in overwork, compassion fatigue, burnout, and injuries, all of which affect the quality of care delivered to patients. Studies have shown a negative correlation between high nurse-to-patient ratios and the quality of patient care (Stanton, 2011). A study by the Agency for Healthcare Research, for instance, found that hospitals with low nurse staffing levels had higher rates of poor patient outcomes, including urinary tract infections, cardiac arrest, shock, and pneumonia (Stanton, 2011). Studies project that the nurse staffing problem could worsen in coming years — the demand for nursing care is expected to grow by around 40% by 2020, whereas the number of nurses is expected to grow by only 6% (Stanton, 2011).
Low nurse staffing has been associated with low morale and job dissatisfaction, both of which compromise the quality of care delivered to patients (Stanton, 2011). Effective nurse leadership can, however, be used to minimize this risk and provide the right support to nurses in the face of current staffing challenges. While individual nurse leaders may do little to influence the number of staff nurses entering the profession, they can influence the attitudes, morale, and performance of the nurses available in order to ensure that patient outcomes are not compromised.
The transformational leadership theory suggests that leaders focus on getting things done through motivation and inspiration rather than commands and instructions. When Nelson Mandela was released from prison, he made a remarkable remark concerning one of Robben Island's cruelest commanding officers — that the man's nature had another facet that, though obscured, still existed. This observation serves as a reminder that every person has a decent core; even the most hardened individual can transform if properly reached, because no one is ultimately without the capacity for good. A person only reflects inhumanity because it has been imposed upon them by a merciless system.
Similarly, staff nurses may display a lack of compassion and low work morale because of the difficulties imposed upon them by a system they have no control over. However, they too can transform with the right leadership. A leader can use the four components of transformational leadership to bring about this transformation in attitudes and to help nursing staff maintain high work standards and high levels of job satisfaction despite the staffing problem. These components are:
(i) Intellectual stimulation — The leader gives followers independence to carry out their roles as a way of minimizing systemic oppression. He provides room and freedom to innovate and develop to their full potential, and offers training opportunities so that staff can realize their maximum capacity despite the difficulties.
(ii) Individualized consideration — The leader offers support and encouragement to followers as a way of making them more able to deal with inherent workplace challenges. He keeps lines of communication open so that followers are able to share ideas, perspectives, problems, and concerns, and are consequently able to handle workplace challenges through constructive dialogue.
(iii) Inspirational motivation — The leader develops a clear vision with well-stated objectives and exhibits passion for the work and for patients' welfare, despite facing his own challenges. Followers are able to emulate this passion and use it as motivation to achieve their own goals and meet the expectations of both themselves and their patients.
(iv) Idealized influence — Through passion and commitment to client satisfaction, the leader serves as a positive role model. Followers are able to trust and emulate him, internalizing his ideals so that they too become a positive influence to others below them and to new entrants into the profession.
By applying the precepts of transformational leadership theory, the leader is able to transform followers' attitudes and get the most out of them even within a strenuous system.
"Role and path-goal theories address power imbalances"
"Situational leadership guides adaptation to new care models"
Nurse leaders have a crucial role to play in ensuring that staff nurses are presented with adequate opportunities to make meaning from their lives. When this does not occur, nurse morale and job satisfaction are likely to dwindle, compromising the well-being of patients. One key way through which leaders can help their followers make meaning from their work is by providing effective leadership and drawing on the precepts of leadership theories to address the issues facing staff nurses in the contemporary organization. Situational leadership, path-goal theory, role theory, and transformational leadership each offer practical tools for tackling inadequate staffing, the authority gradient, and changing models of care — ultimately benefiting both nursing staff and the patients they serve.
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