CE Article

AUTHENTIC LEADERS CREATING HEALTHY WORK ENVIRONMENTS FOR NURSING PRACTICE

By Maria R. Shirey, MS, MBA, RN, CNAA, BC. From Shirey & Associates and the College of Nursing and Health Professions, University of Southern Indiana, Evansville, Ind.

Implementation of authentic leadership can affect not only the nursing workforce and the profession but the healthcare delivery system and society as a whole. Creating a healthy work environment for nursing practice is crucial to maintain an adequate nursing workforce; the stressful nature of the profession often leads to burnout, disability, and high absenteeism and ultimately contributes to the escalating shortage of nurses. Leaders play a pivotal role in retention of nurses by shaping the healthcare practice environment to produce quality outcomes for staff nurses and patients. Few guidelines are available, however, for creating and sustaining the critical elements of a healthy work environment. In 2005, the American Association of Critical-Care Nurses released a landmark publication specifying 6 standards (skilled communication, true collaboration, effective decision making, appropriate stafng, meaningful recognition, and authentic leadership) necessary to establish and sustain healthy work environments in healthcare. Authentic leadership was described as the glue needed to hold together a healthy work environment. Now, the roles and relationships of authentic leaders in the healthy work environment are claried as follows: An expanded denition of authentic leadership and its attributes (eg, genuineness, trustworthiness, reliability, compassion, and believability) is presented. Mechanisms by which authentic leaders can create healthy work environments for practice (eg, engaging employees in the work environment to promote positive behaviors) are described. A practical guide on how to become an authentic leader is advanced. A research agenda to advance the study of authentic leadership in nursing practice through collaboration between nursing and business is proposed. (American Journal of Critical Care. 2006;15:256-268)

CE

Notice to CE enrollees: A closed-book, multiple-choice examination following this article tests your understanding of the following objectives: 1. Discuss the current literature related to creating healthy work environments. 2. Discuss current literature related to authentic leadership. 3. Identify key components of authentic leadership for further research.

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shortage of 400 000 registered nurses is expected by 2020.1 The healthcare work environment as a source of overwork and stress has been implicated in the shortage of nurses.2 Because stress-related illness contributes to rising healthcare costs and disability,3 creating a healthy work environment is a priority for maintaining an adequate nurse workforce. Nurse managers play an integral role in creating the healthcare work environment. Few specic guidelines, however, are available on how to create and sustain the critical elements of a healthy work environment. This void in specific leadership guidelines is alarming given research indicating that the greater the stress faced within complex organizations, the more important the soft side of leadership becomes.4
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In 2001, the American Association of CriticalCare Nurses (AACN) made a commitment to promote the creation of healthy work environments that are safe, healing, humane, and respectful for patients, patients families, and nurses.5 To this end, the AACN recently released a landmark publication specifying the standards necessary to establish and sustain healthy work environments in healthcare.5 Authentic leadership was identied as one of the 6 standards (skilled communication, true collaboration, effective decision making, appropriate stafng, meaningful recognition, and authentic leadership) crucial to creating and sustaining healthy work environments in nursing practice.5 The role of leaders is so pivotal that authentic leadership, not just any leadership, has been identified as the glue that holds together a healthy work environment.6(p2) In fact, so important is leadership in establishing the principles and elements of a healthy work environment for practice7 that a coalition of 60 nursing organizations known as the Nursing Organizations Alliance8 has supported a set of principles that each member organization has been asked to discuss and endorse. Among the 60 members of the alliance9 are AACN; the American Association of Colleges of Nursing; the American Organization of Nurse Executives; Sigma Theta Tau International, The Honor Society of Nursing; and the American Academy of Nursing. These organizations to some extent have incorporated the principles of healthy environments as part of their organizational strategic plans. For example, AACN has contributed with its document5 on standards for a healthy work environment, the American Association of Colleges of Nursing has issued a document 1 0 describing the hallmarks of the professional nursing practice environment, the American Organization of Nurse Executives has produced a 2-volume series11 of exemplars of the healthy work environment, Sigma Theta Tau International has actively engaged in a call to shape the future through renewal,12 and the American Academy of Nursing has through its members broadly contributed in the health policy arena. From a broader perspective, a call for transforming the work environment with leaders as key partners has also been echoed by other inuential organizations.2,13,14

ment to hold together a healthy work environment, the document does not provide an expanded denition for authentic leadership. Further, the document is not explicit about how individuals become authentic leaders. Expanding the discussion relative to the denition of authentic leadership and strategies to develop authentic leaders should help advance the work of AACN and assist in the implementation of the standards.

Purpose
This article has 4 purposes. First, an expanded denition of an authentic leader and the documented attributes of such a leader are presented. Second, the proposed mechanisms by which authentic leaders create a healthy work environment for practice are discussed. Third, a practical guide based on the current understanding of authentic leadership and providing explicit directions on how to become an authentic leader is advanced. Last, a research agenda to advance the study of authentic leadership in nursing practice is proposed. If authentic leadership is so crucial to holding together a healthy work environment, then the focus in advancing the merits of the AACN landmark document5 should be on engaging and developing authentic leaders to transform nursing practice. Thus, we must take the conceptual and theoretical frameworks of healthy work environments and authentic leadership and translate this knowledge into practice. This crucial action should help retain nurses in the profession and should also make a difference in the lives of patients, patients families, nurses, healthcare colleagues, organizations, and communities.

Review of the Literature

Healthy Work Environments: Search Strategy

Authentic leadership, not just any leadership, is the glue that holds together a healthy work environment.
Although the AACN document5 on a healthy work environment identies authentic leadership as a key elehttp://ajcc.aacnjournals.org

A review of the literature on healthy work environments was conducted. Sources that met the following 4 inclusion criteria were selected. First, sources published between 1990 and 2005 were identified by using the Ovid MEDLINE database. Second, only English-language sources were reviewed. Third, both anecdotal and empirical sources were included. Fourth, the sources had to answer at least 1 of the following 3 questions: 1. What is a healthy work environment? 2. How is a healthy work environment manifested? 3. How is a healthy work environment created and sustained? The review of the literature produced 16 articles.15-30
Healthy Work Environments: Findings

What Is a Healthy Work Environment? In the literature, the terms healthy work environment and healing work environment appear to be used as synonyms. The review established that the early notions of a healthy
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work environment date back to the days of Florence Nightingale.23 As is well documented in Nightingales Notes on Nursing,31 an environment conducive to healing is one in which patients have a sense of warmth and wellbeing. Nightingales original assumptions about healing environments appear consistent with the ndings of environmental psychology that colors, sounds, and external environmental stimuli are variables that affect therapeutic outcomes.32 Beyond the requirement to provide a healing and aesthetic physical work environment for patients is the more contemporary assumption that the healing environments must also extend to the nurses who care for patients. Ideally, healthy work environments should have the necessary infrastructures to create sanctuaries of healing that are benecial for all caregivers.33

Healthy work environments are

supportive of the whole human being, are patient-focused, and are joyful workplaces.

Figure 1 Healthy work environments and their interdependence with clinical excellence and optimal outcomes for patients as conceptualized by the American Association of Critical-Care Nurses.5

By definition, a healthy work environment is a work setting in which policies, procedures, and systems are designed so that employees are able to meet organizational objectives and achieve personal satisfaction in their work.18(p3),34(p741) The term healthy work environment with its humane elements appears to be used interchangeably to incorporate healing work environments,23 Magnet-designated nursing cultures,19,28 and joyful workplaces.30 The literature expands the nomenclature of the healthy work environment to include organizational classiers and philosophical approaches that have common characteristics of effective work environments.26 For example, organizational classiers associated with healthy and thus effective work environments include world-class organizations (eg, Baldridge organizations exemplifying best demonstrated practices), Magnet-designated hospitals, and facilities designated as Fortune magazines 100 best companies to work for in the United States. Philosophical approaches associated with healthy and effective work environments include learning organizations, healthy work environments supportive of the whole human being, joyful workplaces, and patient-focused environments.

A sense of family is commonly

reported in healthy work environments and cheer is evident within work teams.

How Is a Healthy Work Environment Manifested? Regardless of whether an organizational classier or a philosophical approach is used to describe the work environment, common characteristics of healthy work environments include 4 elements.22 First, in healthy and effective work environments, employees are treated in a respectful and fair manner. Similarly, concern and value for each person as an individual are apparent. Second, healthy and effective work environments exhibit a strong sense of trust between management and employees. These organizations engage and empower employees in decision making, risk taking, and personal and professional growth. Third, healthy and effective work environments have an organizational culture that supports communication and collaboration, views individuals as assets, and reduces decision making not solely to considerations of money, but also to consideration for the impact of decisions on the organizations mission and its members. Fourth, healthy and effective work environments have a feeling tone in which individuals are encouraged to feel physically and emotionally safe. A sense of family is commonly reported in healthy work environments, and cheer is evident within work teams and the organization as a whole. These 4 elements of a healthy work environment appear to be consistent with the AACN standards5 for establishing and sustaining healthy work environments that include skilled communication, true collaboration, effective decision making, appropriate stafng, meaningful recognition, and authentic leadership (Figure 1).
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According to Disch, 1 8 a common theme that describes the experience of a healthy work environment is the sense of team or community that is evident across disciplines in order to get the work of the organization done. Teamwork and partnerships underscore the importance of communication, trusting relationships, and collegial support 25 necessary to create healthy work environments. Organizations known for having supportive work environments (eg, Magnet-designated hospitals) clearly have more positive perceptions of the work environment,16 overall superior outcomes,35-39 and other attributes desirable in healthy work environments.22 Conversely, not only do unhealthy work environments pose a threat to healthcare organizations and to workers22 but also the conditions evident in unhealthy work environments threaten the quality of patients care and patients safety. How Is a Healthy Work Environment Created and Sustained? The literature consistently supports the key role of the leader in creating and sustaining healthy work environments for nursing practice.17,20-23,27,30 The Institute of Medicine2 has identified the key role of leaders in transforming the work environment for nurses and in keeping patients safe. Five evidence-based management practices are consistently necessary elements of the healthcare work environment: (1) balancing the tension between production and efciency, (2) creating and sustaining trust throughout the organization, (3) actively managing the process of change, (4) involving workers in decision making pertaining to work design and work ow, and (5) using knowledge management to establish the organization as a learning organization. Although empirical data on effective management practices is often difcult to locate and often lags behind evidence-based clinical practices, strong evidence supports the 5 management practices enumerated.2 The key to success in transforming nurses work environments, however, rests with the ability of leaders to translate the evidence related to healthy work environments into nursing practice at the bedside. Ideally, the scope of leadership influence may be extended when leaders (both formal and informal) are cultivated at all levels of the organization.40
Authentic Leadership: Search Strategy

answered at least 1 of the following 4 questions: 1. What is authentic leadership? 2. How does authentic leadership differ from other types of leadership? 3. What are the mechanisms by which authentic leaders create a healthy work environment for practice? 4. How does one become an authentic leader? The literature review produced 8 sources.41-48 Even though AACN5 has identied authentic leadership as the glue that holds together a healthy work environment,6(p2) few published sources address the concept of authentic leadership, particularly in nursing practice. A database search of the term leadership in Ovid MEDLINE produced 18 224 sources, but only 5 of those sources provided a reference when the terms authenticity and leadership were combined. When the term authentic leadership was searched for, 7 sources were found. A similar strategy with the Cumulative Index to Nursing and Allied Health Literature produced 4291 sources on leadership. When the term authenticity was added, only 4 journal sources were found. In a search for book sources on authentic leadership on the Amazon.com Web site, 9 books were found. When the literature search was expanded beyond the nursing and healthcare disciplines and the Business Source Premier database was used, 38 sources on authentic leadership were found. Of the 38 sources identied, almost 50% were related to the book by George45 on authentic leadership. The works of 2 other prominent authors were cited: the third volume of the theory and research-based scholarly studies of Gardner et al49 and the eld-based anecdotal work by Cashman.43,50,51 Clearly, locating published sources on authentic leadership, particularly journal articles, was difcult.
Authentic Leadership: Findings

The literature on authentic leadership was reviewed. Sources that met the following 4 inclusion criteria were selected. First, sources published between 1990 and 2005 were sought; however, only publications from 1998 or later were found. Second, only Englishlanguage sources from both books and journal articles were reviewed. Third, both anecdotal and empirical articles were included. Fourth, the published sources
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What Is Authentic Leadership? George45 describes an authentic leader as an individual in a position of responsibility who is genuine, trustworthy, reliable, and believable. This description is consistent with the AACN denition of the term authentic, which proposes that leaders who are authentic conform to fact or speak the truth and therefore are worthy of trust, reliance, or belief.5 One conceptual denition of authentic leadership is proposed by Avolio et al41 as part of the beginning development of a theoretical framework to guide future research. These researchers dene authentic leaders as those individuals who are deeply aware of how they think and behave and are perceived by others as being aware of their own and others values/ moral perspective, knowledge, and strengths, aware of the context in which they operate, and who are condent, hopeful, optimistic, resilient, and high on moral character.41(p804)
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Passion

Purpose

Compassion

Heart

Authentic leader Inner self Being present

Values

Behavior

Self-discipline

Relationships

Consistency

Connectedness

Figure 2 Characteristics of authentic leaders in complex adaptive systems.

Adapted from George.45 Reprinted with permission from John Wiley & Sons, Inc.

Adequate instruments for exclusively measuring authentic leadership are not yet available; however, empirical research to identify markers of authentic leadership46 and to advance the development of instruments to measure it41 are in progress. Instruments that measure some elements of authenticity are the Servant Leadership Behavior Scale52 and the Multifactor Leadership Questionnaire53 used to measure transformational leadership. Authentic, servant, and transformational leadership styles have distinct differences,54 and thus the instruments cited may not be adequate proxies to measure authentic leadership. An extensive discussion of the differences between the various types of leadership styles, however, is beyond the scope of this article. The conceptual denition of authentic leadership can be further claried by determining the characteristics of
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authentic leaders. According to George,45 authentic leaders have 5 key characteristics (Figure 2): the abilities to understand their own purpose, practice solid values, lead with heart, establish enduring relationships, and practice self-discipline. Fundamental to authenticity is the notion of the individual remaining true to his or her core values; this understanding helps explain the evolution of authentic leadership: the more individuals remain true to their core values, identities, preferences, and emotions, the more authentic these individuals are thought to become.41,55

Authentic leaders conform to fact or

speak the truth and therefore are worthy of trust, reliance, or belief.

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In understanding their own purpose, authentic leaders search for meaning along lifes journey. According to George,45 it is easy to state ones purpose relatively early in life. More difcult, however, is the process by which passion for ones purpose develops. To nd passion and be able to articulate the passion, one must rst believe in the purpose, internalize its intrinsic worth, and nd voice56 to extol its virtues. George45 cites the example of a mentor who understands and subscribes to the mission of the mentors organization. Since actions speak louder than words, the ability of the leader to demonstrate passion for the mission by describing the mission and enlisting employees to jointly live the mission is an example of authentic leadership. The notion of understanding purpose and passion is exemplified by the old adage of walking the talk: modeling behaviors the leader wants repeated or having the leaders actions match their words. Practicing values involves testing ones fortitude under the most difcult situations that may challenge individual values. George45(p37) asserts only in the crucible will you learn how to cope with pressures to compromise your values . . . and make difcult decisions in the context of your values. The essence of being steadfast with ones values, making difcult decisions, and acting in a manner consistent with those values may be more readily communicated by Georges euphemism of when in Rome, dont follow the Romans.45(p127) This particular characteristic of authentic leaders takes on signicant meaning when societys increasing scrutiny of leaders ethical behavior (or lack of it) is considered. Leading with heart requires compassion. Authentic leaders are open to close, personal relationships and embrace the full range of lifes challenges, hardships, and difculties. According to George,45 authentic leaders develop heart and compassion by getting to know the life stories of those with whom they work and by engaging the coworkers in shared meaning. Some ways that authentic leaders may develop compassion include taking on community service projects, having international students living in the leaders home, understanding the roots of discrimination, and traveling through developing countries to understand peoples lives and the human condition. Authentic leaders develop heart by engaging in intimate relationships with family, friends, and coworkers and by cultivating mentoring relationships.

Authentic leaders develop heart and

compassion by getting to know the life stories of those with whom they work and by engaging coworkers in shared meaning.

Establishing enduring relationships requires a sense of connectedness and shared purpose of working toward a common goal.45 Authentic leaders build a sense of connection through sharing lifes stories and developing trust and intimacy. Relationships built on connectedness grow in the face of pressures and adversity. Additionally, the behavior of authentic leaders builds relationships through personal expression that is consistent with values and not merely the result of a desire to please, attain rewards, or avoid punishments.57 Practicing self-discipline involves incorporating balance into ones personal and professional life in order to deliver consistent results. Authentic leaders see themselves as stewards of the assets they inherit and servants of all their stakeholders.58(p3) Practicing self-discipline requires leaders to engage in activities and habits that keep a persons mind sharp and body in shape. Self-discipline in multiple aspects of life helps authentic leaders become predictable and behave with consistency independent of situations and of settings. According to George,45 developing ones personal energy requires a journey of reflection and renewal. Authentic leaders reduce the stress associated with high-demand positions by engaging in activities such as meditation, prayer, celebrations, sporting events, and personal hobbies. Developing the qualities of an authentic leader (purpose, behavior, compassion, connectedness, consistency) requires a never-ending and nonlinear journey through lifes experiences. According to George,45 the rewards of the journey lie in having a fullling life that helps individuals become better persons to then become better leaders. This observation underscores the importance of the attributes of authentic leadership (gifts and talent) that, enhanced over a lifetime of learning, allow individuals to lead in a timeless way.59 How Does Authentic Leadership Differ From Other Types of Leadership? The literature reviewed associates authentic leadership with transformational leadership,42 servant leadership,44 and Zen leadership.48 Although these leadership theories may all be closely related,54 it is the authenticity component inclusive of character, knowing oneself, and demonstrating relational transparency that differentiates authentic leadership from other types of leadership. The key distinction of authentic leaders is that they are anchored by their own deep sense of self and know where they stand on important issues, values, and beliefs.54 Authentic leaders stay their course and convey to others, often times through their actions, not just words, what they represent in terms of principles, values, and ethics.54(p329) Avolio and Gardner54 suggest that authentic leadership can incorporate other forms of positive leadership
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such as transformational leadership. Authentic leadership, however, may or may not be charismatic. 4 5 According to Bennis,59(p5) character (as seen in authentic leaders) more than charisma signals real leadership for the long run. Servant leadership and authentic leadership share elements of self-awareness and commitment to service. Authentic leadership is grounded in the positive and social psychology literature, and this area of psychology is supported by a well-established track record of empirical research.54 Chief ndings of the positive psychology body of research suggest that positive subjective experiences, positive individual traits, and positive institutions improve quality of life and well-being, especially when life (personal or at work) is seen as meaningful.60 In contrast to authentic leadership and its theoretical foundations based on positive psychology, servant leadership theory has been largely atheoretical and not grounded or supported by empirical research.54(p331) Further, literature is lacking to document the contributions of servant leadership to the creation of sustainable values in organizations.54 A comparison of authentic leadership with Zen leadership, a spiritual leadership style, indicates that both focus on integrity, trust, courage, hope, and perseverance (resilience). Zen leadership, however, lacks a strong research base of its own. Components of Zen leadership overlap with those of authentic leadership; however, these component parts have generally been studied as individual concepts. Findings from studies on integrity, trust, courage, hope, and resilience can be found in the literature (eg, self-regulation), but these studies may not necessarily be aligned within the context of leadership theory. Comparisons between authentic leadership and other types of leadership may help increase our understanding of the critical attributes and core components of the various types of leadership. Additional simultaneous concept analysis may assist in the development of valid and reliable instruments to measure authentic leadership and to develop the theory base. What Are the Mechanisms by Which Authentic Leaders Create Healthy Work Environments? The conceptual and empirical links between authentic leadership, followers attitudes and behaviors, and performance outcomes have not been fully developed.41 The theoretical and empirical base of authentic leadership is in its infancy, and marked opportunity exists for theory building and research. The recent interest in authentic leadership seems to stem from an apparent shift in which timeless and genuine attributes are sought in our leaders. With business scandals such as the Enron, Tyco, and Health South debacles in the forefront, the public
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seems to be demanding a shift from the expected charismatic, even arrogant leadership of the past to a more sustaining type of authentic leadership that exemplifies character.59 The early research-based work on authentic leadership supports the eld-based and anecdotal observations of successful authentic leaders.41 Specifically, the positive psychological capacities of condence, optimism, hope, and resiliency have been identied as personal resources of authentic leaders.61 The combined work of multiple contributors41,43,45,49-51 supports the assumption that authentic leaders create lasting organizational value that extends well beyond bottom-line success. In establishing a theoretical and scientic base for authentic leadership, Avolio and his colleagues at the University of Nebraska-Lincoln are pursuing a program of research in authentic leadership. The research-based literature on authentic leadership is relatively new. The inaugural scholarly summit on the development of authentic leadership was hosted by the Gallup Leadership Institute at the University of Nebraska-Lincoln in 2004.54 Groundbreaking articles on authentic leadership have appeared in business and leadership journals only since the early 2000s. Little empirical work is evident in both the business46 and healthcare literature.44 Drawing on the propositions of positive organizational psychology,62 Avolio et al41 have developed a beginning theoretical model for linking authentic leadership to followers attitudes, behavior, and performance outcomes. For the purposes of this article, the model by Avolio et al41 has been expanded and modied to incorporate healthy work environments as a performance outcome (Figure 3). The model contends that the unique stressors facing organizations throughout society today call for a new leadership approach aimed at restoring basic condence, hope, optimism, resiliency, and meaningfulness.41(p802) Hence, the model prominently incorporates hope, trust, and positive emotions and identies these constructs as mediating variables by which authentic leaders facilitate followers attitudes, behaviors, and performance outcomes. Through personal identication with followers and social identication with the organization, authentic leaders are able to enhance the engagement, motivation, commitment, satisfaction, and involvement required from followers to constantly improve their work and performance outcomes.41(p804) On the basis of this proposed model, a healthy work environment (distal or long-term outcome) may logically be assumed to result from a process of employee engagement in which authentic leadership is congured to be the input (or antecedent). The psychological engagement (proximal or more immediate outcome) of employees by authentic leaders may be a key
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Antecedent

Mediating variables

Proximal outcomes

Distal outcomes

Hope Authentic leadership Incorporates elements described in Figure 2 Identication Personal Social Trust Followers work attitudes Commitment Job satisfaction Meaningfulness Engagement Healthy work environment Creation of sustained value demonstrated by performance outcomes related to: People Quality Finance

Followers behaviors Job performance Extra effort Withdrawal behaviors

Positive emotions

Optimism

Figure 3 Proposed mechanisms by which authentic leaders create a healthy work environment .
Adapted from Avolio,41 with permission from Elsevier, and incorporating the work by George.45

mechanism by which the healthy work environment is created. Engagement may be viewed as an important consequence of authentic leadership that mediates its effects on followers outcomes.41 Engagement is currently being identied in the literature on stress and burnout as the key element in the long-term solution to chronic stress and burnout in the workplace.63 If we assume that engaged employees contribute positive emotions, attitudes, and behaviors to the workplace, this engagement may result in a sustainable healthy work environment that is characterized by positive people, nancial, and quality outcomes. How Does One Become an Authentic Leader? The process of becoming an authentic leader appears to be a journey rather than a destination. To become an authentic leader requires that an individual pursue a personal journey of self-discovery, self-improvement, reection, and renewal. To become an authentic leader, a person must develop an individual leadership style that is consistent with his or her personality and character. Becoming an authentic leader requires courage to commit to a process of personal transformation from the inside out.43 Becoming an authentic leader, however, does not dismiss the importance of professional competence and the need to build knowledge in ones discipline. Both professional and personal mastery are needed for success as an authentic leader. Similarly, understanding ones strengths and weaknesses while simultaneously accepting ones shadow side is an essential component of becoming an authentic leader.45 Authentic leadership can be enhanced by the individual alone or by tapping into organizations dedicated

to developing authentic leaders (Table 1). For example, an individual pursuing a personal journey toward authenticity can begin by reading books on the subject43,45,51 or seeking Internet sources to build the authentic leadership toolkit.64 Organizations that assist in the development of authentic leaders are also available. Individuals interested in a certicate program in authentic leadership can nd such a program available through multiple organizations.68-70 Also available are executive coaching programs71,72 and a scholarly authentic leadership development institute.74 Increasingly, courses in authentic leadership are being introduced into the business school curriculum,73 but evidence was not found of such courses being taught in schools of nursing. Although certicate programs, executive coaching, and even practical guides to developing authentic leadership may be useful, few empirical studies (particularly those with controls for extraneous variables) have been done. Experimental studies related to methods of teaching authentic leadership are essential to establish cause-and-effect relationships and to build the teaching-learning scholarship.

Becoming an authentic leader requires a

personal journey of self-discovery, selfimprovement, reflection, and renewal.

Discussion and Implications

Healthy work environments for nursing practice are desirable for both nurses and patients. The evidence,

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Table 1 How to become an authentic leader: a practical guide

Personal development strategies Read books about authenticity in leadership Authentic Leadership: Rediscovering the Secrets to Creating Lasting Value45 Leadership From the Inside Out: Becoming a Leader for Life43 Awakening the Leader Within51 Seek Internet sources to enhance authenticity in leadership Authentic leadership: a toolkit for becoming more effective, efcient, and exceptional64 The Awakening Best Self Weekend65 Volunteer to serve on a community board and actively participate in the groups service projects Participate as a team member in an organization-afliated mission trip to an underdeveloped country or community Initiate a personal program of self-renewal inclusive of, but not limited to, exercise, journaling, meditation, and spiritual healing Complete a self-assessment of personal strengths66 and also explore and reconcile the shadow side67 Commit to mentoring a future leader within or outside your organization Coach or manage an amateur sports team such as a youth team or an adult league Devote time to family, friends, colleagues, and self Find a new hobby or rediscover an old one Develop the art of listening and reection Make time for celebrations and to express gratitude along lifes journey Insert humor into every aspect of life Seek the personal and professional advise of sages in the profession Commit to a philosophy of lifelong learning Organization-assisted development strategies Enroll in a certicate program in authentic leadership Annual certicate program in authentic leadership68 Summer program in authentic leadership69 Center for Authentic Leadership70 Participate in an executive coaching program available at major universities throughout the country (eg, University of Minnesota,71 University of Pennsylvania72) or enroll in a university-based course on authentic leadership73 Attend the annual authentic leadership development institute to learn more about the scholarly development of theory and research in authentic leadership74

particularly evidence from Magnet-designated hospitals, supports the assumption that healthy work environments produce superior outcomes for both staff nurses and patients. It is evident from the literature that healthy work environments offer something special and should represent a workplace standard to achieve.

Healthy work environments, guided by

authentic leaders, produce superior outcomes for both staff nurses and patients.
Authentic leadership is proposed as the preferred style of leadership for creating and sustaining healthy work environments. The conceptual definitions of an authentic leader seem to go well beyond simply being genuine and reliable to include the important characteristics of purpose, values, heart, relationships, and self-discipline. Although the role of leadership in serving as the glue that holds together a healthy work environment is

strongly endorsed, the empirical and theoretical base to support the link between authentic leadership and healthy work environments needs further development. Currently, the support for authentic leadership can best be made through grounding in positive psychology, which has a scientic and theoretical base of its own. The eldbased anecdotal work establishing a relationship between authentic leadership and healthy work environments is reportedly strong, and this work should assist in designing studies to cement the relationship between authentic leadership and healthy work environments. Becoming an authentic leader appears to involve a nonlinear journey of personal growth that is statelike (open to development and change) and multidimensional, containing elements such as traits, behaviors, contexts, and attributions.54 If we assume that authentic leadership can be learned, the process requires personal investment and commitment. This type of leadership supports the need for a solid moral foundation and mastery of a skill set not generally emphasized in charismatic types of leadership. Authentic leadership underscores an emphasis on hard work in character development that

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Table 2 Proposed research agenda to advance the study of authentic leadership in nursing practice
Consensus building Assemble an interdisciplinary group of researchers and practitioners in the elds of business, psychology, and healthcare to initiate collaborative research on authentic leadership within the context of the healthcare work environment. Establish a common conceptual and operational denition of authentic leadership that is measurable and amenable to instrumentation. Engage in the development and psychometric testing of valid and reliable authentic leadership instruments. Methods Conduct qualitative research studies with nurses in practice to answer the following research questions: What is an authentic leader in nursing practice? What does an authentic leader in nursing practice look like? What is the skill set of an authentic leader in a healthcare work setting? Expand the research base to include both quantitative and qualitative studies to identify the mechanisms by which authentic leaders create healthy work environments for nursing practice. In other words, how is the glue in this relationship of variables formed? Is it through engagement, organizational culture, or another mechanism that the glue develops? Assuming that authentic leadership is teachable, conduct both qualitative and quantitative studies to examine the progress that individuals follow in order to become authentic leaders. This research would address the antecedents of authentic leadership. The selection of subjects may begin with recruitment of leaders who are by reputation authentic leaders. Interviews with leader-employee dyads may be useful for further exploration. Measure the outcomes associated with existing programs for the development of authentic leadership to establish a teachinglearning scholarship related to instruction in authentic leadership. Conduct multisite studies with randomly selected subjects to enhance the generalizability of the findings related to authentic leadership. Design quantitative longitudinal studies to examine the sustainable effects of authentic leadership on healthy work environments. Develop a predictive model for identifying characteristics that predispose to authentic leadership and then design targeted interventions based on a characteristic prole to produce authentic leaders. Test the effects of hope, trust, and positive emotions in mediating the relationship between authentic leadership and proximal outcomes (followers work attitudes and behaviors) and distal outcomes (healthy work environments). Follow up by designing experimental studies that use the established mediating variables as targeted interventions.

may in years past have been assumed to develop somewhat innately or through osmosis. Because many similarities exist between authentic leadership and other types of leadership, further simultaneous concept analysis is needed in theory development. Research, both quantitative and qualitative, is needed to develop appropriate authentic leadership instruments. A proposed research agenda to advance the study of authentic leadership in nursing practice is presented (Table 2). Although the proposed mechanisms by which authentic leadership creates performance outcomes (ie, healthy work environments) appear to be plausible, a stronger research base is necessary. Certainly, the highquality work of Avolio et al41 shows great potential. Of particular promise is the work in establishing a relationship between authentic leadership and the creation of a psychologically engaged workforce. The ability to test the effect of engagement on stress and burnout offers hope for a long-term solution to chronic stress and burnout that contributes to the perpetuation of unhealthy work environments.
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An analysis of the role of authentic leadership in creating healthy work environments suggests further implications for research, practice, and policy. As has been proposed, a need exists to build the science of authentic leadership. The opportunity exists for interdisciplinary research collaboration between nursing (eg, AACN) and business (Avolio and his colleagues at the Gallup Leadership Institute). At a minimum, this collaboration should extend to the development and teaching of leadership ethics in service and academic settings both in nursing and in business, with measurement of related teaching and learning outcomes. From a practice perspective, the healthcare service setting can be a beta site for testing authentic leadership instruments and interventions. Because a stronger link between leadership and the ability to create a healthy work environment needs to be established, continuing to support eld-based anecdotal work with authentic leadership until the science is more mature offers greater potential benet than harm. In light of this observation, programs to develop authentic leadership as we under265

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stand authentic leadership today can benet the work environment of nurses. The AACNs annual meeting, the National Teaching Institute, could serve as a vehicle for either a preconference or a mastery session on authentic leadership. Ongoing diffusion of innovation can occur by creating an authentic leadership online community to further support the development of authentic leaders within the AACN membership of 65 000 and extended to include the 400 000 critical care nurses in practice. Similarly, AACN could develop an authentic leadership fellowship program or boot camp to promote the concept of authentic leadership within leaderful organizations. From a policy perspective, additional policy work is needed that is consistent with the emerging scientic base for authentic leadership. From a long-term perspective, AACNs collaboration with other powerful organizations such as the American Nurses Association, the American Medical Association, and the Joint Commission on Accreditation of Healthcare Organizations may result in pilot studies that can link hospital accreditation to authentic leadership and/or healthy work environments. This activity would be consistent with building the political acumen necessary to assist AACN in its ability to become more of an insider within policy networks75 and to promote the agenda for authentic leadership and a healthy work environment. In the meantime, advancing the AACN document5 on a healthy work environment and translating the work into practice represent the early eld-based work that is so necessary. If we look at the general lack of investment in leadership development and succession planning that currently prevails in the healthcare practice setting, advancing the development of authentic leaders is clearly better than continuing the trend of doing little or nothing at all.

standing of what authentic leadership is, how it may be developed, and how it contributes to the creation of healthy work environments. Additionally, developing leaderful organizations implies a commitment to longitudinal research and to an emphasis on fostering leadership development at all levels in the profession. In light of the need for leaderful organizations for the 21st century and for further development of authentic leadership science, AACN is positioned to advance the current understanding of authentic leadership to document the empirical link with a healthy work environment. This important work potentially may affect not only the nursing workforce but also the profession, the healthcare delivery system as a whole, and society at large.
REFERENCES 1. Buerhaus PI, Staiger DO, Auerbach DI. Implications of an aging registered nurse workforce. JAMA. 2000;28:2948-2954. 2. Institute of Medicine. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: The National Academies Press; 2004. 3. Bruhn J, Chesney A, Slacido R. Health and organizational issues in managing a multicultural workforce. Fam Community Health. 1995;18:1-8. 4. Center for Creative Leadership. Survey by Center for Creative Leadership reveals the value of soft skills. Available at: http://www.leadershiponlinewkkf.org/studies/news/survey.asp. Accessed March 1, 2006. 5. American Association of Critical-Care Nurses. 2005 AACN standards for establishing and sustaining healthy work environments: a journey to excellence. Available at: http://www.aacn.org/AACN/pubpolcy.nsf/vwdoc /workenv. Accessed March 1, 2006. 6. McCauley K. Presidents note: all we needed was the glue. AACN News. May 2005;22:2. 7. Thompson PA. An update on the Nursing Organization Alliance. Voice Nurs Leadership. May 2005:3:5. 8. The Alliance, Nursing Organizations Alliance. About us. Available at: http://www.nursing-alliance.org/about.cfm. Accessed March 1, 2006. 9. The Alliance, Nursing Organizations Alliance. Member organizations. Available at: http://www.nursing-alliance.org/member.cfm. Accessed March 1, 2006. 10. American Association of Colleges of Nursing. Hallmarks of the professional practice environment. 2002. Available at: http://www.aacn.nche.edu /publications/positions/hallmarks.htm. Accessed March 1, 2006. 11. American Organization of Nurse Executives. June 2003. Healthy work environments, volume 2: striving for excellence. Available at: http://www .hospitalconnect.com/aone/keyissues/hwe_excellence.html. Accessed March 1, 2006. 12. Pesut DJ. Create the future through renewal. Reflect Nurs Leadersh. 2004;30:24-25,56. 13. Joint Commission on Accreditation of Healthcare Organizations. Health care at the crossroads: strategies for addressing the evolving nursing crisis. 2002. Available at: http://www.jcaho.org/publicpolicy. Accessed March 13, 2006. 14. American Hospital Association. In Our Hands. Chicago, Ill: American Hospital Association; 2002. 15. Baker C, Beglinger J, King S, Salyards M, Thompson A. Transforming negative work cultures: a practical strategy. J Nurs Adm. 2000;30:357-363. 16. Choi J, Bakken S, Larson E, Du Y, Stone PW. Perceived nursing work environment of critical care nurses. Nurs Res. 2004;53:370-378. 17. Disch J. The nurse executive: healthy work environments for all nurses. J Prof Nurs. Mar-April 2000;16:75. 18. Disch J. Creating healthy work environments. Creat Nurs. 2002 8(2):3-4. 19. Disch J. Magnet status as markers of healthy work environments. Creat Nurs. 2002;8(2):4-6. 20. Evans JA. The role of the nurse manager in creating an environment for collaborative practice. Holist Nurs Pract. April 1994;8:22-31. 21. Hawkins AL, Kratsch LS. Troubled units: creating changes. AACN Clin Issues. 2004;15:215-221. 22. Heath J, Johanson W, Blake N. Healthy work environments: a validation of the literature. J Nurs Adm. 2004;34:524-530. 23. Kerfoot K, Neumann T. Creating a healing environment: the nurse managers challenge. Nurs Econ. 1992;10:423-425. 24. Kreitzer MJ, Wright D, Hamlin C, Towey S, Marko M, Disch J. Creating a healthy work environment in the midst of organizational change and transition. J Nurs Adm. June 1997;27:35-41.

Conclusions
The review of the literature indicates that most publications on authentic leadership appear to be anecdotal. Although it may be reasonable to conclude that authentic leadership may be increasingly needed in todays complex healthcare systems, additional empirical work is necessary. Authentic leadership may not only be crucial to creating and sustaining healthy work environments for practice but also may hold promise in creating lasting organizational and professional value. The ripple effects of authentic leadership may be so marked that not only will organizations need to be cultivating authentic leaders in formal leadership positions but authentic leaders also may be needed at the front lines or the point of care. To produce leaderful organizations, however, requires a better scientific under266

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25. Lavoie-Tremblay M. Creating a healthy workplace: a participatory organizational intervention. J Nurs Adm. 2004;34:469-474. 26. McKim SJ. Healthy work environments. Nurse Leader. July/August 2003; 1:15-21. 27. Marcus J, Liberto L. Create accountable, balanced work environments. Nurs Manage. October 2003;34:25-26. 28. Robinson CA. Magnet nursing services recognition: transforming the critical care environment. AACN Clin Issues. 2001;12:411-423. 29. Walker J. Developing a shared leadership model at the unit level. J Perinat Neonatal Nurs. 2001;15:26-39. 30. Whiley K. The nurse managers role in creating a healthy work environment. AACN Clin Issues. 2001;12:356-365. 31. Nightingale F. Notes on Nursing: What It Is, and What It Is Not. New York, NY: Appleton; 1938. 32. Venolia C. Healing Environments. Berkeley, Calif: Celestial Arts; 1988. 33. Kerfoot KM, Ivy SS. Renewing the spirit: sanctuaries for healing. Reect Nurs Leadersh. 2004;30(3):20-23. 34. Disch J. Creating healthy work environments for nursing practice. In: Chaska N, ed. The Nursing Profession: Tomorrow and Beyond. Thousand Oaks, Calif: Sage; 2001:735-749. 35. Aiken LH. Superior outcomes of Magnet hospitals: the evidence base. In: McClure ML, Hinshaw AS, eds. Magnet Hospitals Revisited: Attraction and Retention of Professional Nurses. Washington, DC: American Nurses Publishing; 2002:61-81. 36. Estabrooks CA, Tourangeau AE, Humphrey CK, et al. Measuring the hospital practice environment: a Canadian context. Res Nurs Health. 2002;25:256-268. 37. Laschinger HKS, Shamian J, Thomson D. Impact of Magnet hospital characteristics on nurses perceptions of trust, burnout, quality of care, and work satisfaction. Nurs Econ. 2001;19:209-219. 38. Kramer M, Schmalenberg C. Magnet hospitals: institutions of excellence, part I. J Nurs Adm. January 1988;18:13-24. 39. Kramer M, Schmalenberg C. Magnet hospitals: institutions of excellence, part II. J Nurs Adm. February 1988;18:11-19. 40. Raelin JA. Creating Leaderful Organizations: How to Bring Out Leadership in Everyone. San Francisco, Calif: Berrett-Koehler Publishers; 2003. 41. Avolio BJ, Gardner WL, Walumbwa FO, Luthans F, May DR. Unlocking the mask: a look at the process by which authentic leaders impact follower attitudes and behaviors. Leadersh Q. 2004;15:801-823. 42. Bass BM, Steidlmeier P. Ethics, character, and authentic transformational leadership. Available at: http://cls.binghamton.edu/BassSteid.html. Accessed March 1, 2006. 43. Cashman K. Leadership From the Inside Out: Becoming a Leader for Life. South Provo, Utah: Executive Excellence Publishing; 1998. 44. Dillon TH. Authenticity in occupational therapy leadership: a case study of a servant leader. Am J Occup Ther. 2001;55:441-448. 45. George B. Authentic Leadership: Rediscovering the Secrets to Creating Lasting Value. San Francisco, Calif: Jossey-Bass; 2003. 46. Pittinsky TL, Tyson CJ. Leader authenticity markers: ndings from a study of African-American leaders. Available at: http://www.ksg.harvard.edu /leadership/workingpapers.html. Accessed March 1, 2006. 47. Sutter C, Hollister LR. Facilitating authenticity. Healthc Exec. Nov-Dec 2001;16:50-51. 48. Swanson JW. Zen leadership: balancing energy for mind, body, and spirit harmony. Nurs Adm Q. Winter 2000;24:29-33. 49. Gardner WL, Avolio BJ, Walumbwa FO. Origins, Effects, and Development. Greenwich, Conn: JAI Press; 2005. Authentic Leadership Theory and Practice; vol. 3. Monographs in Leadership and Management. 50. Cashman K. Five touchstones of authentic leadership. Manage Rev. July 1998;87:58-60. 51. Cashman K. Awakening the Leader Within. Hoboken, NJ: John Wiley &

Sons; 2003. 52. Sendjaya S. Development and validation of Servant Leadership Behavior Scale. Available at: http://www.regent.edu/acad/sls/publications/conference _proceedings/servant_leadership_roundtable/2003/proceedings.htm. Accessed March 13, 2006. 53. Bass BM, Avolio BJ. Full Range Leadership Development: Manual for the Multifactor Questionnaire. Palo Alto, Calif: Mind Garden; 1993. 54. Avolio BJ, Gardner WL. Authentic leadership development: getting to the root of positive forms of leadership. Leadersh Q. 2005;16:315-338. 55. Erickson RJ. Our society, ourselves: becoming authentic in an inauthentic world. Adv Dev. 1994;6:27-39. 56. George B. Find your voice. Harv Bus Rev. January 2004;82:35. 57. Remus I, Morgeson FP, Nahrgang JD. Authentic leadership and eudaemonic well-being: understanding leader follower outcomes. Leadersh Q. 2005; 16:373-394. 58. George B. Five questions about the call for authentic leadership. Harv Manage Update. October 2003;8:3. 59. Bennis W. Flight of the phoenix: authentic leaders nd a way to y. Executive Excellence. May 2003;20:4-5. 60. Seligman ME, Csikszentmihalyi M. Positive psychology: an introduction. Am Psychol. 2000;55:5-14. 61. Luthans F, Avolio BJ. Authentic leadership: a positive developmental approach. In: Cameron KS, Dutton JE, Quinn RE, eds. Positive Organizational Scholarship. San Francisco, Calif: Barrett-Koehler; 2003:241-261. 62. Harter S. Authenticity. In: Snyder CR, Lopez S, eds. Handbook of Positive Psychology. New York, NY: Oxford University Press; 2002:382-394. 63. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol. 2001; 52:397-422. 64. Bell J. Authentic leadership: a tool kit for becoming more effective, efcient, and exceptional. Available at: http://www.relationshipsthatwork.com /wsLeadership.html. Accessed February 24, 2006. 65. Sharma R. The Awakening Best Self Weekend. Available at: http:// www.robinsharma.com/success_coach_personalsli_2.htm. Accessed March 13, 2006. 66. Buckingham M, Clifton DO. Now, Discover Your Strengths. New York, NY: The Free Press; 2001. 67. Arasini Foundation. 2005 Awakening self: our shadow side. Available at: http://www.ahealingplace.org/spiritualpsych/awakening/awselfshadow.html. Accessed March 1, 2006 68. Naropa University. Fifth annual certicate program in authentic leadership. Available at: http://www.naropa.edu/leadership/index.html. Accessed February 24, 2006. 69. Shambhala Institute for Authentic Leadership. Transformative learning for transformative action. Available at: http://www.shambhalainstitute.org /about.html. Accessed June 20, 2005. 70. Center for Authentic Leadership. Overview. Available at: http://www .authenticleadership.com/about.htm. Accessed March 1, 2006. 71. University of Minnesota Carlson School of Management. Authentic leadership: courage, coaching, and ethics. Available at: http://www.csom.umn.edu/ page1662.aspx. Accessed March 1, 1006. 72. University of Pennsylvania Wharton School of Business. Leading from within: self-awareness initiative. Available at: http://leadership.wharton.upenn. edu/l_change/trips/self-awareness04.shtml. Accessed February 24, 2006. 73. White BJ. 2004 Building leadership competencies for the workplace: teaching authentic leadership. Available at: http://www.leadershipeducators .org/2004/white.pdf. Accessed March 1, 2006. 74. Gallup Leadership Institute. Programs. Available at: http://gli.unl.edu /programs.asp. Accessed February 24, 2006. 75. Estabrooks CA. Translating research into practice: implications for organizations and administrators. Can J Nurs Res. September 2003;35:53-68.

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CE Test

Test ID A0615032: Authentic Leaders Creating Healthy Work Environments for Nursing Practice. Learning objectives: (1). Discuss the current literature related to creating healthy work environments. (2). Discuss current literature related to authentic leadership. (3). Identify key components of authentic leadership for further research.
7. Who is key in creating and sustaining healthy work environments? a. Physicians b. Organization leaders c. Employees d. Board of directors 8. Which statement best describes an authentic leader? a. An authentic leader has vision and purpose. b. An authentic leader demands the best from all employees. c. An authentic leader gathers facts and uses employee input to make decisions. d. An authentic leader is genuine, trustworthy, reliable, and believable. 9. Which one of the following is not a key characteristic of an authentic leader? a. Practices solid values b. Practice self-absorption c. Practices self-discipline d. Leads with heart 10. Which of the following is not a component of becoming an authentic leader? a. Must develop a leadership style consistent with his/her personality and character b. Must be mentored by an authentic leader who guides the developing leader on his/her journey c. Must understand ones strengths and weaknesses d. Must commit to a process of personal transformation, from the inside out 11. What supporting evidence exists correlating healthy work environments with superior outcomes for patients and nurses? a. Studies by the American Nurses Association b. AACNs healthy Work Environment initiative c. Magnet-designated organizations d. Guidelines from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) 12. Which one of the following, according to the author, would not be affected by development of authentic leaders in healthcare organizations? a. JCAHO b. Workforce and profession of nursing c. Society d. Healthcare delivery system

1. Which of the following has been implicated as a reason for the nursing shortage? a. Decreasing compensation b. Decreasing health benefits c. Overwork and stress of the healthcare work environment d. Decreasing number of hospital beds 2. Which of the following statements is correct? a. Leaders in the healthcare environment today need to be more authoritarian b. The greater the stress of the environment, the more important the soft side of leadership becomes. c. The healthcare environment is no more stressful than other organizations. d. Technology is the key to creating healthy work environments. 3. Which of the following is not 1 of the 6 standards identified by the American Association of Critical-Care Nurses that are crucial to creating a healthy work environment? a. Skilled communication b. Appropriate staffing c. True collaboration d. Increased decision making 4. Which of the following is not a purpose of this article? a. To define the attributes of authentic leaders b. To discuss the disadvantages of authentic leadership c. To describe mechanisms used by authentic leaders to create a healthy work environment d. To provide a research agenda to study authentic leadership 5. Which term is used synonymously to describe the healthy work environment? a. Proactive b. Resilient c. Healing d. Creative 6. Which of the following statements best describes the common characteristics of the healthy work environment? a. Employees are treated with respect, a strong sense of trust is present, the organization supports communication and collaboration b. Employees are directed in creating the environment in their units, a strong sense of trust is present, the organization supports communication and collaboration c. A strong sense of trust is present, the organization supports the physician as being the leader in patient care, and employees feel physically and emotionally safe. d. Employees are allowed to create the environment in their units, a strong sense of trust is present, the organization supports the physician as being the leader in patient care

Test Answers: Mark only one box for your answer to each question. You may photocopy this form.

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Test ID: A0615032 Form expires: May 1, 2008. Contact hours: 2.0 Fee: $12 Passing score: 9 correct (75%) Category: O Test writer: Diane Byrum, RN, MSN, CCRN, CCNS, FCCM

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