LEADERSHIP

IN
ADVANCE NURSING
PRACTICE

Submitted to,
Madam Suvra Roy
Senior Lecturer
College of Nursing, Medical College and Hospital, Kolkata
Submitted by,
Mouli Bhattacharjee
M.Sc. Nursing 1st Year
College of Nursing, Medical College and Hospital, Kolkata
Introduction
There are several concepts that need to be explored to develop advance practice nurse (APN)
leaders. These principles include an understanding of the definitions of leadership,
characteristics of effective leaders and the scientific theories that undergird the principles of
leadership. Because the healthcare environment is undergoing massive change, APNs will
need to develop additional leadership skills that encompass changes in the clinical
environment and will need to provide accountability for quality patient care. Often, APNs are
clinical experts but lack proficiency at managing clinical staff. Perhaps one way to further
develop the skills necessary for APNs to become the future leaders of population-based
clinical care is to provide a leadership framework that balances the theory and application of
leadership principles.

Definition
 “Process of persuasion and by which an individual (or leadership team) induces a
group to pursue objectives held by the leader or shared by the leader and his or her
followers.” (Gardner)
 "Leadership is an attempt at influencing the activities of followers through the
communication process and toward the attainment of some goal or goals.”(Donelly,
J.H. & Ivancevich, J. M. & Gibson)
 "Leadership is a development of a clear and complete system of expectations in order
to identify evoke and use the strengths of all resources in the organization the most
important of which is people.” (Batten, J.D.)
 “Leadership is defined as influence, that is, the art or process of influencing people so
that they will strive willingly and enthusiastically toward the achievement of group
goals.” (Weihrich, H. and H. Koontz. 2005. Management a Global Perspective, 11th
ed., McGraw Hill, Singapore.)
 “A leader is one or more people who selects, equips, trains, and influences one or
more follower(s) who have diverse gifts, abilities, and skills and focuses the
follower(s) to the organization’s mission and objectives causing the follower(s) to
willingly and enthusiastically expend spiritual, emotional, and physical energy in a
concerted coordinated effort to achieve the organizational mission and objectives.”
(Winston, B.E. and K. Patterson. 2006. An Integrative Definition of Leadership.
International Journal of Leadership Studies 1, 2, pp. 6–66.)
 “Leadership involves the use of interpersonal skills to influence others to accomplish
a specific goal.” (Sullivan, E.J. and G. Garland. 2010. Practical Leadership and
Management in Nursing. Pearson Education Limited; Harlow.)
 “Leaders do more than delegate, dictate, and direct. Leaders help others achieve their
highest potential. At ANA, we empower nurses to be professional, competent leaders
in healthcare. Through a variety of educational and advocacy activities, our work
increases the leadership capacity of nurses to advance health and lead change.”
(American Nurse Association (ANA). 2014. Leadership Definition. Retrieved May
19, 2014.)
Effective Leadership
Research has shown that effective leaders achieve results by influencing, motivating, and
inspiring employees over whom they may or may not have direct supervision (Cummings
2008). In fact, leaders that focused on relationships (transformational, supportive,
considerate) were associated with higher nurse job satisfaction and increased retention.
Noneffective leaders were more inclined to focus on tasks versus the individual employee
that resulted in low morale, decreased job satisfaction, and increased staff turnover.
Guyton (2012) proposed nine principles that contributed to effective leadership. These
principles were proposed to guide clinical nurse leaders and were targeted at leading clinical
staff.
 Commitment to excellence: Commitment to excellence begins with the leader.
 Measure the important things: Identifies the need to measure patient and
employees’ satisfaction; quality of care; your employee’s progress, unit growth, and
development; and the unit’s financial wellbeing.
 Build a culture around service: Reinforce the need for your staff to appreciate
patients and families as customers.
 Create and develop leaders: Leaders have a professional obligation to develop
future leaders from within their ranks. The benefit to developing clinical nurse
leadership is the ability for the unit to run when the senior leader is not present.
 Focus on employee satisfaction: Employee satisfaction leads to employee retention.
Focus on establishing an ongoing relationship with your employees.
 Build individual accountability: Hold all employees responsible for their
role/responsibilities within an organization.
 Align behaviors with goals and values: Consistent behavioral standards that align
with the organizational values, mission, and standards should be enforced.
 Communicate on all levels: Communication should be based on an interdisciplinary
framework.
 Recognize and reward success: A system/program of ongoing recognition and
rewards will reinforce the employees’ excellence.

General theories of leadership

The desire to develop a theory of leadership that simplifies the conditions that result in
exceptional leaders has led to the development of a large number of theories across multiple
disciplines. In nursing, APNs are expected to expand their roles as leaders in administration,
education, and clinical practice. Today, APNs are challenged to incorporate leadership
theories across clinical agencies in order to meet the future needs of healthcare providers and
patients. However, the theory and practice of leadership has been developed from other
disciplines and applied to the discipline of nursing.
Great man (1930–1940) theory
Proposes that great men are born, not made, leading to the belief that great leaders will arise
when there is a great need (Bolden et al., 2003). This theory has since fallen out of favour.
Scholars attempted to identify characteristics of great leaders that were based on the
prevailing leaders of the day who were usually male and from the upper classes
Trait/behavioural (1940–1980) theory
A softer version of the Great Man Theory, it assumes that certain inherent traits and qualities
make an individual better suited to a leadership role. These traits are generally described as
personality or behaviour characteristics that are shared by current or previous leaders.
Contingency/Situational (1950–1980) theory
Contingency theories are situational by their very nature. There is no one leadership style,
quality, or trait that is best for all situations. The emphasis is on the factors that affect a
particular situation. This theory chooses to focus on the environment that may influence the
situation and that the ability to lead is contingent on the situation, the leader, and the
follower. Situational-contingency theories do not recognize any one leadership approach.
Fundamental to the theory is that different circumstances will require different types of
leadership. Therefore, leaders may be effective in one situation and unable to lead in another.
Leader/Member exchange/ Transformational (1970) theory
Today The focus is on the relationships formed between the leader and their followers as
beoing of critical importance (Boden et al. 2003). A transformational leader will motivate and
inspire individuals by facilitating group members to see the importance of the goal at hand.
Transformational leaders concentrate on the performance of group members, encouraging
each member to fulfill his potential.

Leadership styles
Autocratic:
● Strong control is maintained over the work group.
● Others are motivated by coercion.
● Others are directed with commands.
● Communication flows downward.
● Decision making does not involve others.
● Emphasis is on difference in status (“I” and “you”).
● Criticism is punitive
Democratic:
● Less control is maintained.
● Economic and ego awards are used to motivate.
● Others are directed through suggestions and guidance.
● Communication flows up and down.
● Decision making involves others.
● Emphasis is on “we” rather than “I” and “you.”
● Criticism is constructive.

Laissez-fair:
● Is permissive, with little or no control.
● Motivates by support when requested by the group or individuals.
● Provides little or no direction.
● Uses upward and downward communication between members of the group.
● Disperses decision making throughout the group.
● Places emphasis on the group.
● Does not criticize.

Transformational: The visionary leaders motivate. Communication is up and down by

sharing information and shared leadership. Criticism is discussed and shared for
improvements within the organization.

Transactional: Non-visionary leaders follow procedures and policies consistent with the
organization. Often solutions are top to down, and innovation or creativity is minimal.

Authentic: The visionary, charismatic leaders with great self-awareness. Communication is

shared throughout the organization and teams are built to develop others. Authentic leaders
provide trust and empower others in the organization.
Competencies of a leader
 Leaders must foster a clear vision with an endowed purpose that is owned by the
people involved with the leader.
 Getting people to support a vision or mission takes work. Leaders must keep
reminding people of what is important [because] people really can forget what they
are there for. Follower also need regular recognition in order to maintain their
engagement with and commitment to the vision.
 Leaders must be optimistic and see possibilities. Leaders must be adaptive to the
constant change in our society, which takes a hardiness attitude that allows to face
challenges and adapt all of it in a way that results in alignment.
 Leaders must create a culture of work, such a culture requires integrity, which evolves
from a balance of ambition, competence, and having “a moral compass.” When
ambition surpasses competence or overrides one’s moral compass, for example,
integrity is lost, a culture of work cannot be created, and one cannot be an effective
leader.
 Leaders must mentor others and acknowledge their ideas and accomplishments.
 Good leaders must be in tune to getting results.

Need of leadership in nursing

 Raise the consciousness of nurses: The nursing leadership is required to raise the
consciousness of nurses through an ongoing critique of present system and to offer
philosophical and practical rationales for fundamental change based on nursing
values.
 For team building: leadership techniques are required for team building at the
organizational level ensuring success in all aspects of nursing and maintaining high
qualities in areas of nursing administration as a whole. It is needed to align employees
in support of goals, for group interaction and blend efforts of diverse specialities.
 Foundation block for nursing practice: leadership skills are foundation blocks for
nursing professional practice. Nurses can exercise leadership in various ways. It is not
limited to formal role. Nurses may be able to lead at bedside, in client teams and
management teams.
 Increases the body of knowledge: it helps the nurses to increases knowledge of
business, human resource, organizational behaviour and health care system issues in
addition to clinical knowledge and skills. She can leadership skills if she knows public
speaking, project planning, management of resources and developing and position
papers.
 For advocacy in nursing: leadership is required to convey the standards and ethics of
nursing profession and advocate for contribute to advances in nursing education.
 To provide direction: leadership is required for directing for the staff and people
towards common goals by use of assignments, orders, policies, procedures, rules,
regulations, standards, opinions, suggestions and questions to direct behaviour.
 Supervision: It helps in providing supervision and contribution towards continuous
growth of supervision by inspecting the work of other nurses and evaluating their
performance.
  Inspiring the staff: Nursing leadership is required to inspire staff and fulfil their
personal and institutional goals, create an atmosphere where one would live and work
in a dignified manner.
 Role model: Nursing leader is a role model to set an example by own actions and as
an advocate for patients and staff.

Role of nursing leader

 Setting standards and best practices to improve the quality of patient care
 Evaluating current health care processes and identifying opportunities for
improvement
 To enhance professional knowledge and skill
 Developing new procedures and overseeing their implementation
 Strive towards professional autonomy
 Meeting with stakeholders to provide progress reports and develop strategies
 Ensuring nurses and other hospital staff align with the health care organization’s
vision and mission.

Leadership in health systems

In order to understand the impact a leader can have on a health system, the different levels of
the system must first be understood.

The APN may participate in leadership on a micro-, macro-, or mega level.

The nurse leader is aware of the systems and organization as they lead their employees
through change.

The interface between the patients and their caregivers is considered a microlevel of the
health system. It is the patient/provider interaction; or it may be a place, a provider’s office,
emergency room, or urgent care facility and the day-to-day activities that occur within that
space.

The macrolevel is the organization itself, the hospital, institutions, or clinics that compose the
microsystem.

If we take this one step further, we can consider the mega level as the healthcare delivery
system as a whole.

The micro- and macrolevels are within the mega system. Another consideration at the mega
level is the relationship to the affordable care act; this is healthcare at a larger level,
nationally or globally. It is important that the nurse leader is aware of the systems level and
the interaction between all three levels. The leader must be mindful of all levels and resources
at each level.
Ways to improve nursing leadership

 Power at high level: Increased recognition of role of nursing has usually come
through appreciation of their significant contribution towards health
 Prepare nurses for collective bargaining: by removing wide variations in many
nursing organization.
 Make INC and state nursing council’s strong and autonomous bodies.
 A define number of nurses to be prepared for top management level
 Nursing administrators must have authority to reward as well as to initiate punitive
measured to subordinates according to need.
 Nursing should have role in planning care of patients and insist change in doctor’s
order and contribute towards effective patient care.
 Nurse managers should be provided adequate resources such as phones, computers in
well maintained office, financial and clerical support.
 The professional associations must prepare nurses to be well informed in collective
bargaining, labour relations, public relations, legal and ethical aspects, nursing
standards, media awareness and use, improvement in interactive skills with doctors,
patient and administrators.

Conclusion
 Nurses lead and manage nursing care for patients, families, aggregates, and
communities in a variety of settings, ranging from ambulatory to community to
inpatient. Nurses also lead and manage care across the health-care continuum,
including primary health promotion and prevention; secondary skilled, long term, and
rehabilitative; and tertiary: emergent, urgent, and acute care. Strategies are drawn
from both leadership and management theories. Leadership involves both the leader
and the follower.

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