Leadership in LTC

Module 1
• Understand how the concept of leadership has evolved over
time
• Understand current leadership theories in the context of
long-term care (LTC)
• Define clinical nurse leadership
• Reflect on personal leadership strategies 
• Identify personal leadership strengths

Objectives: Module 1
Trends That Impact Health Care in Canada
Focus on
Focus on
patient safety
diversity Enhancing role of
RN more in acute
care
Trends in nursing
education Increased
Self–care is responsibility of
the norm RPN in LTC
Nursing
shortage More nurses in full-time
positions 70%
Focus on nurses working in
inter-disciplinary teams
Issues in the workplace:
Violence, workload, overtime,
scheduling, lack of professional Villeneuve & MacDonald, 2006
autonomy
What changes have you seen in LTC over the past five years?
• One case of Alzheimer's Disease in Canada every 5min - will
increase to 69% in 2034
• 76% of people over age 65 have a chronic health problem
• More RPNs, fewer RNs in long-term care
• Focus on increasing quality care
• Deprescribing
• More of a leadership role for nurses as the complexity of care
increases

Changing Health Care Environment

• Restructuring
• Bed closure & merger of hospital services
• Patient acuity (hospital, LTC, and home care)
• Complexity in care delivery (technology)

Nursing human resources and quality of work life

• Recruitment and retention
• Sick time
• Team work
• Conflicts
• Resident/patient satisfaction - compliance

Impact on Nursing
 Standards of Practice

• College of Nurses of Ontario (CNO)

• Regulated Health Professions Act (RHPA)
• Nursing Act
• Ministry of Health and Long-term Care (MOHLTC)

Governing Bodies…
Evidenced-Based Practice
• Nursing research
• Review of literature
• Clinical Practice Guidelines
• Experience, judgment, and skill
• Quality improvement
• Access to websites
• Patient, consumer interest, knowledge, and expectations

Knowledge, Skill, Judgment

Essential for nursing and nursing leadership:
• Health and well-being
• Choice
• Dignity
• Confidentiality
• Fairness
• Accountability

Practice environments that are conducive to safe, competent, and ethical care

ETHICS…
Leadership in the 21st
Century
It is all about change and adaptation
• Vision
• Cope with change
• Empowers others
• Influence others by what they say, how they say it, and what they do
• Create environments for success
• Develop people, versus controlling people
• Respect others
• Trust their experiences
• Model rather than mold

What Makes a Leader?

• Are key to client/resident care
• Choose their results
• Articulate their expectations
• Understand the organization structure
• Understand the nature of power and politics – a choice to take it and skills to build
it
• Take risks and encourage others
• Use a problem-solving approach that focuses on positive results

Nursing Leaders
 LEADERSHIP MANAGEMENT

Position Selected/allowed by group Appointed by higher person in organization (org)

Power – comes from… Knowledge, credibility, & ability to motivate Position of authority

Goals/visions Personal /passion – may not align with org Prescribed by organization

Risk level High risk, high creativity & innovation Low risk/ balance/ maintain status quo

Degree of order Relative disorder Rationality & control

Nature of activities r/t Vision & judgment Efficiency /cost effect

Focus People Systems & structure

Short range – eye on the bottom line often
Perspective Long-range – with an eye on the horizon
present

The carrot always wins over the stick, Just ask your horse  - Maxwell
Leaders:
• Engaging & influencing
• Visionary, energetic, inspirational, innovative
• Go beyond status quo
• Critical thinking, action, advocacy (CNA, 2009)
Managers:
• Getting job done, work with HHR, budgets, traditional – authoritative, timelines
Followership:
• Engaging with others leading, promotes team effectiveness, collaboration, offering
constructive critiquing

Leaders, Managers, Followers

(Yoder-Wise & Grant, 2015)
Theoretical
Perspectives
Past to present
 Trait
Theories

Key Yoder-Wise, 2015

Leadership Style Theories

Theories
Situational-
Contingency Theories

Transformational
Leadership

Authentic
Leadership
• “GREAT MAN THEORY”
• Born to lead
• Studied from 1900-1950
• Leaders had a certain set of physical and emotional characteristics
that were crucial for inspiring others toward a common goal
• Useful if self-aware, particularly if traits are: drive, motivation,
integrity, confidence etc.

Trait Theories
 • Based on two types of behaviour
• Task
• Relationship
• Combination of task/relationship that
determines effectiveness
• Believed to be learned and cultivated – not
born but taught

Style Theories
• Dependent upon the situation
• Path-Goal Theory – dependent upon task and relationship of followers
• Supportive
• Directive
• Participative
• Achievement oriented
• Situational Leadership Theory
• Level of follower maturity influences appropriate mix of task characteristics –
leader may be more directive if follower new

Situational-Contingency Theories
• Authentic leaders are aware of their own values and moral convictions and
are constantly realigning actions to match their values
• Transparent
• Truthful
• Consideration not given to others
• Works if you are congruent with the leader
• Some association with Emotional Intelligence

Authentic Style Leadership

TRANSFORMATIONAL LEADERSHIP
Transformational Leadership
• Raise each other up to higher levels of motivation for resident outcomes
• Behaviour – charisma, intellectual stimulation, individual consideration,
self-confidence, self-direction
• Moves resources from areas of lesser to greater productivity

Outcomes
• Job satisfaction
• Quality of Life
• Empowerment
• Retention of staff
• Resident satisfaction
“The ultimate goal of transformational leadership is for the
leader and the follower to discover meaning and purpose in
relation to their work, in addition to growth and maturity.”

(Atkinson-Smith, M. 2011, p. 44)

Transformational Leadership
 “Transformational leadership is viewed as the most
effective model of leadership because, while it recognizes
the importance of rewards, it goes further to satisfy the
higher needs of the follower by engaging this person
emotionally and intellectually.”

(Surakka, 2008)
Five Practices of Transformational
Leadership

RNAO Guidelines
Building Relationships and Trust
• Is a critical leadership practice, the foundation on which the other practices rest.
• Relationships include those formed between individual nurses, on teams, and in
internal and external partnerships.

Creating an Empowering Work Environment

• depends on respectful, trusting relationships among people in a work setting.
• An empowered work environment has access to information, support, resources,
and opportunities to learn and grow, in a setting that supports professional
autonomy and strong networks of collegial support.
Creating a Culture that Supports Knowledge Development and Integration
• involves fostering both the development and dissemination of new knowledge
and instilling a continuous-inquiry approach to practice, where knowledge is
used to continuously improve clinical and organizational processes and
outcomes.

Leading and Sustaining Change

• involves the active and participative implementation of change, resulting in
improved clinical and organizational processes and outcomes.
Balancing the Complexities of the System, Managing Competing
Values and Priorities

• entails advocating for the nursing resources necessary for high-

quality patient care, while recognizing the multiple demands and
complex issues that shape organizational decisions. Proper use of
evidence is the key.
• Validate the nurses critical role
• Supply sufficient human resources
• Provide necessary information and decision support
• Create a culture and a climate conducive to effective, efficient nursing care

RNAO, 2013

Organizations that Support this...

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

Chu, C. H., Wodchis, W. P., & McGilton, K. S. (2014). Turnover of regulated nurses in long-
term care facilities. Journal of Nursing Management, 22, 553-562.

Cook, Michael J. "The attributes of effective clinical nurse leaders." Nursing Standard 15.35
(2001): 38-44.

Cummings, G. G., MacGregor, T., Davey, M., Wong, C. A., Lo, E., Muise, M. & Stafford, E.
(2010). Leadership styles and outcome patterns for the nursing workforce and work
environment: a systematic review. International Journal of Nursing Studies, 47, 363-385.

Enterkin, J., Robb, E., & McLaren, S. (2013). Clinical leadership for high-quality care:
Developing future leaders. Journal of Nursing Management, 21, 202-216.

References
Hutchinson, M., & Jackson, D. (2013). Transformational leadership in nursing: Towards a more
critical approach. Nursing Inquiry, 20(1), 11-22.

Kelly, P., & Crawford, H. (2008). Nursing Leadership and Management. (1st Canadian ed.).
USA: Thomson Delmar Learning.

Kelsey, C., & Hayes, S. (2012). A framework for educational leadership. Change Management,
22(8), 16-20.

Lacasse, C. (2013). Developing nursing leaders for the future: Achieving competency for
transformational leadership. Oncology Nursing Forum, 40(5), 431-433.

McIntyre, M. & McDonald C. (2014). Realities of Canadian Nursing; Professional, practice,

and power issues. (4th ed.). China: Lippincott Williams & Wilkins.

References
Munir, F., Nielsen, K., Garde, M.H., Albertsen, K., & Carneiro, I.G (2012). Mediating the
effects of work–life conflict between transformational leadership and health-care workers job
satisfaction and psychological wellbeing. Journal of Nursing Management, 20, 512-521.

Rankin, V. (2015). Clinical nurse leader: a role for the 21st century. MedSurg Nursing, 24(3),
199-203.

RNAO, (2013). Developing and sustaining nursing leadership. Best Practice Guideline (2nd
ed.).

Squires, M., Tourangeau, A., Spence Laschinger, H. K., & Doran, D. (2010). The link between
leadership and safety outcomes in hospitals. Journal of Nursing Management, 18, 914-925.

References
Surakka, T. (2008). The nurse manager's work in the hospital environment during the 1990s and
2000s: responsibility, accountability and expertise in nursing leadership. Journal of Nursing
Management, 16(5), 525-534.

Weberg, D. (2010). Transformational leadership and staff retention: An evidence review with
implications for healthcare systems. Nursing Administration Quarterly, 34(3), 246-258.

Welford, C. (2002). Matching theory to practice. Nursing Management, 9(4), 7-11.

Weiss, S.A., & Tappen, R.M. (2015). Essentials of Nursing Leadership and Management. (6th
ed.). Philadelphia: F.A. Davis Company.

Yoder-Wise, P.S. (2015). Leading and Managing in Canadian Nursing. (1st ed.). Toronto:
Elsevier Canada.

References