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The Impact of Transformational Leadership in the Nursing Work Environment and Patients’ Outcomes: A Systematic Review

Line miray kazin ystaas.

1 Department of Health Sciences, School of Life and Health Sciences, University of Nicosia, Nicosia 1700, Cyprus

Monica Nikitara

Savoula ghobrial, evangelos latzourakis, giannis polychronis, costas s. constantinou.

2 Department of Basic and Clinical Sciences, Medical School, University of Nicosia, Nicosia 1700, Cyprus

Associated Data

The articles’ data supporting this systematic review are from previously reported studies and datasets, which have been cited. The processed data are available in Table 2 and in the reference list. Further information can be requested from the corresponding author.

Background: With the increasingly demanding healthcare environment, patient safety issues are only becoming more complex. This urges nursing leaders to adapt and master effective leadership; particularly, transformational leadership (TFL) is shown to scientifically be the most successfully recognized leadership style in healthcare, focusing on relationship building while putting followers in power and emphasizing values and vision. Aim: To examine how transformational leadership affects nurses’ job environment and nursing care provided to the patients and patients’ outcomes. Design: A systematic literature review was conducted. From 71 reviewed, 23 studies were included (studies included questionnaire surveys and one interview, extracting barriers and facilitators, and analyzing using qualitative synthesis). Result: TFL indirectly and directly positively affects nurses’ work environment through mediators, including structural empowerment, organizational commitment, and job satisfaction. Nurses perceived that managers’ TFL behavior did not attain excellence in any of the included organizations, highlighting the necessity for additional leadership training to enhance the patient safety culture related to the non-reporting of errors and to mitigate the blame culture within the nursing environment. Conclusion: Bringing more focus to leadership education in nursing can make future nursing leaders more effective, which will cultivate efficient teamwork, a quality nursing work environment, and, ultimately, safe and efficient patient outcomes. This study was not registered.

1. Introduction

Patient harm caused by errors in healthcare is the leading origin of morbidity and mortality internationally [ 1 ]. Researchers are linking adverse patient safety outcomes to a lack of effective leadership, while relational leadership styles, like transformational leadership, continue to be associated with reduced adverse patient outcomes [ 2 , 3 ]. Nursing is dynamic and requires inspiring and engaging leaders and role models. However, the development of nurse leaders is challenging for the nursing profession.

Currently, nurses face a burnout epidemic rooted mainly in the work environment influenced by excessive workloads and a lack of organizational support and leadership [ 4 ]. Maben et al. (2022) reported that nurses globally face a heightened vulnerability to mental health issues and suicide, surpassing other occupational groups, while the COVID-19 pandemic has exacerbated the existing challenges in their work environment, further intensifying the already demanding conditions [ 5 ]. The engagement in emotional labor within the nursing profession exposes practitioners to a notable susceptibility to experiencing burnout, moral distress, and compassion fatigue. Prior to the onset of the pandemic, the international cadre of nurses was already confronting considerable hurdles, encompassing prolonged duty durations, rotation schedules, inadequate staffing, and periodically arduous situations [ 5 , 6 , 7 ]. Throughout the pandemic, nurses encountered a range of stress-inducing factors, including managing heightened public expectations and pressure, adapting to new work responsibilities, facing elevated mortality rates, dealing with the infectious nature of COVID-19, experiencing psychosocial stress, confronting the scarcity of personal protective equipment, handling demanding job requirements, and contending with inadequate psychological support [ 8 ]. At the same time, scholars have found poor working conditions for nurses and inadequate staffing to predict adverse patient outcomes based on the low-quality nursing job atmosphere and the absence of appropriate leadership styles [ 9 , 10 ].

Safety issues in care, such as adverse events, medication errors, falls, and surgery mistakes, have plagued healthcare systems internationally for decades. Several investigations have acknowledged healthcare environments as high-risk with a lack of safety culture, causing long-delayed discharge, disability, or even death [ 2 , 11 ]. Inherently, the nursing profession and current healthcare climate are chaotic, and a positive safety culture has been proven to come from a creditable and visible leader who supports patient safety behaviors [ 12 ]. It is important to recognize that nurses have the highest patient interaction, making nurse leaders central catalysts to positively influencing patient safety culture to reach safer patient outcomes [ 13 , 14 ].

The quality of the nursing work environment is an indicator of nurse satisfaction. A leader who involves staff fosters teamwork, rewards good performance, and encourages motivation can impact the quality of work life [ 15 , 16 ]. The leadership style describes how the leader interacts with others and can be categorized into two main styles: task-oriented and relational [ 17 ]. Historically, leadership theories started with the Great Man Theory during the Industrial Revolution with strong hierarchical leader-centric decision making, focusing on command-and-control, productivity, and seeing the organization as linear, operating like a machine [ 18 ]. This leadership style model in healthcare is no longer sustainable, as proven by a lack of change and persisting patient safety issues. Researchers have found that healthcare innovation requires nonlinear and emergent social processes that result in improved organizational outcomes [ 19 ]. In recent years, the two relational styles, transformational and transactional leadership, have been explored through nursing literature and have become high profile in general healthcare research.

Transformational leadership is composed of four key components. Firstly, “idealized influence” involves the leader behaving as a robust role model toward followers, demonstrating a work ethic and strong values while preaching the organization’s vision, thereby winning the staff’s trust and confidence [ 20 ]. The second type of behavior is referred to as “inspirational motivation”. It includes creating a compelling and inspiring vision for the future and communicating it to followers through emotionally charged speeches, vivid imagery, and captivating symbols. This encourages followers to strive to reach this shared vision, thus creating a deeper level of commitment and higher performance [ 17 ]. The third type of behavior is called “intellectual stimulation”. Intellectual stimulation encourages followers to think outside the box and consider different approaches to everyday issues, enabling them to devise innovative solutions to these problems [ 21 ]. The final category of behaviors is “individualized consideration”, including coaching, helping followers achieve goals, and providing a supportive climate. By carefully listening, leaders can help fulfill those needs [ 22 ]. For instance, some followers might require explicit guidance regarding how to get a job done, while others require the provision of needed resources so they can figure out the solution on their own. Nonetheless, TFL’s four behaviors construct a transformational leader if performed consistently and are found to bring respect and admiration by followers [ 23 ].

1.1. Rational

Healthcare systems are globally facing a crisis, with nurse shortage being a perennial issue. Nurses have the highest patient interaction, making nurse leaders central catalysts in positively influencing patient safety culture to reach safer patient outcomes [ 13 ]. At the same time, negative nursing work environments cultivate dissatisfied nurses who are likely to suffer from emotional exhaustion or burnout because of ineffective leadership [ 14 ]. Amidst these challenges, there is growing recognition of the potential impact of transformational leadership in healthcare settings.

Transformational leadership is characterized by its focus on relationship-building, empowering followers, and emphasizing shared values and vision. This leadership style has been found to positively affect various industries and sectors, including healthcare. However, there remains a gap in knowledge regarding its specific effectiveness in healthcare settings. A comprehensive analysis of the potential benefits of transformational leadership in the healthcare context is warranted. This systematic review aims to address this gap by investigating the effectiveness of transformational leadership and its potential to create better working environments, ultimately leading to improved patient outcomes. We have identified a crucial area of inquiry that has not been thoroughly examined in the existing literature—a systematic review that delves into the relationship between transformational leadership and its effects on both the working environment and patient outcomes. We have identified a single literature review from the preceding decade (2002–2012) that focused on the efficacy of transformational leadership in relation to both work environments and patient outcomes [ 24 ]. Considering this, our current investigation is oriented towards delving into scholarly works spanning the subsequent decade (2012–2022), with the intention of comprehensively examining the evolving discourse on this subject matter. By exploring and synthesizing the current body of knowledge on this topic, our study will contribute valuable insights to the field, allowing healthcare organizations to better understand the impact of transformational leadership and make informed decisions regarding their leadership practices.

The significance of this research lies in its potential to shed light on a promising approach to address the pressing challenges faced by healthcare systems—nurse shortage and dissatisfaction—through effective leadership strategies. By providing evidence-based insights, this review seeks to guide healthcare leaders in adopting transformational leadership practices to create a positive work environment for nurses, reducing emotional exhaustion and burnout, and ultimately enhancing patient care and safety.

In conclusion, the dearth of research on the relationship between transformational leadership, work environment, and patient outcomes in healthcare settings highlights the necessity of this review. By examining the effectiveness of transformational leadership and its potential impact on nurses’ well-being and patient outcomes, our study aims to fill this critical gap in knowledge and contribute to the advancement of healthcare leadership practices.

1.2. Objective and Research Question

Having delineated the rationale and imperative for conducting this systematic review, our primary aim was to search, retrieve, and critically evaluate all pertinent studies centered around the concept of transformational leadership, with a particular focus on its efficacy in fostering an improved working environment for nurses and influencing patient outcomes comprehensively and systematically.

Our aim was to synthesize and analyze studies, and therefore, we used the PICo framework for studies to determine a research question. PICo is the simplest of the frameworks to use for qualitative questions; it stands for Population, Interest, and Context and can be used to find a range of primary literature. The Population in our study is nurses; the Interest is transformational leadership, working environments, and patient outcomes; and the Context is hospitals. Based on the PICo framework, we formulated our research question as follows: “What is the impact of transformational leadership on staff nurse work environments and patient outcomes?”

2. Methodology

To effectively accomplish our aim and investigate our research question, we utilized a systematic review approach following the guidelines outlined in the PRISMA 2020 statement [ 25 ]. The PRISMA 2020 checklist is available in Appendix A . In the subsequent subsections, we provide a comprehensive overview of our methodology.

2.1. Eligibility Criteria

Each of the chosen studies incorporated in this systematic review had to fulfill specific inclusion criteria, as outlined in Table 1 provided below.

Inclusion/Exclusion Criteria.

2.2. Information Sources and Search Strategy

We used the following databases to choose the articles: MEDLINE, CINAHL, and SCIENCE DIRECT. The search approach employed the Boolean operator OR between the keywords nurse, working environments, patients’ outcomes, and transformational leadership and comparable MeSH phrases. To refine the search, phrases with diverse meanings were joined using the Boolean operator AND. The search approach used on the EBSCO platform for the aforementioned databases is described in Table 2 We limited the search to journal articles in English with the full text available. However, numerous studies were rejected as they referred to other leadership styles than transformational leadership in addition to other healthcare settings than a nursing work environment.

Search approach.

* The asterisk in Ebsco platform wildcard in search finds words with a common root.

2.3. Selection of Studies Process

Two researchers (the first two authors) conducted independent searches, retrievals, and selections of studies, initially based on three primary criteria: (a) the presence of primary research, (b) the inclusion of transformational leadership as a topic, and (c) relevance to nursing care. Subsequently, additional criteria, such as peer-reviewed articles published in journals or conference proceedings, as well as the publication date, were employed for further refinement. Upon completing the initial selection process, the two researchers engaged in discussions and compiled a list of prospective articles. This list was shared with four other researchers, who collectively determined the final articles to be included in the review, making any necessary additions or removals as deemed appropriate.

2.4. Data Collection Process

The data from the selected studies were independently collected by two researchers. They extracted the components, items, statements, or competencies that had achieved consensus among experts during the final round of each study. Specifically, the following data from each study were extracted: title of the study, authors’ names, publication year, study design, tools, sample characteristics, and summary of main findings and results. Subsequently, the researchers thoroughly reviewed the extracted data multiple times and proceeded to code and identify overarching themes.

2.5. Synthesis Methods

The data were synthesized by content analysis, and the findings were categorized into themes. After carefully examining the results and findings section of a chosen article, an initial set of codes was created. These codes underwent further improvement as more articles were analyzed. Each line of text was assigned a code, and a code tree was utilized to identify emerging themes. From the interpreted meanings, sub-themes were derived and combined. These sub-themes underwent further analysis and were eventually condensed into a single overarching theme. Content analysis can aid in the identification and summarization of submerging key elements within a large body of data during the review process [ 26 ]. The themes of the effectiveness of TFL in the nursing environment were organized according to the content analysis suggested by Zhang and Wildemuth (2009) [ 27 ].

To ensure the validity of the results, a two-level quality assurance process was implemented. The authors of this paper independently followed the review procedure, including coding, categorization, revisiting the studies, and refining the codes and categories. Subsequently, they convened, engaged in discussions, refined the analysis, and finalized the results.

This review was conducted in accordance with the PRISMA statement ( Figure 1 ) [ 25 ], which provides a set of guidelines for conducting reviews and meta-analyses in a comprehensive and systematic manner.

An external file that holds a picture, illustration, etc.
Object name is nursrep-13-00108-g001.jpg

PRISMA flowchart with the search strategy of the systematic review.

3.1. Studies Selection

The initial search process resulted in 71 articles related to transformational leadership. There were no duplications ( Figure 1 ), and therefore, 71 articles were included for advance screening. Fourteen (14) articles did not relate to nurses’ work environment and were omitted. Two researchers thoroughly reviewed the remaining 57 articles independently. From this process, 34 articles were excluded as they did not satisfy the criteria for inclusion. The final number of articles that met the criteria for inclusion was twenty-three (23).

3.2. Studies Characteristics

These 23 articles were conducted in various countries and assessed the effect of transformational leadership in a nursing clinical work environment. Most of the studies included a multifactor leadership questionnaire to evaluate nurses’ perceived effectiveness of transformational leadership (1–10, 13, 14, 16, 18, 19, 22, 23). Further information about the articles, such as author, year, tool, methodology, sample, and main results, is described in Table 3 below.

Articles Description.

3.3. Study Assessment

The quality of the articles included in this review was checked by the Joanna Briggs Institute Qualitative Assessment and Review Instrument Critical Appraisal Checklist. The Joanna Briggs checklist evaluates the methodological quality of a study while determining the possibility of an indication of bias in its conduct, design, and analysis. As can be seen from Table 3 , there were 21 cross-sectional studies (1–11, 13–19, 21–23), 1 descriptive–correlational study (12), and 1 qualitative study (20).

All the included studies largely adhered to the Joanna Briggs criteria, providing comprehensive and detailed descriptions of their respective methodologies and procedures Table 4 , Table 5 and Table 6 . However, it was observed that two of the cross-sectional studies did not explicitly outline any specific strategies to address the stated confounding factors. Nevertheless, as Dekkers et al. (2019) argue, confounding is not dichotomous but rather a continuum where varying degrees of confounding influence can exist [ 28 ]. Furthermore, in accordance with the Joanna Briggs guidelines, the qualitative study failed to disclose the researcher’s cultural or theoretical standpoint, as well as the potential influence of the researcher on the research process. It is worth noting that such omissions are common in qualitative studies, where the focus is on understanding the subjectivity of the participants and allowing their perspectives to emerge naturally.

JBI Critical Appraisal Checklist for Analytical Cross-Sectional Studies.

Risk of Bias Assessed by the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Study Results.

JBI Critical Appraisal Checklist for Studies Reporting Prevalence Data Results.

3.4. Results of Synthesis

Two major themes emerged, effectively addressing the research questions. Within each theme, several categories were identified, shedding light on the multifaceted nature of the topic under investigation. The themes and their corresponding categories were as follows.

Theme 1: Staff nurses’ work environment:

  • Job Satisfaction and Organizational Commitment;
  • Reduce Nurse Retention;
  • Nurses’ Empowerment and Autonomy;
  • Nurses’ Compliance with Safety Measures.

Theme 2: Patients’ outcomes:

  • Patient Safety Culture;
  • Reporting Adverse Events.

3.4.1. Job Satisfaction and Organizational Commitment

Various studies that investigated the mechanism of TFL detected its strong influence on employee attitudes and behaviors in nursing. Nurses’ work attitudes are reflected in their levels of job satisfaction and organizational commitment [ 29 , 30 ]. It was clear from the literature that TFL frequently positively influenced nurses’ work environment by indirectly increasing job satisfaction [ 31 , 32 , 33 , 34 ]. Employees’ positive perception of jobs and organization is revealed through job satisfaction [ 30 ]. Researchers link TFL and empowerment to the establishment of self-determination and competency, which is proven to impact job satisfaction, suggesting the direct relationship between nurse empowerment and nurse job satisfaction, enhancing the quality of the nurses’ work environment [ 9 , 32 ].

There is also evidence to construct a strong link between organizational commitment and job satisfaction. Interestingly, the statistics showed that nursing staff committed to their organization with a strong sense of loyalty and dependence also had higher levels of job satisfaction [ 29 , 33 ]. Further, higher levels of organizational commitment and job satisfaction were also associated with increased health status in the nurses [ 33 ]. More specifically, TFL was related to more excellent supervisor support, increasing job satisfaction among the nurses, and resulting in more significant organizational commitment [ 29 ]. In a study examining the effectiveness of TFL in the environment of elderly care, TFL was found to effectively strengthen the nursing staff’s sense of belonging to the organization, reducing their burnout. The clan culture established through TFL effectively influenced organizational commitment and job satisfaction, where the atmosphere of a home culture created within their work environment promoted the intrinsic values of nursing staff while improving cohesion between the nurses and the quality of care [ 33 ]. However, TFL was found to have a direct positive effect on organizational commitment [ 33 , 35 ].

3.4.2. Reducing Intention to Leave the Job/Organization

Studies also found that TFL can reduce the nurses’ intent to leave the job, which is closely related to the previous category, as job dissatisfaction can be the primary precursor of nurses’ intent to leave [ 29 ]. The literature generally highlights that the TFL style shapes employees’ perceptions and feelings around their nursing managers and affects their desire and obligation to maintain the intent to stay in their organization [ 36 ]. A recent cross-sectional study examining 645 nurses working during the COVID-19 pandemic found that a supportive workplace culture can construct an adaptive mechanism through which transformational leaders can improve retention [ 37 ]. Additionally, the literature found TFL to decrease emotional exhaustion amongst nurses by encouraging a spiritual climate, indicating that a positive spiritual climate facilitated through TFL can reduce burnout and decrease nursing staff’s intent to leave [ 31 ]. However, there was insufficient evidence proving a direct correlation between TFL and staff nurses’ decision to stay or leave their job [ 33 , 35 ], but it was suggested that TFL has the potential (but not the primary factor) to slow down attrition and retain nurses by improving job satisfaction and organizational commitment, creating a positive work environment and increasing nurses’ probability of staying [ 35 ]. TFL seems to not act directly on job satisfaction or intent to stay but rather create a multifaceted positive work environment leading to a quality nursing environment. Consequently, it was reported that TFL indirectly influenced willingness to stay by positively influencing staff organizational commitment and job satisfaction [ 29 , 33 , 35 ].

3.4.3. Nurses’ Empowerment and Autonomy

Literature highlights that the TFL style within nursing can give staff nurses increased autonomy through empowerment strategies and meaningful participation in decision-making [ 30 , 31 , 36 ]. In turn, TFL-facilitated empowerment has been proven to increase employee commitment within their units by delegating power to nurses, leading to increased authority within their work environment [ 30 , 36 ]. Empowerment through decision-making involvement via removing formal organizational barriers has been found to reduce powerlessness in the nurse work environment, reducing job burnout and increasing job satisfaction [ 30 ]. RN-MD collaboration and teamwork within and across units were thought to be necessary for the nurse’s autonomy [ 38 ]. Further, the literature relates to the concept that a well-functioning patient safety climate requires nurses with autonomy to deal with problems regarding patient safety while proposing specific solutions and getting support and encouragement from organizations to facilitate patient safety-based innovations [ 39 ].

TFL and transactional leadership behaviors were found to affect empowerment amongst the nursing staff positively. However, TFL behaviors allowed nursing managers to reach even higher levels of success without congruence and reward, embedding empowerment into the clinical environment [ 40 ]. Some studies also identified the empowerment subscale, autonomy, as the statistically significant predictor of commitment, indicating that managers can engage nurses in appropriate decision making about patient care and safety in their work environment [ 30 , 36 ]. Management that does not accept decision-making participation dissembles empowerment, which frustrates and makes staff dependent on an authoritarian structure [ 36 ].

3.4.4. Nurses’ Compliance with Safety Measures

Lievens and Vlerick (2014) found a strong association between TFL and nurse safety compliance [ 41 ]. The more transformational the leader was perceived, the more the nursing staff participated and complied with patient safety practices. Further, staff nurses’ structural empowerment also experienced a significant correlation with the degree to which they perceived nursing managers’ (NMs) TFL behaviors [ 36 , 40 ]. Research also suggested that when nurses perceived their TFL to facilitate an innovative work climate, they automatically contributed to developing innovation behaviors [ 39 ]. Previously mentioned research suggested that nurses need to feel a part of their work environment. However, countries where staff are hesitant to challenge authority create a reluctance to change, and compliance can breed a lack of stimulation [ 31 ]. It was reported that nurse managers should be trained to challenge nurses to resolve problems and specialize their competence to foster innovation and grow talents and creativity [ 36 ].

Lievens and Vlerick (2014), in their cross-sectional study which included 145 nurses, also found intellectual stimulation to strongly impact knowledge-related characteristics, suggesting an indirect link between safety performance and TFL through skills and ability demands, where the more knowledge-related job characteristics were perceived, the more nurses complied with safety rules [ 41 ]. Skill utilization or intellectual stimulation was further found to be the strongest single predictor of work engagement, compared to TFL, where nurses appreciated opportunities for personal development, learning new things, and achieving something meaningful, encouraging work engagement [ 2 , 42 ].

Patients’ outcomes:

The literature shows a positive relationship between TFL and the improvement of patient safety climate and culture, emphasizing that nursing managers are key to developing a safety climate and maintaining a culture of patient safety, preventing adverse events.

3.4.5. Increase Patient Safety Culture

There was a significant prevalence of findings reporting TFL to facilitate patient safety either directly [ 2 , 9 , 38 , 42 ] or indirectly [ 32 , 39 , 41 ]. Seljemo et al. (2020), in their cross-sectional study, questioned 156 nurses; Ree and Wiig (2019), also in a cross-sectional design study, questioned 139 nurses and found TFL to be the strongest predictor of patient safety culture and overall perception of patient safety compared to job demands and resources [ 2 , 42 ]. This was suggested to result from TFL having a positive direct effect on the psychosocial work environment. Further evidence also links TFL directly to quality patient outcomes, reducing the possibility of adverse patient outcomes and increasing the quality of care [ 9 ].

Patient safety culture includes themes such as teamwork within units, managers’ support, organizational learning, overall perceptions of safety, feedback and communication openness about the error, frequency of events reported, staffing, handoffs and transitions, and non-punitive response to errors. “Teamwork within units” generally had a common positive perception amongst the nurses, indicating collaboration within their units as effective within TFL [ 38 , 43 , 44 ]. Anselmann and Mulder (2020) asked 183 geriatric nurses in their cross-sectional study, and they support the above, finding that TFL has a positive impact on team performance when a safe climate is fostered [ 45 ]. Even though nurses found cohesion within their units, literature revealed a common theme of insufficient “teamwork between units”, indicating that each unit had an independent culture [ 38 , 43 , 44 ]. Further, a generally weak perception of the effectiveness of RN-MD collaboration was also observed [ 38 , 43 ].

Researchers stressed the necessity of having efficient teamwork between units and on a multi-professional level to create an effective patient safety culture [ 9 ]. Another reoccurring subdimension, “feedback and rewarding”, was also identified as a weak component of TFL in relation to patient safety culture, illustrating a lack of adaptation and implementation of TLF behavior [ 9 , 43 , 46 ]. The TFL nursing manager generally seemed to conduct insufficient work around feedback and rewards, resulting in staff nurses not being encouraged and ensuring that medical errors were prevented and learned from [ 43 , 46 ].

3.4.6. Reporting Adverse Events

Adverse events can result in patient disability or death, prolong the time necessary to provide care, and increase healthcare costs and patient dissatisfaction [ 47 ]. However, a part of the literature showed that when TFL and transactional leadership were compared, reporting errors without blame and discussing errors openly were the two initiatives that transactional leadership implemented better than TFL [ 40 , 48 ]. A significant finding in the literature was the reoccurring theme of weak patient safety culture in relation to “non-punctual reporting of adverse events” in hospitals with TFL, where staff nurses rarely reported occurring medical errors to their NMs [ 34 , 44 , 46 , 48 , 49 ]. In a Finnish study, one in four nurses showed to not have reported one or more medication errors using their units’ adverse event registration system [ 46 ]. Tekingündüz et al. (2021), in a cross-sectional study with 150 participating nurses, also found a significant weakness in their organization’s patient safety culture, where 52.7% of the nurses did not report any adverse events in the last 12 months, 31.3% reported 1–2 adverse events while 10% reported 3–5 adverse events [ 49 ]. Further, in a qualitative study, the eleven nurse manager participants expressed the importance of nursing staff reporting the occurrence of adverse events to detect why each event happened and identify patient safety risks and solutions [ 50 ]. There was evidence to suggest that nurses reported that the occurrence of errors only sometimes led to a positive change, whereas at other times, it did not lead to any change, and errors were repeated [ 38 ]. The literature explained blame culture and fear in the nurse’s work environment as a factor distancing them from punctuative reporting of medical errors [ 46 , 49 , 50 ]. It was suggested by researchers that nursing staff were not encouraged to report and discuss adverse events openly and blame-free [ 48 , 49 , 50 ]. This involves handling adverse reports by nursing managers without making nursing staff feel guilty.

Managers reported that a culture where it is recognized that everyone makes mistakes is imperial, while it was observed that nurses tended to report other colleagues’ mistakes compared to their own [ 50 ]. Further, nursing managers noticed that nursing staff may blame themselves for a patient safety incident where they feel ashamed and worry about their colleague’s perception of them [ 49 ]. These perceptions were confirmed by nursing staff in another study, expressing their tendency to avoid reporting due to fear of punishment, humiliation, damage to reputation, disciplinary action by a licensing board, malpractice lawsuits, and limited follow-up after reporting loss of job [ 48 ]. Tekingündüz et al. (2021) also found the defect in reporting medical errors to be rooted in nurse’s fear of punishment and lack of confidentiality [ 49 ]. Generally, fear was perceived as a major reason for not reporting adverse events, and nursing managers saw this as a barrier to the effectiveness of their leadership and the attempt to develop their operational models to improve patient safety [ 46 , 49 , 50 ]. However, visionary leadership styles such as TFL correlate positively with both incident reporting and patient safety outcomes. Additionally, TFL is linked to improved patient safety, including reduced mortality rates, fewer medication errors, lower incidences of pneumonia and urinary tract infections, and fewer patient falls, attributed to the leaders’ approach of using errors as chances to enhance processes and promoting the reporting of near misses and adverse events [ 17 , 51 ].

Interestingly, a part of the literature showed that when TFL and transactional leadership were compared, reporting errors without blame and discussing errors openly were the two initiatives that transactional leadership implemented better than TFL [ 40 , 48 ]. These findings confirm the weakness around reporting adverse events and blame culture within TFL units.

4. Discussion

This review has collectively reviewed literature that has examined the effectiveness of transformational leadership (TFL) in a nursing work environment and patients’ outcomes. TFL has a complex, interconnected effect on nurses’ intrinsic environment and patient outcomes.

Nurses’ Work Environment:

The literature revealed substantial evidence that TFL can significantly enhance nurses’ psychosocial work environment by indirectly increasing job satisfaction. Three significant mediators between TFL and job satisfaction were nurse empowerment, organizational commitment, and spiritual climate, which altogether were thought to prevent retention in nursing [ 29 , 30 , 31 , 33 , 34 , 35 , 37 ]. Simultaneously, TFL was not the primary factor in job satisfaction but instead a facilitator and constructor of structural empowerment, organizational commitment, and spiritual climate. It is, therefore, evident that the literature revealed a positive domino effect that transformational leaders in nursing can generate. Generally, the literature revealed a strongly positive relationship between TFL and workplace culture in nursing [ 33 , 37 ]. Specific TFL attributes created an inclusive and supportive work environment, either directly or indirectly enhancing the nurses’ work environment and decreasing the risk of nurse burnout [ 37 , 52 ]. Nurses continuously reported managers’ support as a particularly important resource in their work environment, where establishing a high-quality relationship with their leaders was seen as imperial for patient safety culture [ 38 , 42 ].

The correlation observed between supportive leadership and favorable patient safety outcomes underscores the significance of Transformational Leaders (TFLs) possessing a comprehensive grasp of patient safety protocols, as well as recognizing the pivotal role played by bedside nurses in advancing improved safety outcomes. [ 17 ]. More specifically, managers’ support was also found to reinforce innovative behavior [ 39 ], increase job satisfaction [ 35 , 37 ], and even be the primary factor in a positive work environment, compared to TFL [ 29 ]. Conversely, the literature also described managers’ support as a core transformational behavior, where the more transformational the leader was perceived, the more the staff nurses experienced individual support in their clinical environment [ 29 , 42 , 46 ]. As concluded by the literature, TFL is not the primary factor but rather a mediator to job satisfaction, which was determined as an essential nursing outcome, shadowing quality work environment and may be an effective retention strategy in nursing. Previous studies confirm that safety outcomes are improved when workplace empowerment takes place in a positive nurse–leader relationship based on trust and respect, where they, together, work toward a patient safety culture [ 53 ].

Therefore, incorporating transformational leadership in nursing has numerous implications, with a direct and positive impact on job satisfaction. By nurturing a sense of purpose, providing support and empowerment, and promoting individual growth, transformational leaders create a fulfilling work environment that motivates nurses to excel. As nurses experience greater job satisfaction, patient care quality also improves, resulting in cooperative success for healthcare organizations, nursing staff, and the patients they serve.

Patients’ Outcomes:

The connection between supportive leadership and positive patient safety outcomes points to the importance of the TFL’s understanding of patient safety processes and the role of bedside nurses in promoting better safety outcomes [ 38 ]. However, several researchers reported not having a visible leader [ 43 ], which is documented as essential for patient safety changes to occur [ 53 ].

Researchers are linking negative patient safety outcomes to a lack of effective leadership, while relational leadership styles like transformational leadership continue to be associated with reduced adverse patient outcomes [ 17 ]. However, TFL nursing managers were repeatedly reported by the staff nurses only to communicate errors and problems after the adverse event, waiting for the event before resolving problems and taking proactive action [ 36 , 50 ]. Literature highlights that organizations that have successfully created a non-blame culture have better patient safety outcomes because the staff are encouraged to report errors, unsafe practices, and adverse events, perceiving safety around seeking help and assistance without threat [ 54 ]. Therefore, avoiding a blame culture and developing a reporting system serves as a proactive approach to identifying and mitigating risks, ultimately preventing errors and recurring mistakes, which, when left unaddressed, can result in significant social and economic burdens due to fatalities and preventable incidents [ 51 ] Additionally, developing a safety culture through managers’ interdisciplinary walkabout safety rounds has been associated with safety outcomes [ 17 ].

Transformational leadership in nursing has far-reaching implications for patient outcomes and care quality. By fostering a collaborative and patient-centered approach, empowering nursing staff, encouraging continuous learning, and promoting a culture of excellence, transformational leaders enhance the overall care experience for patients. Ultimately, the positive impact of transformational leadership on patient outcomes establishes it as a key factor in ensuring the delivery of high-quality healthcare services in nursing settings.

This literature review enriches nursing practice and research in a time where nursing leaders are sought to have an important and prominent role in healthcare policy development and improvement. Increased demand and complexity of patient care require effective and competent leadership skills and an understanding of TFL’s function in the current healthcare environment. Even though literature has constructed the idea of the nexus between patient safety and leadership, patient safety outcomes are unlikely to improve without facilitating and fostering the professional growth of future leaders. Additionally, factors influencing organizational job satisfaction and organizational commitment are significantly under the influence of TF nurse leaders. Therefore, healthcare organizations and the educational sector should invest in leadership training and curriculum to implement it further into nursing to support and ensure safe, quality work environments for both nurses and patients.

5. Limitations of the Study

This literature review predominantly incorporated quantitative research methodologies, which, in certain instances, can present challenges in contextualizing a phenomenon comprehensively, as the data may not always possess the robustness required to elucidate intricate issues. Additionally, it should be noted that the review’s scope was confined to studies published exclusively in the English language, with no inclusion of relevant content from the grey literature beyond the stipulated publication sources, and unpublished dissertations were also omitted from consideration. Consequently, it is essential to acknowledge that this review may not provide a fully representative overview of all pertinent scholarship within the field.

6. Conclusions

Despite the global recognition and attempted implementation of TFL in healthcare, the statistics still show that TFL is yet to be mastered within nursing. The strong relationship between TFL, structural empowerment, job satisfaction, and organizational commitment signify that an improved quality work environment may be the most essential element to enhance job effectiveness and patient safety in nursing. TFL is a vital facilitator that could help healthcare to improve job satisfaction and reduce adverse events. Evidence suggests that nursing managers who possess effective TFL attributes are likely to influence their nursing staff’s satisfaction and mitigate the risk of burnout by establishing a supportive and inclusive work environment directly or indirectly. Focusing on the adoption of a blame-free culture through effective leadership is likely to break down barriers to safety culture, which has resulted in poor patient care worldwide. Patient safety outcomes rely on a well-established patient safety culture, which is most influenced by the bedside nurse, either directly or indirectly. With effective leadership engagement and education, emerging nursing leaders can be supported while the nursing team can be empowered to make the necessary changes to reach levels of excellence within their units. It is important to comprehend that leaders are not just in executive and senior positions but include any part of the healthcare team that is influential to patient care. Effective TFL engagement has the potential to enhance patient safety, where it is conveyed that all healthcare workers, from executive to bedside nurses, participate in a positive safety culture.

PRISMA 2020 Checklist.

From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi: 10.1136/bmj.n71. For more information, visit: http://www.prisma-statement.org/ , access on 26 March 2023.

Funding Statement

This research received no external funding.

Author Contributions

Conceptualization, search, coding, and drafting, L.M.K.Y. and M.N.; search and quality assurance, coding, and feedback, S.G., E.L., G.P. and C.S.C. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Data availability statement, public involvement statement.

No public involvement in any aspect of this research.

Guidelines and Standards Statement

This manuscript was drafted against the PRISMA 2020 Statement. A complete checklist is found in Appendix A of the manuscript.

Conflicts of Interest

The authors declare no conflict of interest.

Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

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Leadership, Management and Team Working in Nursing

Leadership, Management and Team Working in Nursing

  • Peter Ellis
  • Description

Leadership is central to all aspects of the nursing role, from managing the delivery of high quality care to acting as a role model for best practice. Written specifically for nursing students, this book introduces you to the principles and practice of leadership, management and multi-disciplinary team working.

relevant to the programme

really comprehensive text, informative and thought provoking for third year nursing students.

I particularly like the activities; reflection, critical thinking, evidence base and research

Ordered for our library. Useful text with comprehensive coverage

This is an excellent book and I have adopted this for my DN Programme for post graduate students. We are already using some of the reflective exercises within it. Some students have since purchased it.

This book will offer the students a framework for them to develop their knowledge of leadership and be able to reflect their own position then build on key knowledge and skills to enhance their role. It is clearly written and easy to understand making it a good resource for nurses new to general practice

This book is easy to understand and contains helpful information on leadership theory, managing change and working in teams effectively. Having used it with final year student nurses, it has been very helpful at introducing these concepts for development of their service improvement projects and their roles as leaders. The activities aid reflection on one's own practice as well as further exploration.

a comprehensive update that will be of great benefit to students

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Leadership, management and team working in nursing, jacqueline harley senior lecturer, nursing and midwifery higher education department, st helier, jersey.

HEALTH AND social care services require staff who can demonstrate leadership, management and teamwork skills. It is therefore vital that nursing students are encouraged to acquire such skills as soon as possible.

Nursing Management . 22, 10, 16-16. doi: 10.7748/nm.22.10.16.s14

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leadership management and team working in nursing essay

01 March 2016 / Vol 22 issue 10

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Good leadership means better care

“Show me the environment and I will tell you the kind of leadership in that place. If staff are smiling and welcoming it’s because the leader is smiling and welcoming. Staff follow the leader as role model, and the leader’s relationship with their team translates into making such a big difference to the care provided.”

Wendy Olayiwola, National Maternity Lead at NHS England and NHS Improvement

For safe, kind, effective care to be delivered, good leaders are crucial.

Leadership covers a wide range of behaviours and ways of working such as speaking up to advocate for patients or to raise concerns, supporting teams working in pressured environments and creating inclusive working environments for people from a diverse range of backgrounds.

Leaders can be found at all levels in nursing and midwifery. All leaders promote effective management and act as positive role models for best practice in the delivery of care by teams and organisations. 

What leadership means to me

Leaders in nursing and midwifery share their reflections on what leadership means for them, and how good leadership supports teams to deliver the best possible care.

What do nursing and midwifery leaders think is important to look after their teams, and help them deliver the best possible care? Read the below reflections to learn from a range of views and experiences.

How leadership supports better care

leadership management and team working in nursing essay

Fortune says leaders must create an inclusive environment for a flourishing diverse workforce. This also comes down to how leaders listen and respond to concerns.

“A sense of belonging and being included is really important to me, as somebody from the global majority. A leader always needs to consider, how can I make people feel part of my team, of the institution I’m leading, of the decisions being made? Your behaviours can make people feel they matter and are valued.

“It’s about how you talk to people and importantly, how you listen and respond when people come to you with concerns.”

It is also vital that leaders demonstrate cultural intelligence to understand their teams, as well as the people their teams care for.

Fortune said: “In nursing and midwifery where you have so many internationally educated or internationally recruited people, leaders need to have cultural intelligence in terms of equality, diversity and inclusion so they can best support the diverse workforce.”

Fortune urges leaders to be more proactive in supporting internationally educated nurses and midwives to reach senior positions.  

“We’ve heard enough about people being excluded or discriminated against. At this point, good leaders are asking, ‘what are we doing about this?’ If we are saying someone is not ready to go into a senior leadership position, let’s understand what their needs are, and create leadership programmes to support them so the picture can change in a positive way.

Linked to this is the importance the NMC’s standards place on cultural awareness and how this can impact on outcomes for people receiving care :

“Anti-racism should be a priority for leaders today. They need to be more proactive, stand up and make it count. Let’s have more allyship training – a lot of our colleagues are not intentionally discriminating – they need help to understand some of the prejudices they may not have been aware of.

“If somebody feels they are being treated differently, because of the way they look or how they sound, we need to listen and believe them. Let’s validate how people are feeling, otherwise people stop reporting it and nothing gets done.”

For Fortune, good leaders never lose sight of people as individuals, and always take into account the feelings of others.

“It’s really important that leaders think about people’s health and wellbeing, have the right wellbeing support services in place, and listen and support people.”

“Seeing people as humans goes a long way. Maya Angelou said ‘ people will forget  what you said,  people will forget  what you did, but  people will  never  forget  how you made them feel.'”

Fortune Mhlanga is Deputy Head of Nursing in Buckinghamshire. She is passionate about ensuring everyone feels valued and included as this impacts staff well-being in a huge way and there is a direct link between staff well-being and quality and safety of care. Also, teams where everyone has s sense of belonging perform better, have a better safety culture where people feel psychologically safe to raise concerns and improve care. Fortune has a background in mental health nursing

leadership management and team working in nursing essay

“A good leader is a good listener who allows their team members to be themselves, to express their ideas and opinions. A leader is someone who creates opportunities for others. I believe in nurturing potential for everybody, whether it is teaching new skills, encouraging the expression of ideas or advocating for colleagues.”

Lincoln’s ethos includes listening to and supporting everyone, whatever their role or background, and helping the team to meet the diverse needs of communities.

“Demonstrating leadership means engaging with colleagues in a positive and constructive way so we can build relationships regardless of who they are or if they have a different background. “I want to support every single person who comes in the Trust. Being inclusive means including everybody to meet diverse needs. There are different communities but for me, being there for everybody means seeing people as individuals.”

Lincoln knows the wellbeing of his team is important in order for them to deliver the best possible care for people – particularly in difficult periods such as winter. He makes sure his door is always open and has set up a support booking system for staff members, but he also offers alternatives.

“Being accessible and offering support when it’s needed is so important,” he said. “I am going into clinical areas as well, to offer that 1:1 support to our preceptors. I also signpost people to our wellbeing teams. “This initiative has been getting so much feedback – whether it’s a struggling student thinking about withdrawing from a course or a staff member, they just want someone to listen. I believe our workforce needs this support.” 

Placements can be demanding for students and they need plenty of support from their supervisors and assessors in order to learn effectively and deliver good care on their placements.

 “The real work is meeting the student who is struggling and asking them how they are they feeling today. And letting them know it’s OK, we are going to help. “We need to harness those students who are motivated and encourage them to go far – and help them stay in a positive frame of mind that’s focused on our patient experience.”

Lincoln says he was fortunate to have good support as a student, and wants to pass that support on to his team now. Good preceptorship when they join the register can also support with staff retention and good care.

“We all need that support to help us to see our way through things and that’s what I’m trying to do. My vision is to create a strong network so all our students feel better known and understood, are helped to find their purpose and supported to be the best they can be.”

Lincoln Gombedza is an award-winning Learning Disability Nurse with a passion for integrating digital technologies in nursing and through his work developing education and training programmes for North Staffordshire Combined Healthcare NHS Trust. Lincoln is a member of the NHS Digital Decision-Making Council, and involved in the Florence Nightingale Global Innovation and Entrepreneur Group, among others.

You can learn more about the importance of student supervision and assessment by watching our animation at Standards for student supervision and assessment - The Nursing and Midwifery Council (nmc.org.uk)

leadership management and team working in nursing essay

For Martyn, good leadership means focusing on the outcomes, and treating everyone fairly. 

“I think great leaders don't set out to be leaders, they set out to make a difference and help others. “They’re the ones that treat everyone the same, regardless of their job title or perceived status.” 

Listening to patients and speaking up for them is a core skill for leaders at all levels, he says – and crucial for delivering the best possible care.

“Leadership is especially important when it comes to the people in your care - being their voice when they most need it. It can take courage to speak up for what you know is right for the patient or for your team, particularly if you’re not in a senior role – but speaking up is real leadership.”

Martyn believes leaders need to provide close support to teams working under pressure. Small actions and fostering a strong team spirit goes a long way.

“Teams caring for very vulnerable people often find themselves in highly stressful situations,” he said. “They need their leader to ensure they’re supported emotionally and physically and managed in the best interest for everyone, including the patient and staff. Experience supporting patients with mental health issues, cancer diagnoses or people dealing with bereavement has taught Martyn to ‘find the happiness amongst the sad bits.’ “At very difficult times, a leader will help their team to find that diamond and buff it so it sparkles. Sometimes the small things can make such a big difference. I remember coming out of a stressful situation to find the leader waiting with a cup of tea, ready to talk. That human approach is key. “At the end of a tough shift, you wait for that last person to come through the door, and then we all go out together.”

Leaders need to be accessible to their teams and encourage their desire to learn – this helps teams to deliver the best possible care for people

“Leaders understand there is no such thing as a silly question, and it’s okay to ask. If you've got a question, just ask and I'll help guide you in any way I can. For me, that’s what a leader is. “Good leaders recognise it’s important to support everyone and help when needed. Enabling others is the most important part, it’s what nursing is all about. I always refer to that Marvel quote: ‘with great power comes great responsibility’.”

Martyn Davey was one of the first wave of trainee Nursing Associates. He now works in General Practice and is a Visiting Lecturer at Birmingham City University. Martyn set up a national network supporting more than 5,000 TNA and RNAs on Facebook.

leadership management and team working in nursing essay

For Paul, prioritising people is fundamental and that means ensuring staff have the support they need to care for people as well as they can – especially through difficult periods such as Winter Pressures.

“Nurse leaders need to prioritise how they treat their most vital resource – their staff. If you don’t look after nurses, especially newly-qualified nurses, and give them support and guidance, then you’ll never see their full potential.”

Paul feels leaders need to advocate for staff to be able to access the support they need – and that this has a direct link to them being able to provide safe care for patients.

“Giving nurses the chance to share and reflect, and get support for the challenges they face, has been absolutely vital in my experience. If nurses can’t access clinical supervision and support, they can get burnt out. And this carries a risk to patients. “As a leader you realise you have to make that happen, it doesn’t just happen naturally. So you have to take away the barriers, be brave at the boardroom table, and build it into your operational plans.” “Being conscious of moral injury is part of my leadership values. If we don’t make the space for nurses to have the right support and supervision, the teams we support can become very susceptible to moral injury and this has an impact for patients. As leaders, we let nurses down when we don’t provide that space. “Leaders need to understand clinical supervision and support as a priority – you can’t deliver safe, effective care without it.”

Paul sees creating a supportive culture with an ‘open door’ to leaders as key to enabling learning. That means demonstrating your humanity and treating people with respect so they realise there’s a leadership culture that cares for them.

“The dementia specialist Admiral Nurses  on our helpline and in our clinics have access to an immediate debriefing after a challenging call or appointment,” he said. “They can check how they did, and get support.  That’s not usual – and leaders need to make it more usual. Being able to chat and reflect really helps with the complex situations nurses are dealing with. “We also encourage nurses to support each other. If I’ve got a really challenging situation, I’ll find the person who knows more than I do, and ask them. As a leader you think you should know it all and can’t ask anybody else, especially someone junior to you – that’s nonsense. “Nurse leaders have to prioritise creating those cultures of support and learning or you’re not only missing a trick, you’re putting patients at more risk than they need to be.”

Paul is a nurse who specialises in dementia care, with 25 years’ experience working across the NHS, academia and the independent sector. At Dementia UK he is responsible for the development, governance and growth of clinical services, helping to ensure services are run to provide safe and effective care and support to people with dementia and their families.

leadership management and team working in nursing essay

“Leadership is about showing we advocate for women and they have choice. And enhancing our midwives’ knowledge, skills and confidence to provide that care. “Advocating for women is a key part of the midwife’s role. Being that woman’s voice in her journey is vital to what we do, and having that partnership with women is the joy of being a midwife.”

For Shona, providing positive feedback is beneficial to midwives and the care they provide.

“It’s important to pause, and give positive feedback, saying ‘that woman really appreciated what you did for her’. We can’t expect midwives to provide high quality, safe care unless they feel psychologically safe themselves.”

Shona aims to be accessible and build good relationships so that individuals and teams feel able to speak up with any concerns. 

“Good communication and team work is critical. It’s key for leaders to foster positive relationships with their team because you want people to be able to speak out. And you need to listen effectively and be responsive.”  “We talk a lot about women in maternity services being heard, and that’s really important. The same goes for our staff. “As a leader, your team needs to feel safe and secure that you are an accountable leader, and you are going to do the right thing.”

In Shona’s view, the NMC’s standards and Code could help teams working in pressured environments to feel supported

“We need to bring the Code and standards to life, to show how we can use them to enhance what we do or for guidance, to look at our services to see how we are meeting the standards.”

Shona thinks self-reflection can help leaders learn to accept challenge.

“It can take time to learn to accept challenge and not to see it as a personal attack. Leaders need to recognise they don’t know everything all the time, sometimes change comes from the ground up. “Self-reflection is important: ‘Am I really listening?’ ‘Am I allowing this challenge or cutting it off?’. I don’t think we can champion reflective supervision if we are not prepared to be that practitioner ourselves.” 

She wishes for all midwives to be able to receive the support that was critical to her own career progression.

“Early in my career there was a very senior midwife in Northern Ireland who provided me with a listening ear, encouragement and challenging feedback. That support is so beneficial when you’re trying to progress and become a leader, we should look to provide that to midwives over the course of their careers. “Midwifery is such a lovely career and it’s hugely rewarding – I can’t say that strongly enough. There is something about being there at that moment of birth and new life, of helping create a new family that is really very lovely. “There really is nothing like it.”

Shona Hamilton is consultant midwife at the Northern Health and Social Care Trust and Queens University Belfast. She qualified as a nurse and then a midwife and has worked in a variety of posts within nursing and midwifery during her 30 year career. Her professional and academic interests lie in public health, intrapartum care and perinatal mental health.

leadership management and team working in nursing essay

For Wendy, good leadership is about embracing and valuing diversity. That means talking to your team, and taking an interest in different cultures and backgrounds.

“The job for leaders is very simple: know your team - who they are and their background, appreciate them and their culture, “You don’t have to know everything. All you need to do is respect them and talk to them. Facilitate the conversation for all staff – whether they’re from Scotland or a country in Africa – to be able to talk about their culture and values, what their beliefs are.”

Wendy feels good leaders go further, to help empower their teams to be aware of the cultural needs of the people they care for. This helps nursing and midwifery professionals to really tailor care to the needs of the person they’re caring for

“This empowers staff to talk about what is not talked about. When we have that culture it in turn empowers the team to have those conversations with people in their care, which is so beneficial to their experience and to safety. “Being compassionate should cut across everything we do. Leaders have to learn how to provide fair and equitable support to all colleagues, from all backgrounds.”

Wendy believes the care patients receive is directly linked to the behaviour that the leader role models.

“Show me the environment and I will tell you the kind of leadership in that place. If staff are smiling and welcoming it’s because the leader is smiling and welcoming. Staff follow the leader as role model, and the leader’s relationship with their team translates into making such a big difference to the care provided.” 

For Wendy, a diverse population and workforce needs diverse leaders who respect the contributions of the whole team.

“We have a diverse workforce and population, if there is also diversity at the leadership level it will flourish in the workforce and we can reflect the culture and values of the communities we serve, in the care we provide. It reduces the disparity in equality that we currently have. “A diverse and multi-disciplinary leadership that listens to different perspectives brings together knowledge and expertise to provide culturally sensitive care. “A diverse team is an excellent team and different values and opinions make it colourful and beautiful. Diverse teams have so much positive impact for the people in our care and their families.

Wendy Olayiwola is a registered nurse and midwife with more than two decades serving community and public health. She has received multiple awards including the British Empire Medal for services to the NHS and Equality during the Covid-19 response. Wendy is passionate about promoting equalities among Black and minority ethnic groups and supporting and empowering nurses and midwives to provide culturally sensitive and holistic care for women and their families.

leadership management and team working in nursing essay

“Good leadership relies on communication, and creating an open culture that spans the whole adult social care community.   “It’s about involving people in their care planning so they are at the centre of everything that happens. It’s making sure team members know what’s going on and bringing them on the journey with you.    “As a leader, it’s also imperative to get the right relationships and communication channels between members of your multi-disciplinary team. Building relationships across all members of the health and social care team benefits care for residents.”

In Zoe’s view, leaders need to set an example and enable supportive teams working in pressured environments.  

“You don’t know everything people have going on in their lives, in addition to any work pressures. Good leaders make time to ask team members how they are doing, if they need help with anything, and allow team members to ask each other those questions as well. I believe ‘it’s OK not to be OK’.”

Zoe believes there is more potential to involve and support the wider community in adult social care.

“Debriefing is incredibly important. It may involve revisiting an incident weeks or even months later. Consider including the community – following an incident, we offered group counselling and invited relatives to attend, too – they’re very much part of the team. “Everyone benefits when you bring in the community. Families can play a critical role and they also gain a greater understanding and ability to support a loved one. Volunteers are also important, and they aren’t used enough.”

She believes acknowledging where you need help is core to good multidisciplinary working that makes sure people receive the care they need.

“To achieve good multidisciplinary working you need to build confidence on all sides.  There’s a need to let down barriers and show vulnerabilities.  Nurses in adult social care deal with a wide range of situations – you can’t know everything. We should be proud of what we do, and call on professional expertise when we need it. “Ultimately, people need to involve the right person at the right time to ensure safety. Good leaders build relationships that enable teams to contact specialist nurses or consultants if they need to.”

In Zoe’s view, good delegation is vital to empower teams and to ensure patient safety.

“Good delegation improves safety. If leaders don’t delegate effectively, they risk burn out for themselves, and losing the respect of their team who are not empowered to take things forward.   “Recognise what people can do, and give them the support and tools to do it. It doesn’t have to be another nurse or carer. If you have a chef who is amazing why not have them lead on nutrition and hydration within the home? “It’s about delegating to the right people, and enabling them to do what they do really well.”

She thinks it’s important for people in leadership roles to have support from peer networks.

“I’d like to see more informal coaching and support across adult social care organisations. I recommend leaders find that person or group they can talk to because they need support too.”

Zoe Fry OBE is a Director of the Outstanding Society Community Interest Company who shares and celebrates best practices across Social Care while helping others improve. A registered nurse, she started her career in the NHS before purchasing a nursing home and achieving Outstanding ratings from the CQC. In 2023 Zoe was awarded an OBE in the Kings Birthday Honours List in recognition for Services in Social Care and Services to Nursing.

leadership management and team working in nursing essay

For Karen, leadership occurs at all levels in organisations, and takes many forms.

“I believe we’re all leaders and leadership comes at every level.” “For me, being compassionate, open, authentic, approachable and inclusive are the most important leadership traits along with being willing to evolve and adapt.” “As a leader it’s important to surround yourself with people who are really good at what they do – better than you in some ways. They are here to advise and support the leader with their expertise, and the leader supports them to do their jobs well, and learns from them at the same time.”

In Karen’s view, the NMC’s Code and standards provide a guide for nurses and midwives in all situations.

“The health service is all about people so it’s right that they are also central to our standards which underpin what every nurse and midwife does, at all levels in an organisation. The standards are inter-connected, they provide a national framework people in our profession can lead from, and work from.”

Karen sees a direct link between good leadership and patient care.

“Leadership is integral to good care. If you lead well and look after your colleagues, your patients will get good care. People who feel valued will work to the best of their ability.” “As you become a more senior leader there’s a feeling you can get further away from the patient – you have to understand how much you continue to influence their care. I hold to the idea if I can no longer be hands-on with patients, I am still able to do that by appointing the best people and leading in a way that enables those giving direct care to do their best. I call it my tentacles! “And I make myself visible – leaders have to engineer their time to be visible and accessible.”

Karen thinks leaders need to be present, and honest in order to best support teams working under pressure.

“When teams are working under pressure, a leader needs to be present, acknowledge the reality of a difficult time and share honest reflections. Show compassion and humanity – it enables teams to speak up.”   “It’s for leaders to inspire and motivate people, asking ‘how do we work together to enable us to give our best, and look after ourselves at the same time?’” “Make sure to thank people for working through difficult times.”

Additionally Karen believes leaders have to support professionals who arrive from come from other countries to join the UK workforce:

“The NHS is built on internationally educated nurses and midwives and we have to challenge ourselves to think about how wider society supports these people, holding ourselves responsible for the way they are integrated and how they are treated.” “It’s important for us to remember we need them, we ask them to come, and we should show understanding and gratitude for the sacrifices they’re making. They’ve left their loved ones, their people to be here, and care for our communities.” “There aren’t many Chief Nurses from diverse backgrounds and I don’t know what it’s like to come to the UK from a different culture. I know what it was like for my parents losing loved ones overseas, and not being able to be there with them. I remember not being accepted for the colour of my skin as a little girl. The White British experience will be different - that’s why listening, really hearing people’s experiences, and learning is important.”

Karen Bonner is Chief Nurse and Director of Infection Prevention and Control at Buckinghamshire Healthcare NHS Trust. She is a Member of the General Advisory Council at the Kings Fund, a member of the Nurse Executive Council at the Beryl Institute and a Trustee of Helpforce – gaining recognition as a Burdett Hero by the Burdett Trust for Nursing, in 2022. Highly commended for her work in diversity and inclusion, she is regarded as one of the 50 most influential Black, Asian and minority ethnic people in health.

leadership management and team working in nursing essay

For Hilary, leading in challenging times calls for compassion, and courage.

“You have to have courage to show compassionate leadership when there may be lots of pressure to ‘fix things now’.   “A more courageous approach is to improve the culture – that means working alongside people rather than in a ‘top down’ management style, having honest conversations and delivering difficult messages in a supportive way. “If you allow teams to come up with their own solutions , you get a responsive, self-directed culture where teams are much more innovative.” “Being authentic – true to your professional and personal values – is key for leaders. Your values as a nurse, together with your professional accountability and responsibility, come to the fore when you are tested through challenging times.”    “As a Chief Nurse, it’s balancing being clear and directive, setting high standards but also being kind and compassionate, and brave enough to take everyone with you.” “My job is simply to support people to be the best they can be and provide the best care. It’s making sure staff know they and their wellbeing are valued. Encouraging them to take a lunchbreak – it’s a small thing - but it’s really important.”

She considers psychological safety is crucial  to encourage teams to raise concerns.

“Leading teams is about creating psychological safety, and a compassionate culture. We’ve introduced a restorative learning culture approach where people are not afraid to report concerns and speak up. This makes patient care a lot safer – and if leaders know where there are concerns they can take steps to improve.” 

In Hilary’s view, collective leadership creates better solutions

“For me, leadership is all about improving care for patients, and collective and distributed leadership are really important.  It’s not one person, it’s all of us all working together, and in partnership with patients.” “Shared governance and decision-making – it’s not telling people what to do – but working with them to support them – because they often know best how to fix it.” “Because we’ve taken this approach, we’ve changed the culture, we’ve changed mindsets and invigorated people’s passion.  As a result, our work on nutrition and hydration has gone beyond anything we might have done had we taken a process approach. “By enabling  teams to share decision making and ownership and accountability around care, they came up with so many ideas – from daily allocation of additional staff for  patients in need of assisted feeding, to encouraging people to focus on nutrition and hydration – our ‘Food for Thought’ and a ‘Sip Sip Hooray’ campaigns have become mantras. Most importantly, our patient survey results (including for nutrition) have gone up – something we’re really proud of.” “When you get everyone involved in this way, people don’t feel there’s another new initiative they have to do, the initiative comes from them. For me, that’s the right approach  – we are all leaders, and the senior team is there to support the leaders to do the right thing.”

Hilary thinks supporting internationally-educated nurses is integral to a compassionate culture.

“It feels easier to support our internationally-educated nurses because we have a compassionate culture. When they arrive, we get their shopping for them – making sure they’ve got everything they need, and feel at home. We put on social events so they feel part of the community and are well-supported by their mentor and ward managers. We know recognising everyone’s culture is important. An international educated colleague recently said, ‘We’ve got our family at home but we’re part of the South Tees family.’”

Leaders need to role model good relationships to create good multi-disciplinary teams

“As a senior team we’ve got a responsibility to make sure we work well together, providing a role model for the rest of the organisation on multi-professional working. Together we promote the restorative and learning culture. It’s about respecting we’ve all got different strengths.”

Hilary believes collective leadership, with all staff working in partnership with patients, leads to better care.

“With shared leadership and decision-making you are going to the heart of the organisation  to make decisions. It’s brave, because it can feel as though you have less control – but it creates a richness – staff know they are supported to make decisions in partnership with patients. It makes patient care better, safer, and a happier experience.”

Hilary Lloyd is Chief Nurse at South Tees NHS Foundation Trust. She is also Chief Nurse Clinical Research Network NENC and a Visiting Professor at the University of Sunderland. Hilary qualified in 1989 and has held a number of nursing posts including in acute healthcare, education and research. Most recently she served as director of nursing, midwifery and quality at Gateshead NHS Foundation Trust.

Resources to support you

Our Code and standards can support all nurses, midwives and nursing associates to be good leaders. To learn more about some of the key themes covered in these case studies, you can also use the following NMC resources:

Being accountable means being open to challenge. It means accounting for and being held to account for your actions, and being able to confidently explain how you used your professional judgement to make decisions – even in complex and challenging situations.

To find out more, watch our  Caring with Confidence  animation

Nursing and midwifery professionals deliver fantastic care for people but no-one can do everything on their own. So, leaders need to know how to delegate safely and with confidence.

To find out more, watch our  Caring with Confidence  animation

Our leadership case studies show that being inclusive and challenging discrimination is crucial to providing the right environment for the best possible care.

Everyone has the right to dignity and respect, and to feel included. Professionals on our register should feel confident about challenging discrimination wherever they see it. To do this, they need leaders to create an environment where they feel safe to do this.

To find out more, watch our  Caring with Confidence animation  and read the  anti-racism resource  produced by NHS England, in partnership with NHS Confederation and the NMC.

Good leadership is always important for delivering the best possible care – but these case studies show how that’s particularly important at busy and difficult times, such as during winter.

Last year we published a  joint letter  with the UK’s four chief nursing officers and the CQC to help leaders and professionals during winter pressures.

Martyn and Shona both explained the importance of listening to the people you care for and advocating for their needs.

Our midwifery resources  The best care happens in partnership  explain why listening to and working in partnership with the women in your care is key to the person-centred midwifery care that every person has the right to expect. You can read the stories of women who have recently given birth and use our CARE aid to reflect on your practice.

Listening to people you care for and acting on what you hear is just as important for nurses and nursing associates as well.

Nurses, midwives and nursing associates are often best placed to recognise things that might create risk or cause harm to people.

We want you to feel confident about raising concerns, and speak up if you see something you feel isn’t right.

To find out more, read Shona’s case study above or watch our  Caring with Confidence  animation .

All nurses and midwifery professionals need the support of good leaders to be able to provide the best care they can. This is particularly true for students and people who are new to the register, as Lincoln and Fortune explain above.

Our  Principles for Preceptorship  help leaders welcome and integrate newly registered professionals into their new team and place of work. It helps these professionals translate their knowledge into everyday practice, grow in confidence and understand how to apply the Code in their day to day work.

And our Standards for Student Supervision and Assessment (SSSA) set out the roles and responsibilities of practice supervisors and assessors, and how they must make sure students receive high-quality learning, support and supervision during their practice placements. The resources on  our SSSA page  include an animation, a webinar and a link to our SSSA Supporting Information hub.

  • Last updated: 05/12/2023

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Bass B. The Bass handbook of leadership: Theory, research, and managerial applications.New York (NY): Simon and Schuster; 2010

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Collaborative leadership: new perspectives in leadership development. 2011. https://tinyurl.com/2usp5yve (accessed 24 February 2021)

Dover N, Lee GA, Raleigh M A rapid review of educational preparedness of advanced clinical practitioners. J Adv Nurs. 2019; 75:(12)3210-3218 https://doi.org/10.1111/jan.14105

Edwards A. Being an expert professional practitioner. The relational turn in expertise.London: Springer Verlag; 2010

Evans C, Pearce R, Greaves S, Blake H. Advanced clinical practitioners in primary care in the UK: a qualitative study of workforce transformation. Int J Environ Res Public Health. 2020; 17:(12) https://doi.org/10.3390/ijerph17124500

Hamric A, Hanson C, Tracy M, O'Grady E. Advanced practice nursing. An integrative approach.Philadelphia (PA): Elsevier Saunders; 2014

Health Education England. Advanced practice. 2021. https://www.hee.nhs.uk/our-work/advanced-clinical-practice (accessed 24 February 2021)

Heinen M, van Oostveen C, Peters J, Vermeulen H, Huis A. An integrative review of leadership competencies and attributes in advanced nursing practice. J Adv Nurs. 2019; 75:(11)2378-2392 https://doi.org/10.1111/jan.14092

Kotter JP. Leading change.Boston (MA): Harvard Business Review Press; 1996

Kramer M, Maguire P, Schmalenberg CE. Excellence through evidence: the what, when, and where of clinical autonomy. J Nurs Adm. 2006; 36:(10)479-491 https://doi.org/10.1097/00005110-200610000-00009

Lamb A, Martin-Misener R, Bryant-Lukosius D, Latimer M. Describing the leadership capabilities of advanced practice nurses using a qualitative descriptive study. Nurs Open. 2018; 5:(3)400-413 https://doi.org/10.1002/nop2.150

Better leadership for tomorrow: NHS leadership review. 2015. https://tinyurl.com/ev7thw68 (accessed 24 February 2021)

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Leadership and management for nurses working at an advanced level

Senior Lecturer, Leadership and Management: Public Health, Birmingham City University

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Leadership and management form a key part of advanced clinical practice (ACP) and work in synergy with the other pillars of advanced practice. Advanced clinical practitioners focus on improving patient outcomes, and with application of evidence-based practice, using extended and expanded skills, they can provide cost-effective care. They are equipped with skills and knowledge, allowing for the expansion of their scope of practice by performing at an advanced level to assist in meeting the needs of people across all healthcare settings and can shape healthcare reform. Advanced practice can be described as a level of practice, rather than a type of practice. There are four leadership domains of advanced nursing practice: clinical leadership, professional leadership, health system leadership and health policy leadership, each requiring a specific skill set, but with some overlaps. All nurses should demonstrate their leadership competencies—collectively as a profession and individually in all settings where they practice.

Leadership and management form an essential part of advanced clinical practice, as outlined by Health Education England (HEE) in 2017:

‘Advanced clinical practice is delivered by experienced, registered health and care practitioners. It is a level of practice characterised by a high degree of autonomy and complex decision making. This is underpinned by a master's level award or equivalent that encompasses the four pillars of clinical practice, leadership and management, education and research, with demonstration of core capabilities and area specific clinical competence …’

There is an appreciation that leadership and management skills work in synergy with the other pillars of advanced practice. Stanley et al (2008) advised that advanced clinical practitioners (ACPs) can shape healthcare reform, are trained to focus on improved patient outcomes, and with application of evidence-based practice, using extended and expanded skills, they can provide cost-effective care. ACPs are equipped with skills and knowledge, allowing for the expansion of their scope of practice by performing at an advanced level to assist in meeting the needs of people across all healthcare settings.

When considering a nursing context, the Royal College of Nursing (RCN) defined advanced practice as:

‘A level of practice, rather than a type of practice. Advanced nurse practitioners are educated at master's level in clinical practice and have been assessed as competent in practice using their expert clinical knowledge and skills. They have the freedom and authority to act, making autonomous decisions in the assessment, diagnosis and treatment of patients.’

Rose (2015) advocated that ACPs also need to respond to, inform and influence policy, and political and practice changes, while being aware of the complex needs of patients and new healthcare demands. Hamric et al (2014) delineated four leadership domains of advanced nursing practice:

  • Clinical leadership
  • Professional leadership
  • Health system leadership
  • Health policy leadership.

Each requires a specific skill set, but with some overlaps. These four leadership domains will guide the discussion that follows, with a focus on advanced nurse leadership.

Background: leadership and autonomy

Revisiting the HEE (2021) use of the word ‘leadership’ and the RCN's (2018) use of the term ‘autonomy’ as part of the definition of advanced nurse practitioners will set the scene and enable these two terms to be briefly examined. Naively, or perhaps traditionally and historically, we tend to put administrator and manager roles into a metaphorical box that considers them as formal leaders, while nurses in clinical roles are either not considered as leaders or they are identified as in formal or clinical leaders. As Scott and Miles (2013) stated, leadership is an expected attribute of all registered nurses, and, yet, leadership in the profession is often considered to be role dependent. All nurses—from student to consultant—are leaders, yet defined clinical leadership competencies are often not reflected in undergraduate nurse education. Research examining the impact of leadership demonstrated by nurses on patients, fellow nurses and other professionals and the broader health and care system is deficient ( Cummings, 2011 ). Nurses need to accept that leadership is a core activity of their role at all levels—once this is acknowledged the transition to advanced roles will be easier. Frequently, nurses approach the topic of leadership when studying for advanced practice as if it is something that they have never done and know little about. Yet they already have an enhanced leadership skill set developed throughout their careers, although they often fail to appreciate this. A solid foundation and affirmation that all nurses are leaders should form the basis of advanced practice.

Despite a blurring of boundaries between management and leadership, the two activities are different ( Bass, 2010 ). Working out who leads and who manages is difficult, with the added anomaly that not all managers are leaders, and some people who lead work in management positions. Kotter's seminal interpretation articulated that leadership processes involve setting a direction, aligning people, motivating and inspiring, and that management relates to organisational aspects such as planning, staffing, budgeting, controlling and solving problems ( Kotter, 1996 ). So leaders cope with new challenges and transform organisations, while managers maintain functional operations using resources effectively.

These explanations direct us to consider what is meant by the allied term of autonomy from the individual and organisational perspective. The Cambridge Dictionary (2020) defines autonomy for an individual as ‘independent and having the power to make your own decisions’ and for a group of people as ‘an autonomous organization, country, or region [that] is independent and has the freedom to govern itself’ (https://tinyurl.com/2h5canfa). In nursing, the concept of autonomy has a range of definitions. Skår defined professional autonomy as:

‘Having the authority to make decisions and the freedom to act in accordance with one's professional knowledge base.’

Skår, 2010:2226

In a clinical practice setting, Kramer et al (2006) outlined three dimensions of autonomy: clinical or practice autonomy, organisational autonomy, and work autonomy. However, they also advised caution with the use of the term autonomy because it has different meanings across the literature. Nevertheless, it has a place within advanced nursing roles, especially in connection with leadership.

Leadership and management for advanced practice

Recent research has examined leadership in advanced nursing practice. Hamric et al (2014) delineated four leadership domains. These link with the findings of Heinen et al (2019) in their review of leadership competencies and attributes in advanced nursing practice. The purpose of their research was to establish which leadership competencies are expected of master's level-educated nurses, such as advanced practice nurses and clinical nurse leaders, as described in the international literature. Note that in North America ‘advanced practice nurse’ is used as an umbrella term to include nurse practitioners and clinical nurse specialists ( Sheer and Wong, 2008 ).

Boxes 1 to 4 are based on the competencies identified by Heinen et al (2019) for the four leadership domains ( Hamric et al, 2014 ), and Box 5 gives some generic competencies that span each of these.

Box 1.Clinical leadership

  • Provides leadership for evidence-based practice for a range of conditions and specialties
  • Promotes health, facilitates self-care management, optimises patient engagement and progression to higher levels of care and readmissions
  • Acts as a resource person, preceptor, mentor/coach, and role model demonstrating critical and reflective thinking
  • Acts as a clinical expert, a leadership role in establishing and monitoring standards of practice to improve client care, including intra- and interdisciplinary peer supervision and review
  • Analyses organisational systems for barriers and promotes enhancements that affect client healthcare status
  • Identifies current relevant scientific health information, the translation of research in practice, the evaluation of practice, improvement of the reliability of healthcare practice and outcomes, and participation in collaborative research
  • Acts as a liaison with other health agencies and professionals, and participates in assessing and evaluating healthcare services to optimise outcomes for patients/clients/communities
  • Collaborates with health professionals, including physicians, advanced practice nurses, nurse managers and others, to plan, implement and evaluate improvement opportunities
  • Aligns practice with overall organisational/contextual goals
  • Guides, initiates and leads the development and implementation of standards, practice guidelines, quality assurance, education and research initiatives

Source: adapted from Heinen et al, 2019

Box 2.Professional leadership

  • Assumes responsibility for own professional development by education, professional committees and work groups, and contributes to a work environment where continual improvements in practice are pursued
  • Participates in professional organisations and activities that influence advanced practice nursing
  • Participates in relevant networks: regional, national and international
  • Develops leadership in and integrates the role of the nurse practitioner within the healthcare system
  • Employs consultative and leadership skills with intraprofessional and interprofessional teams to create change in health care and within complex healthcare delivery systems
  • Participates in peer-review activities, eg publications, research and practice

Box 3.Health system leadership

  • Contributes to the development, implementation and monitoring of organisational performance standards
  • Lead an interprofessional healthcare team with a focus on the delivery of patient-centred care and the evaluation of quality and cost-effectiveness across the healthcare continuum
  • Enhances group dynamics, and manages group conflicts within the organisation
  • Plans and implements training and provides technical assistance and nursing consultation to health department staff, health providers, policymakers and personnel in other community and governmental agencies and organisations
  • Delegates and supervises tasks assigned to allied professional staff
  • Creates a culture of ethical standards within organisations and communities
  • Identifies internal and external issues that may impact delivery of essential medical and public health services
  • Possesses a working knowledge of the healthcare system and its component parts (sites of care, delivery models, payment models and the roles of healthcare professionals, patients, caregivers and unlicensed professionals)

Box 4.Health policy

  • Guides, initiates and provides leadership in policy-related activities to influence practice, health services and public policy
  • Articulates the value of nursing to key stakeholders and policymakers

Source: Heinen et al, 2019

Box 5.Generic competencies spanning the four domains

  • Possesses advanced communication skills/processes to lead quality improvement and patient safety initiatives in healthcare systems
  • Uses principles of business, finance, economics, and health policy to develop and implement effective plans for practice-level and/or system-wide practice initiatives that will improve the quality of care delivery
  • Advocates for and participates in creating an organisational environment that supports safe client care, collaborative practice and professional growth
  • Creates positive healthy (work) environments and maintains a climate in which team members feel heard and safe
  • Uses mentoring and coaching to prepare future generations of nurse leaders
  • Provides evaluation and resolution of ethical and legal issues within healthcare systems relating to the use of information, information technology, communication networks, and patient care technology

The findings presented in Boxes 1 to 5 provide a research-based scoping of the international literature to identify aspects of leadership competencies connected with advanced nursing practice ( Heinen et al, 2019 ). Revisiting the theoretical differences between leadership and management ( Kotter, 1996 ), it can be appreciated that many of these competencies are blurred, with both existing as part of advanced roles. The clinical, professional and health system domains dominate the number of competencies recorded, giving an idea of the weight given by nurses to different areas of leadership. Competencies relating to the health policy domain were minimal. This is supported by a study describing the leadership capabilities of a sample of 14 advanced practice nurses in Canada using a qualitative descriptive study ( Lamb et al, 2018 ). Two overarching themes describing leadership were identified: ‘patient-focused leadership’ and ‘organisation and system-focused leadership’. Patient-focused leadership comprised capabilities intended to have an impact on patients and families. Organisation and system-focused leadership included capabilities intended to impact nurses, other healthcare providers, the organisation or larger healthcare system. Figure 1 summarises the leadership themes and capability domains identified in Lamb et al's study (2018) .

leadership management and team working in nursing essay

These findings also support the theory that advanced nurses do not recognise their wide reach as a major leadership part of their roles. In addition, it should be stated that all advanced nursing roles have their own idiosyncrasies based upon the individual practitioner, the environment and organisational needs; there is no ‘one size fits all’.

Multiprofessional working, leadership and the ACP role

With a move in the UK to multiprofessional working, especially in England, and changes towards core advanced practice skills crossing professional boundaries ( HEE, 2021 ) ACPs need proactive skills in cementing their leadership roles within teams. Anderson (2018) advised that successful multiprofessional working needs the individual professional to know the ‘standpoint’ of other professionals to enable their own understanding of complex problems. Edwards (2010) cautioned that professionals may work together and share personal values, but rarely do they work inter-professionally. The ACP role is complex, requiring autonomy and leadership of self within various aspects of the roles required of the individual in distinctive settings, in addition to performing and leading in teams often with professionals from other specialties.

What overt leadership skills may assist in delivery multiprofessional integrated care? Writing from a UK primary care perspective, Swanwick and Varnam (2019) described a necessary shift from the traditional individualistic hierarchical leader, working within and for single teams, to collective leadership encouraging a compassionate and inclusive culture. De Meyer (2011) also advised providing responsible collaborative leadership using the skills of co-operation, listening, influencing, and flexible adaptation, in contrast to what he terms the traditional ‘command and control’ top-down hierarchical approach. It could be suggested that this ‘way of being’ is aligned with the core skills of nurses but these may not be recognised by them as ‘real’ leading.

To ensure the success of the ACP role across the four pillars framework ( HEE, 2021 ) requires that the educational pathway and role has clarity, consistency and standardisation ( Dover et al, 2019 ) so that everyone will feel that they are entering on a level playing field. The framework ( HEE, 2021 ) represents a step forward by providing an overarching structure to align practice and education and creating greater consistency across ACP workforce developments. As the framework is implemented, it will be imperative to have an evaluation of its impact ( Evans et al, 2020 ).

The ACP is tasked with operating at an autonomous advanced level across the four pillars of education, leadership, research and clinical practice, and to be competent in the core capabilities for each pillar. Understanding the ACP role as a level of practice rather than a specific role with the distinguishing feature of autonomy may add clarification. Leadership is a crucial part of the ACP role and advanced nurses therefore need to conduct themselves as leaders so that others can recognise that they embody these skills. Yet, the time has come for all nurses to demonstrate their leadership competencies, collectively as a profession and individually in all settings where they practice. If every nurse is recognised as a leader, the transition to advanced practice will be fluid, streamlined and less of big deal.

Nursing Leadership and Management

Nursing leadership and management essay examples like this one will help you write your own excellent leadership in nursing essay. We recommend it to student nurses and other healthcare workers.

Leadership in Nursing Essay Introduction

  • Continuous Quality Improvement & Patient Satisfaction
  • Nurse Leaders & Managers: Comparison of Perception

Personal Position and Rationale

In the past, nursing was an amorphous and unrecognized engagement that was often left at the discretion of close family members and relatives of patients. However, after the efforts of Florence Nightingale, it was recognized as a fully-fledged profession and was integrated into the healthcare system. As the profession grew in stature, concepts such as nurse leadership and nurse management emerged. A layperson may use the two concepts are interchangeable. However, within the healthcare context, these two concepts have some key differences that set them apart. This essay explores the similarities and differences between leadership and management in the nursing profession. It specifically focuses on how nurse leaders and managers perceive continuous quality improvement and patient satisfaction.

Continuous Quality Improvement & Patient Satisfaction

The quality of healthcare is a core concern of governments across the world. According to Heyrani et al. (2012), the concept of quality in the healthcare system is multifaceted. It entails resource management, personnel management, patient satisfaction, efficiency enhancement, and safety promotion, among other elements. Until recently, healthcare organizations underscored the importance of some of these elements and ignored others. This trend culminated in poorly performing healthcare systems that prompted the development of a comprehensive framework that incorporates all the tenets of quality in the healthcare system. The framework was named clinical governance. It requires every healthcare organization to commit itself to continuous quality improvement and accountability. Therefore, patient satisfaction is at the heart of this framework.

Nurse Leaders & Managers: Comparison of Perception

Stanley (2006) describes nurse leaders as individuals, who do not necessarily have delegated authority but empower, motivate, inspire, and influence their colleagues. A nurse manager, on the other hand, is an individual who is formally appointed to oversee the operations of a healthcare organization or a section within the organization (Swansburg, 2002). Essentially, the nurse manager plays a conventional managerial role, but in a healthcare context. Both leaders exhibit the following similarities in their perception of continuous quality improvement and patient satisfaction.

Firstly, both of them think on a long-term basis (Swansburg, 2002). In their leadership positions, both nurse leaders and managers think beyond the horizon because the nurses in their teams look unto them for direction and motivation. Their ability to think beyond the present makes them indispensable to the healthcare system, especially considering the fact that continuous improvement of quality in the healthcare system requires people who can envisage future trends and steer nurses towards the right direction. Without this kind of leadership, the nursing profession would not cope with the fast-changing quality standards in the healthcare system.

Secondly, both nurse leaders and managers look beyond their units to understand the relationships that exist between their units and the immediate external environment (Swansburg, 2002). For instance, within a healthcare organization, both nurse leaders and managers have a clear understanding of how their units affect or are affected by other departments. This knowledge helps them to provide leadership that enables their units to contribute positively to the objectives of the organization. This type of thinking is pertinent to the continuous improvement of quality and patient satisfaction because it is not possible to improve quality by simply focusing on one unit within a system (Heyrani et al., 2012). Rather, the head of each unit should clearly understand the role their unit plays in the quality improvement process and then lead it to discharge that role effectively.

Thirdly, nurse leaders, and managers both have the political skill to contain the conflicting requirements of the multiple constituencies that exist within the healthcare system (Swansburg, 2002). While every well-meaning nurse might want to make the health care system better, balancing the conflicts that occur between the different elements that constitute it often prove impossible. However, nurse leaders and managers demonstrate courage without necessarily being reckless as well as caution without being considered cowards (Coonan, 2007). This skill is closely tied to their ability to think beyond the present and to know what to do in any given circumstance. It helps them to show courage and determination when necessary and takes well-timed precautionary steps when certain measures prove to be counterproductive. This ability is invaluable to the continuous quality improvement process and patient satisfaction because they do require not only bold people but also diligent individuals who can detect and alter counterproductive measures (Kerridge, 2012).

Having examined some of the key similarities between nurse leaders and managers, it is important to note that they also exhibit some notable differences as discussed below. The first key difference between nurse leaders and managers is that while the leaders are concerned with affirming the values that are consistent with the nursing profession and challenging those that are not, nurse managers focus on upholding established organizational values (Coonan, 2007). Consequently, in circumstances where organizational values are inconsistent with the situation on the ground, the nurse leader can make the necessary adjustment as opposed to the nurse manager. Therefore, a nurse leader is in a better position to move with changing trends. This attribute places them in a position of advantage insofar as continuous quality improvement and patient satisfaction are concerned.

The second major difference is that the nurse leader is in a better position to achieve workable unity among nurses as opposed to the nurse manager (Coonan, 2007). The nurse leader banks on earned trust to build cohesion and mutual tolerance while simultaneously controlling emergent conflicts. The nurse manager, on the other hand, strictly focuses on ensuring that the assigned duties are discharged as required. Unity, cohesion, and trust may not be of much importance to a nurse manager as long as there is obedience. Consequently, the nurse leader is in a better position to facilitate continuous quality improvement and patient satisfaction than a nurse manager due to a better understanding of what goes on among unit members.

Several other instances of differences between the two categories of nurse leadership exist, but the two discussed examples will suffice for this essay. A point worth noting, however, is that after examining these similarities and differences, it becomes apparent that each of the leadership approaches has its merits and demerits insofar as continuous quality improvement and patient satisfaction are concerned. However, although nurse leaders lack delegated authority, their style of leadership is preferable. They are in a position to achieve their agenda without formal authority. This ability is advantageous because Stanley (2006) asserts that people prefer to be led rather than to be managed. Consequently, they may resist and resent the nurse manager, especially when the manager is high-handed. Therefore, as a nurse leader, it is possible to bring positive change to the nursing profession in a shorter time compared to a nurse manager as long as bureaucracy does not stand in the way.

In conclusion, leadership is necessary for every setting that calls for the combined effort of many people. It is even more important for the nursing profession because nurses have become indispensable to the healthcare system, and leadership ensures that they remain committed to providing quality, safe, and reliable care. As such, the best leadership approach should be adopted when leading nurses.

Coonan, P. R. (2007). A Practical Guide to Leadership Development: Skills for Nurse Managers . Danvers, MA: HCPro Incorporated.

Heyrani, A., Maleki, M., Marnani, A. B., Ravaghi, H., Sedaghat, M., Jabbari, M., & Abdi, Z. (2012). Clinical governance implementation in a selected teaching emergency department: A systems approach. Implementation Science , 7 (1), 84.

Kerridge, J. (2012). Why management skills are a priority for nurses. Nursing Times , 109 (9), 16-17.

Stanley, D. (2006). Role conflict: leaders and managers. Nursing Management, 13 (5), 31-37.

Swansburg, R. J. (2002). Introduction to management and leadership for nurse managers (1st ed.). Sudbury, MA: Jones and Bartlett Publishers.

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Nursing Leadership and Personal Skills Personal Essay

Introduction.

Strong leadership is required to establish a healthy working environment at all levels of an organization. Evidence shows that the presence of a nurse leader in an emergency department of a health facility makes the working environment healthy while at the same time increasing staff retention. In line with this, the American Association of Critical Care Nurses has revealed that for optimal performance of staff and improved patient care, nurse leadership needs to be developed. I have realized the importance of nurse leadership. For this reason, I intend to share my experience at my workplace and relate it with various theories, leadership styles, and technology.

Experience with the Supervisor

As quoted by Lachlan Mclean, “You can only lead others when you are willing to go.” My Emergency Room Director at Providence Park in the Emergency Department (ED) is an example of this. She allows us to help and motivate each other to become better through teamwork. She creates a positive working environment where all nurses can improve themselves through creativity and sharing of information. At one time, she asked for my opinion on the ED and on how she could make it better. It was an excellent opportunity to be creative and contribute to the improvement of this department.

Emergency Nurses Association (ENA)

The Emergency Nurses Association was formed to serve emergency nurses in different ways. The main purpose of ENA is to enhance service delivery through continuous training, research, and funding of other projects. The services offered by ENA ensure continuous improvement of service delivery. It also assists in finding solutions to new problems in the field of nursing (Hammond & Zimmermann, 2012). In addition, ENA provides an opportunity for one to contest for a position in management. One crucial role of ENA in the emergency room (ER) is leadership training. Leadership training is essential in the emergency room as it contributes to coordination and teamwork. ENA has gone further to partner with ENA Foundation in order to improve service delivery.

Time Management

According to Magnet’s Model of transformational leadership, time management, and leadership cannot be separated. My area of operation deals with emergencies and patients in critical conditions. As such, time wastage jeopardizes the lives of patients. In sharpening my time management skills, I have resorted to prioritizing and delegating duties. Prioritizing has allowed me to deal with urgent issues while delegation has enabled me to seek the help of my subordinates. Otherwise, as a team leader, possession of such qualities has enabled me to inspire and create a sense of commitment among my team members.

Leadership Skills

The issues of leadership and management have been taken to mean the same thing. However, a manager exerts authority over others. This means that, others are not involved in decision-making unlike in leadership where the views of all stakeholders are taken into consideration. Since leadership calls for the participation of all, it is important that managers possess some leadership skills to enhance teamwork.

Nurse leaders can execute their functions efficiently depending on how powerful they are. There are various sources of power. They include the legislative, professional qualification and personal qualities. The legislative provides rules and regulations meant to guide the activities of nurses. They govern the responsibilities of a nurse and determine the steps to take in various situations (Lauby, 2010). Secondly, possession of professional skills gives nurses the power to act according to their level of qualification. Finally, personal qualities determine the nurses’ ability to lead.

My personal skills have a significant impact on my leadership skills. I am very persistent, determined and communicative. My persistent nature has enabled me to stay focused on achieving my goals. My determination has kept me going even when faced with challenges. Moreover, I am very communicative. This quality has enabled me to develop a good working relationship with my workmates. However, I don’t like being criticized. This quality has affected my performance as a team leader and had severe adverse impacts on the results of the team. For this reason, I am trying very hard to change my behavior for the benefit of my group and patients (Manojlovich, 2007).

Change and Conflict Handling

Nurses, apart from executing their duties, also act as change agents. They initiate changes that impact the nursing field. One way through which they bring change is by contesting various political positions. When they win in such contests, they can push for favorable legislation (Barker & DeNisco, 2013). Another way is by applying various organizational and change theories. Organizational theories are applied in specific contexts to bring orderliness while change theories are mainly applied to bring about behavioral changes which help nurses to co-exist and relate well with patients. This helps to avoid the emergence of conflicts.

Conflicts are bound to arise in any setting and the nursing field is no exception. As such, methods of handling conflicts are necessary. One of the effective ways is through compromise. Another alternative is the avoiding strategy, where the focus is on creating delays in conflicts so that measures to combat them are put in place.

Leadership and Differences in Character

The issues of culture and gender have resulted in a number of differences among people. These differences have had an impact on performance at work. According to Lieberman (2015), men originated from Mars while women came from Venus. This difference according to him has had an impact on the style of communication. A good nurse leader should appreciate such differences and devise a plan to overcome them.

Emotional Intelligence

Nurse leaders should possess Emotional Intelligence (EI) skills. EI enables them to read emotions and make the necessary adjustments according to the perceived emotional state of their subordinates (Cassady & Eissa, 2008). Cassady and Eissa (2008) illustrated this by carrying out an experiment using a nurse who worked in a very busy ED of a hospital. The nurse was subjected to different types and levels of stressful situations. In this case, emotions were frayed and as a result the nurse was unable to function well. EI enables leaders to strike a balance between work performance and emotion, and as such enables the application of measures that ensure emotions do not affect the performance of nurses.

Nursing Informatics

Nursing Informatics is the use of information systems and electronic health records in the provision of health services. It helps nurse leaders to carry out their functions efficiently by making information readily available to them. The same systems assist in administration by helping in relaying information quickly. However, nursing Informatics may detach leaders from their subordinates and for this reason kill the spirit of teamwork (McCartney, 2004).

Nurse leaders perform numerous duties in emergency departments which require them to possess excellent leadership skills that will enable them to work efficiently with other nurses towards the realization of optimal results. They should be able to gauge the performance of their subordinates by reading their emotions. Finally, leadership is not only about applying what you have learned. Rather, it is about developing personal skills. Good personal skills combined with what I have discussed above will result in the best performance.

Barker, M., & DeNisco, S. M. (2013). Advanced practice nursing: Evolving roles for the transformation of the profession . Boston: Jones & Bartlett.

Cassady, J., & Eissa, A. (2008). Emotional intelligence: Perspective from educational and positive psychology . New York: Peter Lang.

Lauby, S. (2004). 7 Types of Power in the Workplace. Web.

Lieberman, S. (2015). Differences in Male and Female Communication Styles. Web.

Manojlovich, M. (2007). Power and Empowerment in Nursing: Looking Backward to Inform the Future. Web.

McCartney, P. (2004). Leadership in nursing informatics. Journal of Obstet Gynecol Neonatal Nurses , 33 (3), 371-380.

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Essay: Leadership in Adult Nursing (reflective)

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Introduction Leadership is a process which involves individual activity to state desire objective and vision in a situation, providing support and motivating other people to attend set goals (Swearingen, 2009). Danae et al. (2017) believe that leadership is broadly recognised as a key aspect of overall effective healthcare. Therefore, nurses require strong leadership skills to accomplish various tasks to improve care quality. In this assignment, I will cross reference six experts (see appendices) from my professional development portfolio related to the four domains of standards of competence for preregistration nursing (NMC, 2010). Additionally, I will address each domain using Rolfe, Freshwater and Jasper (2001) reflection model, which is composed of three stages ‘what’, ‘so what’, and ‘now what’. This model is suitable to link practical experiences with theory, it helps to improve clinical practice and identify further learning opportunities; which will be addressed by formulating a S.M.A.R.T action plan (Doran, 1981). Domaine 1: Professional values What? Appendix 1 shows aspects of the professional values that I need to address. It contains mentor’s comment about patient advocacy skill. During my Nursing Practice 5 (NP5), I looked after a 56-year-old disabled woman with Spina Bifida who was alert and orientated, unable to move on her own, but, had clearly expressed her need to be moved every two hours to avoid another pressure ulcer as she had one before. This was not respected by health care assistant taking for excuses “the ward is very busy, she is not the only patient”. I regret I didn’t advocate for her. Furthermore, appendix 2, which is the leadership framework self-assessment tool demonstrates aspects of personal quality that I need to review. These are related to the (NMC, 2010) instructing nurses to take all reasonable steps to protect people who are vulnerable or at risk from harm, neglect or abuse. So what? Professionalism means practice through the application of the Code (NMC, 2017). In the UK, nurses must act as advocates for their patients, challenge poor practice and discriminatory attitudes and behaviour relating to the care of vulnerable people, (NMC, 2015). This is supported by the Royal College of Nursing (RCN) stating that speaking on behalf of another is an integral part of the nurse’s role (RCN, 2008). Moreover, The International Council of Nurses emphasises the need for nurses to respect the rights, values, customs and beliefs of individuals and families, and to advocate for equity and social justice in resource allocation and in access to health (ICN, 2012). Such endeavours are central, as illness nearly always increase levels of patient vulnerability and dependence (Marquis and Huston 2012). Emphasizing the fact that nurses should influence the way care is given in a manner that is open and responds to individual needs (RCN, 2015). Unfortunately, there have been cases where nurses have failed to provide fundamental care to patients. The report into the failing at the Mid Staffordshire Hospital identified poor leadership coupled with clinical staff accepting standards of care that should not have been tolerated (Ellis and Bach, 2015). More recently, Care Quality Commission (CQC) has issued a Warning Notice requiring some trusts to improve safety, patient consent and overall leadership (CQC, 2017). This accentuates the role of leadership in prioritising patient safety and in listening to and learning from patients (storey and Holti, 2013). Stressing the need for nurse leaders to be self-aware and recognise how their own values and principles may affect their practice (NMC, 2010). Leaders encourage teamwork by appreciating individuals’ contributions and ideas; this creates needed behaviour, such as shared respect, compassionate care, attention to detail, between team members (NHS Leadership Academy, 2013), and create a motivating work environment (Adair, 2002). Therefore, the quality of leadership has a direct impact on the quality of service provided at all levels. The leader’s obligation is to create an environment in which good people can provide good care (Engard, 2017). Pointing out personal attributes of nurses that help to enable advocacy like flexibility, empathy, self-motivation, professional commitment, sense of responsibility, and the ability to cope with stress (Choi, 2015). Reflecting on the above scenario, transformational and transactional leadership can both play a role in the negotiation of a win-win situation. Transformational leadership is defined as a leadership approach that causes changes in individuals and social systems. It is about having a vision of how things should or could be and being able to communicate this idea effectively to others (Ellis and Bach, 2015). Whereas transactional leadership is based on contingent rewards and can have a positive effect on followers’ satisfaction and performance (Tomlinson, 2012). Transformational leadership plays a more critical role in the present scenario. it can motivate and inspire healthcare assistant and have a more significant impact to change both their thinking and behaviour Jie-HuiXu (2017), thus, allowing them to reach their potential and deliver sustainable changes to care. Now what? Now I should strive on developing and sustaining my engagement in patient advocacy by the end of NP7. In my Ongoing Achievement Record document, I will work with my mentor to complete competency 1.2. called: Understand and apply current legislation to all service users, paying special attention to the protection of vulnerable people, including those with complex needs. I will actively seek mentor, patients, family and others health professionals’ feedback and reflect on when I have been involved in patient advocacy during placement and review this with my mentor at mid- and end-point review. Domain 2: Communication and Interpersonal Skill What? Communication and interpersonal skill are vital parts of collaborative working (NMC, 2010). I reflect on communication using Situation, Background, Assessment and Recommendation (SBAR) mentioned in appendix 3, which is a reflective writing during placement 5. In a surgical ward, during routine observation of a patient who had undergone a cystectomy, I noticed that the patient was spiking in temperature (38.5) although NEWS score was 1, I immediately informed my mentor who directed me to blip the doctor in charge of his care. While communicating with him I was unable to give a clear response to questions about the patient’s condition. Even though he reassessed my patient immediately, I regret I didn’t use SBAR tool, because it could have helped to communicate clearly and prevent any potential delays. Appendix 1 in the section ‘working with others’ further shows that I need to improve my interpersonal skills. These relate to part of the NMC (2010) stating: nurses must use a range of communication skills and technologies to support person-centred care and enhance quality and safety. So what? Bach and Grant (2010) state that good communication and interpersonal skills are essential characteristics of high-quality nursing practice. The NMC (2010) also said that all nurses must use the full range of communication methods, including verbal, nonverbal and written, to acquire, interpret and record their knowledge and understanding of people’s needs. Emphasizing the use of communication tools like SBAR. SBAR is a tangible approach to framing conversations, especially critical ones that require a nurse’s instant attention and action. It promotes the provision of safe, efficient, timely, and patient-centred communication (Chaboyer et al., 2010; Day, 2010). Moreover, SBAR can be used for multiple forms of communication. It can be a change-of-shift report (Pope et al., 2008; Thomas et al., 2009), or can be applied to written communication (Perry, 2014). In addition, SBAR helps nursing students and recent graduate nurses organize their thoughts prior to calling physicians, to save time, reduce frustration, and improve overall communication (Pope et al., 2008). Furthermore, the use of SBAR communication tool temporarily flattens the hierarchy perceived in most healthcare settings, resulting in more effective channels of communication between healthcare providers (De Meester, Verspuy, Monsieurs, & Van Bogaert, 2013). According to Hackman and Johnson (2013), leadership is first, and foremost, a communication-based activity. Depending on the circumstances, a leader should try to be more authoritarian, democratic or laissez-faire (Mitchell, 2012); or should focus the communication on the tasks or use a more interpersonal style (Hackman and Johnson 2013). Reflecting on the scenario related to this domain, an assertive, clear and focus communication using SBAR format would have provided a brief, organized, predictable flow of information improving critical thinking communication skills and patient safety (Olin, 2012). It can be argued that it is hard to serve as an effective leader without effective communication (Hackman and Johnson 2013). This is agreed by Perry et al (2014) stating that effective commutation is a central attribute of clinical leadership. Clinical leaders can influence their colleagues with effective communication skill such as good listening skill and extremely good at explaining things at the right level that can be understood by followers. However, it is important to note that each clinical leader has a preferred style of communication that would not necessary works every time. Hackman and Johnson (2013) recommend choosing a leadership communication style that will work best according to the situation and the level of knowledge of followers. Now what? During next placement (NP7), I will strive to change communicating SBAR in a more professional, concise, clear, in a timely manner when communicating with the multidisciplinary team to improve patient outcome. I will actively seek feedback from my mentor and other professionals at mid- and end-point reviews. I will also change my preferred communication style from passive aggressive to an assertive communication style. For that, I will use the communication style questionnaire at the beginning then altered my behaviour during the first part of the placement, then repeat the questionnaire at mid-point and ask for feedback to my mentor base on the comparison on two questionnaire results and base on her observation. And repeat this again by end-point. Domain 3: Nursing Practice and Decision Making What? Here I reflect on nursing practice and decision making, see appendix 4, which is an end-point mentor comment during NP3 showing that improvement is needed in this domain. This is underpinned by appendix 5: a reflection done at the beginning of NP6 when I looked after a patient with hypoxic brain damaged who had a seizure. On my entry into his room, I found the patient unconscious, I took the decision to clear his airway before pressing the emergency bell which could have jeopardised patient safety. This is related to the NMC (2010) stating that nurses must be able to recognise and interpret signs of normal and deteriorating mental and physical health and respond promptly to maintain or improve the health and comfort of the service user. My behaviour pointed out the need to enhance my skill and knowledge in this domain. So what? Judgement and decision-making are important facets of healthcare for nurses (Traynor et al., 2010). Judgement is defined as weighing up different alternatives; while decision-making involves choosing a specific course of action to follow between alternatives (Lamb and Sevdalis, 2011). Hence, (Undre et al., 2009) define efficacious judgement and decision-making as skills that go beyond clinical knowledge and technical competence, highlighting the fact that nursing judgement and decision-making contribute significantly to the safety and quality of patient care (Traynor et al., 2010). However, several studies have high-pointed that when given the same information, and undertaking the same decisions, nurses will make consistently different judgements and decisions (Thompson et al., 2008; Thompson and Yang, 2009). Differing judgement and decision indicate different types of reasoning, in situations where time is not constrained, newly qualified nurses will make structured judgments with a rational-analytical decision. For those situations where time is limited, information is perceptual, and the nurse has some perceived expertise, it is appropriate to use intuition as the basis for judgement (Hammond et al., 1987). Thompson et al (2008) suggest that the key to successful reasoning is to adapt reasoning to the demands of the task. However, such adaptive reasoning by nurses is sometimes absent. Thus, good decisions and judgements are not independent to the cognitive process but can be influenced by how information is prioritised and the nurse’s ability to identify and respond to vital aspects of the clinical situation (Pearson, 2013). Thompson et al (2013) state that recent studies have shown positive benefits associated with the introduction of Computerised Decision Support Systems (CDSS) to support nursing decisions. Hence, helping to promote patient’s safety and improve their outcome. Reflecting on the scenario related to this domain, future decisions making process, whether they are based on normative, prescriptive or descriptive theory must include clinical expertise, patient value and best available research evidence (Sackett, 1996). because evidence by itself, does not make the decision, but it can help support the patient care process. In the same order, Marquis and Huston (2015) suggest that to be effective as a leader, one needs certain skills for making decisions, such as self-awareness, fairness and transparency which are skills also needed in decision making. This is supported by Thompson and Dowding (2009 p5) affirming that “One of the distinguishing features that mark out exceptional nurses is their skills in judgement and decision making”. Decision making is considered important leadership skills and is recognised by Sofarelli and Brown (1998) as qualities associated with transformational leadership. Now what? I have realised that decision making, particularly in nursing, is vital as it influences patient safety and outcomes (Ellis and Bach, 2015). It has been mention earlier that experience is a factor that affects decision making. To gained experience in judgement and decision making, I will use every opportunity during NP7 to practice evidence base in nursing practice and decision making by always based my decision on useful information sources like clinical guidelines, protocol and policy and patient preference. After what I will actively seek feedback from my mentor and others healthcare professionals and of course to patients to check their satisfaction about their involvement in the decision-making process about their own care at mid- and end-point reviews. . Domain 4: Leadership, management and team-working What? My leadership, management and team working skill are measured in appendix 2 and appendix 6 which are both leadership self-assessment tools. The first one showing aspects of my leadership that needs to be improved and the second one showing my leadership style which is “guiding” needing improvement to become more empowering. These are further supported by appendix 4: mentor end NP3 comment. During the leadership module, I took part in several group activities, which enabled me to understand team role importance and that there is no leader without followers. This part relates to NMC (2010) stating that nurses must work independently as well as in teams; be able to take the lead in coordinating, delegating and supervising care safely, managing risk and remaining accountable for care given. So what? Tomlison (2012) states that self-assessment helps individuals to appreciate their qualities, strengths and weaknesses thereby, enabling better transformational leadership. Bass (1985) found that transformational leadership contributes to individual performance and motivation. Whereas transactional leadership (Burns, 1978) is short-lived, and task-based, with the leader intervening with negative feedback when things go wrong. Adair (2002) proposed a three-circle model of strategic leadership, with the circles being the needs of the task, the individual and the team. This is a democratic model of leadership matching the NMC code, where Individuals and groups are involved in decision-making processes concerning their work (Adair, 2002). Management skills are as important as leadership skills in addressing some failings like those identified in the Francis report (Kerridge, 2013). Kerridge suggests they are closely linked, effective management and leadership both require putting first thing first. The King’s Fund report (2011) concurs, defining leadership as the art of motivating people toward a shared vision and management as getting the job done, suggesting that the exercise of leadership across shifts could be extended to management practice; pointing out that every member of healthcare team has some management and reporting functions as part of their job (Baker et al., 2012). Lord Darzi (2008) said: ‘Leadership is not just about individuals, but teams’. A successful leader will see each person as an individual, recognising their unique set of needs, as not everyone will perform at the same level (Hackman and Johnson 2013). This rejoins the description of team role by Belbin (1996) as he described a team role as ‘a tendency to behave, contribute and interrelate with others in a particular way’. Suggesting that Belbin assessment would be an ideal way for a team to examine: the roles they play, how these fit in with the team and the contribution of roles to the team (Frankel, 2011). Therefore, it would be advisable that team members use the questionnaire to helps identify individuals’ preferred roles, their manageable roles and their least preferred roles within the nine teams’ roles as described by Belbin in-order-to improve the success of teamwork. Nurse leaders need also to be able to respond to an ever-changing healthcare environment (Frankel, 2011). The literature suggests that leadership, effective communication and team working are among the most important elements for planned change (Schifalacqua et al., 2009a). Kurt (1951) identified three steps of change: unfreezing, moving and refreezing. This work was modified by Rogers (2003) who described five phases of planned change: awareness, interest, evaluation, trial and adoption. Another change theorist, Ronald Lippitt (Lippitt et al., (1958), identified seven phrases. Mitchell (2013) advises that Lippitt’s work is likely to be more useful to nurses because it incorporates a detailed plan of how to generate change and is underpinned by the four elements of the nursing process: assessment, planning, implementation and evaluation. Now what? To improve my Leadership, management and teamwork skills, I will use the first week of my MP7 to observe my mentor and nurses in charge leading some shifts, then, I will seek clarification on grey areas of my understanding and ask to have my own patients. This will enable me to practice leading others, managing patients and working with the multidisciplinary team. I will actively seek feedback till mid-point review, then, I will lead and manage my mentor whole set of patients under her observation and correction whenever needs arise till end-point. This will help me to move toward an empowering leadership style. Conclusion I have learnt that: a good leader or manager remains grounded in the values, beliefs and behaviours that guide professional nursing practice; understanding your role and that of other will nurture clear communication thus improving the success of the team; safe decision-making must be evidence-based; and effective leadership fosters a high-quality work environment leading to positive safe climate that assures better patient outcomes.

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Leadership, Management, And Team Working For Professional

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In the contemporary world, nursing leadership and management have evolved significantly in most healthcare settings. There are several different types of management and leadership that go hand in hand, although they are not the same but complement each other as indicated (Azad et al. 2017). It is essential for to identify the style most suitable for an organisation or institution (Giltinate, 2013). According to West et al. (2015) the most influential factor in leadership is shaping organizational culture that guarantees leadership conducts, which ensures a continuous delivery of safe, high quality and compassionate care. The Nursing and Midwifery Council (NMC, 2018a) reinforced in the Code of Professional Conduct that everyone is a leader for quality right from the start, including newly registered nurses and support workers. Although it is vital to have managers within the healthcare setting there needs to be a clear role difference between leaders and managers, and identify the areas were they might not overlap (Sanderson, 2011). The aim of this essay is to analyse the qualities and impact of leadership and management in a healthcare setting. It is based on a management and leadership style observed during placement on a day ward and medical ward at a local Trust.

Northhouse (2007) described leadership as a method where individuals are influenced and motivated to accomplish a common goal, a driving force behind an organisation which brings success. There are several common attributes to leadership and these include influence, innovation and autocracy (Brady, 2010, Cummings, 2010). According to Hersey, Blanchard and Johnson (1998) a leader’s style is “the consistent behavior pattern that they use when they are working with and through other people, as perceived by those people”. Biggerstaff (2012) also points out that leadership styles can also be viewed as the observed behavior that an individual displays whilst trying to impact the actions of others. Darling-Hammond (2017 p.295) stated that leadership is an approach that an individual uses towards other team members with a desire to attain an established goal or outcome. Wilson (2016) also defines leadership as a procedure that provides direction, control, gives motivation, and creates inspiration towards achieving a goal that is already started. According to Darling-Hammond (2017 p.301), effective leadership is not only about capability, knowledge, or experience; it must also include character, morals, and requirements, which make one be a leader. The Francis Report (2013) stresses the importance of strong leadership at all levels of healthcare and emphasises openness, transparency and candour. Leadership and management is a combination of principles that relate to functions of providing planning, finance and control to utilise the available resources to attain the organisational goals. Karamat (2013) has drawn the attention of how important leadership is to any institution or organisation. Daly (2014) has drawn attention to the fact that peoples’ skills, internal motivation and personality traits are combined by leadership enabling teams to develop values and behavior attitudes.

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According to the NMC (2015), communication is an essential fundamental nursing tool in a healthcare setting which oversees all the work that nurses undertake from point of patient admission to discharge. Francis (2013) also expresses a similar view, that effective communication benefits nurse and patient relationships, which promote the overall well-being and treatment outcomes. Efficient and effective communication is vital amongst healthcare professionals and can make the difference between life and death, as pointed out by Vermeir et al. (2015). Effective communication can be in different forms, but needs to be clear and concise, so that all the healthcare professionals collaborate in an interdisciplinary approach where specialized skills are integrated for the benefit of the patient as suggested by O’Danie and Rosenstein (2008).

Autocratic Leadership

The leadership styles observed whilst on placement on a day ward was autocratic and transformational. This ward performs angiograms, angioplasty, implants pacemakers and defibrillators and this procedure is carried out by a cardiac consultant, radiographers and nurses. Kurt Lewin, a German-American psychologist, developed leadership styles and characterised them as democratic, laissez-faire and autocratic also known as authoritarian (Lewin, 1947). The autocratic leadership style demonstrated by the consultants displayed a leader follower rapport, which encouraged group success, problem solving, risk taking, morale boast and supports relationships. According to Dyczkowska and Dyczkowski (2018 p.193), autocratic leadership is a directive kind of leadership that involves making all decisions oneself as a leader, directing the staff to adhere to specific directions, and anticipating that employees accomplish assigned tasks on time. This leadership style involves the leader to dictate, dominate, and make independent decisions with minimal employee participations Robbins & Coulter (2009. This style expects followers to abide to leaders’ instructions unchallenged, autonomous rule making and assignment of tasks. This style lacks creativity, creates dissatisfaction, tension and is oppressive to Subordinates (Raus and Haita, 2011). Furthermore this does not allow followers to express their opinions and partake in decision making. Although Gastil (1994) claims that this leadership leads to high staff turnover, dissatisfaction and absenteeism this did not appear to the case on this particular ward. This style appeared to work effectively on here because there is pressure to complete the procedure on time by having an assigned leader, who gives clear specific roles and sets tasks. This ensures that followers acquire high skills at certain duties and this leads to procedure being completed efficiently and ensures everyone equal contribution. Laub (2018 p.165) argues that an autocratic leader is well-prepared to deal with a crisis condition without deliberation because decisions are made faster without, unlike other leadership styles (Dyczkowska and Dyczkowski, (2018 p.198). Autocratic leadership eliminates pressure from their staff as they are fully accountable for the decisions made (Laub, (2018 p.185). Having a clear direction with a defined path towards success provided to followers helps autocratic leaders to focus on productivity rather than problem-solving (Harms et al., 2020 p.106).

After the completion the procedure all staff including the consultant congregates at the nurse’s station to discuss the procedure and give feedback. The consultants changed their leadership style to transformational leadership, one that is motivating; discuss ideas, moral values and suggestions for the future (Bass and Avolio, 1997). This allows the consultant to have a dialogue with the staff. According to Curtis et al. (2011) transformational is defined as a method that transformational leadership can be defined as an approach that forms valued and positive change in people and a social system. This style creates an attachment amongst followers and leaders whilst showing an interest in the wellbeing of all employees. Jin (2010, p.174) points out that this style of leadership incorporates the elements of “empathy, compassion, sensitivity, relationship building, and innovation”. This developed trust amongst the team, encourages and promotes employee confidence, inspires development and participative decision making and power sharing, as stated (Aldoory and Toth 2004). The leaders provided individualised team support which reflected in the respect for employees, concern about their personal needs, feelings and well- being. This is viewed as leaders stimulating which challenges employees to think creatively, participate intellectually and take risks (Harms and Crede, 2010, p.6). The consultant’s attitude towards team members earned him respct, trust and showed appreciation and loyalty for his followers. The benefit of this is it changes follower’s behavior for the benefit of the ward. From the observation of the two different leadership styles demonstrated it shows that although the styles have disadvantages, they are suitable for the purpose of this particular setting. According to (Tuckman, 1965) five stages of development the team on this ward seem to have already explored all the stages and a general consensus has been agreed. The team norms have been formed through interacting and relationships have been formed.

The leadership observed on a medical ward by the ward manager was democratic. This is a cardiac ward for patients waiting for procedures and some recuperating. The ward requires the leader to exercise effective communication because style requires most staff in decision making process and perform the duties delegated by the leader after a consensus from the group. The manager’s roles involved effecting policies and procedures whilst ensuring tasks are accomplished effectively. This style allows for criticism, praise is given and members can identify issues and propose a solution (Amzat and Ali, 2011). Marquis and Huston (2015) expressed leadership style should consider staff contribution although the leader ultimately makes the final decision. Responsibilities are allocated to individual staff are accountable however individuals are responsible and are accountable for accomplishing the intended goals. This empowers them to improve their own skills. Bass (2008) expresses that the leader’s stress levels are lessened and feedback empowers the team to improve their performance. Whitehead et al. (2009) cites that this leadership style often exhibits less control compared to autocratic style, it guides rather than give orders therefore conflicting views might hinder performance. Bach and Ellis (2015) suggest that this style is applicable in a hospital setting where duties are given to nurses who are expected to work unsupervised. The manager also collaborated with several members of the multidisciplinary team, patients, families, and carers, this demonstrated a good leadership culture which promotes patient outcomes, reduce staff turnover and ensures job satisfaction (MacPhee, 2012). This meets the social, psychological, physical, spiritual and mental needs of patients. It is essential for nurses to display good leadership skills to avoid a repetition of failures found in wards in Mid Staffordshire (Francis Report, 2013). The manager ensures that the old and new staff receives quality training required to ensure patient safety and making sure staffing numbers, skill mix are safe and meet patients’ needs (NMC, 2016). The ward manager also regularly spoke to all members of staff to ensure no one was experiencing burnout due to heavy work load as this will affect work quality and performance (Jennings, 2008).

Although many aspects of the ward appeared to function well an observation was made were a certain member of staff consistently cancelled shift frequently, sometimes shortly before the shift started. The manager did not appear keen to address this problem because a friendship outside work existed. Several other staff did not agree with this scenario and appeared displeased. There seemed to be a conflict were other staff members felt there was a degree of favoritism towards this individual and no action was being taken. Overton and Lowry (2013) states that conflict can be managed but cannot be eluded therefore the manager should acquire the necessary skills required to appropriately have the difficulty conversation and diffuse the conflict. Healthcare setting requires effective cooperation and teamwork to properly function. Angelo (2019) states that Incivility in health care setting is disruptive and unprofessional which can possibly compromise patient safety. This behavior could potentially lead to other team members staying away and increase turnover. There was no evidence that this conflict was resolved.

Effective teamwork is important and fundamental to contemporary organisations and institutions. This is a group of people who come and work together; bring the best out of each other for a common cause (Kozlowski and Ilgen, 2006). The leadership styles displayed by a nurse on a cardiac ward were a participatory management style and laissez-faire leadership style. The participatory is task oriented and person centered style. The nurse assessed the task and then the person’s capability to carry it out in order to successfully complete it and also offered support and input where require. She let staff that was confident to work independently with little or no assistance. She exercised the laissez faire leadership which requires little supervision from the leader allowing staff to take ownership and responsibility (Bradley Edu, 2017). time. Therefore, it might be less productive to be used in emergency situations (Bradley Edu, 2017).

The nurse attended ward rounds with the ward doctors, pharmacists, occupational therapists and other professionals who formed collaboration and she exercised interpersonal communication skills that are an essential aspect of nursing. She continually offered education to staff on various critical clinical skills such as effective communication skills and interpersonal relations. Effective teamwork exercised improved staff morale, productivity and improves understanding of ones responsibilities and the importance of implementing hospital policy and procedure (Mao and Woolley, 2016 p.933). The nurse was always available to teach and assist students in practice, willing to demonstrate skills and explain the reason why procedures are carried out in a particular fashion. Working as a team is a creative way of encouraging the staff to learn from others and understand their roles to achieve quality patient outcomes (Van Knippenberg, 2017 p.352). The nurse encouraged staff to be open and discuss any issues to prevent conflict arising and avoid judging people and treat all individuals fairly and equally. The nurse emphasised the importance of effective communication and engage in successful collaborations as cited by Lewitter, Bourne and Attwood (2019. Maintaining open lines of communication amongst staff improves employee satisfaction that provides a clear understanding of effective teamwork (Valentine, Nembhard and Edmondson, 2015 p.26. Valentine, Nembhard, and Edmondson (2015 p.28) indicate that showing and understanding and empathy encourages employees to work as a team and meet mutual goals.

In conclusion, this essay has shown that there is need for effective leadership to be established in the provision of high quality care. Ellis and Bach (2015) argue that there is need for effective managers and leaders to exercise compassionate care as fundamental aspect of nursing training and care delivery. Nursing is forever changing and becoming complex. Because of the busy nature of the nursing profession burnout cannot be totally eliminated but workforce awareness should be raised. The manner in which managers and leaders guide and treat their followers determines the effect this displays on the performance and care provided (Curtis, 2011). The evidence shows that effective leadership displayed on team members can present a positive behaviour that influence improved organisational outcomes. Time spent on separate wards has helped me understand different styles of leaderships and how effective and rewarding if implemented effectively.

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