NURSE EDUCATOR
EFFECTIVE LEADERSHIP:
MAKING THE DIFFERENCE
Author: Jason Wade Grimm, RN, MS, CEN, Capt, USAF NC, San Antonio, TX
Earn Up to 8 CE Hours. See page 90.
he term leadership brings to mind the characteristics and actions of notable figures. Individuals such
as Florence Nightingale, John F. Kennedy, Ronald
Reagan and other people in history are regarded as leaders
because of the qualities they possessed and the decisions
they made. They often had a vision of change and achieved
it by imparting the need to set a new course and by inspiring their followers to share in their vision. Many times circumstances forced them to act without much regard of the
consequences of their actions.
Leadership is a complex entity, composed of numerous
definitions and qualities that describe successful leaders.
Furthermore, leaders use many different approaches to
achieve their objectives. This article explores the various
definitions of leadership and discusses traits and approaches
that enable leaders to move their followers and organizations toward a new horizon.
T
What is Leadership?
Many definitions of leadership reside within the literature. For
example, Benton 1 described leadership as the art of
influencing people to accomplish the mission. Tomey 2 characterized a leader as one who focuses on the mission, does the
right thing, and maintains an eye on the future. Another definition characterizes leadership as having a vision and possessing a plan that uses strategies for change. Leaders must be able
to mobilize people and resources to accomplish their vision of
change.3 In addition, a leader must be deft at seizing opporJason Wade Grimm is Active Duty Member, United States Air Force,
San Antonio, TX.
The views expressed in this article are those of the author and do not reflect
the official policy or the position of the United States Air Force, the Department of Defense, or the U.S. Government.
For correspondence, write: Jason Wade Grimm, RN, MS, CEN, Capt,
USAF NC, 13000 Vista Del Norte #1425, San Antonio, TX 78216; E-mail:
jasonwgrimm@aol.com.
J Emerg Nurs 2010;36:74-7.
Available online 6 September 2008.
0099-1767/$36.00
Copyright © 2010 Emergency Nurses Association. Published by Elsevier Inc.
All rights reserved.
doi: 10.1016/j.jen.2008.07.012
74
JOURNAL OF EMERGENCY NURSING
tunities, have integrity, and be accountable. Having a sense of
humor is essential for easing tension and maintaining balance.3 Clinical leadership in particular is characterized by
direct involvement in clinical care while constantly influencing others to improve the care they provide.4
Leadership Distinguished From Management
The literature draws distinctions and similarities between
the terms leadership and management. For example, Benton1
described leadership as an art. Management, on the other
hand, is a science, composed of calculations, methods,
and statistics.1 While management is focused on consistency and order in an organization, leadership is focused
on dealing with change. 5 In spite of these different
approaches, the two are similar in that they involve a decision about what needs to be done, establishing networks of
people to accomplish the goals, and ensuring that the people, the followers, actually get the job done.5
Each approach accomplishes these tasks in unique
ways. For example, managers cope with complexity by
establishing goals to be accomplished. Then they set forth
a plan and obtain the resources to achieve those goals.
Leaders, on the other hand, develop a vision and create strategies needed to accomplish the changes required to reach
the vision.5 Managers establish their networks by creating
an organizational structure staffed with qualified people
who know the plan and have the delegated authority to
accomplish it. Leaders align people by sharing their vision
and forming coalitions that are committed to achieving it.
To accomplish their plan, managers control and solve problems. They monitor results and identify deviations, then
develop a plan to solve the problems.5 Leaders appeal to
their followers’ emotions, values, and needs in order to
inspire and motivate them to accomplish the vision.5
Traits of Leadership
Effective leaders must possess the following traits, which
apply to any style of leadership.
CONFIDENCE
A leader must be confident in herself or himself. To be confident means to believe that he or she has what it takes to get
VOLUME 36 • ISSUE 1 January 2010
Grimm/NURSE EDUCATOR
the job done—in this case, to lead. Confidence is developed
over time. A new leader should have a base level of confidence that is developed from having completed the training
necessary to assume the leadership position. Leaders’ confidence should grow over time as they gain experience. As their
confidence grows, leaders should be willing to take on more
responsibility. However, they should know their limits so
they do not become overburdened.
thing. Such commitment may cause a leader to undergo ridicule and shame and perhaps even the loss of his or her job.
It is imperative for current leaders to mentor their successors on the importance of developing and maintaining
ethical fitness. Consistent training in developing ethical fitness ultimately will allow a leader to know the right answer
when he or she has little time to reflect. Knowing the right
answer is the hallmark of moral courage.7
PURPOSE
SETTING PRIORITIES
Leaders must a have a purpose and convey it to those in
their charge. When the followers know their purpose, they
will have a sense of direction and likely will not feel adrift.6
If the leader is in a new position and envisions a new purpose for the organization, he or she should have honest and
open discussions with staff. The leader should be receptive
to concerns voiced from the staff and not interpret tough
questions as resistance. The toughest questions often will
be asked by the strongest advocates.6
An important quality of leadership that cannot be overlooked
is the ability to establish priorities. The result of not having
priorities was demonstrated during President Carter’s administration. Siegel6 stated that President Carter was not able to
establish policy priorities during his term because he did not
have a guiding vision, a reason for his presidency. His lack of
prioritization meant that President Carter was personally
involved in as many as 35 different issues.6 It has been suggested that a president (or anyone in a leadership position)
should not be involved in more than perhaps 3 to 5 issues
at a time.6 Limiting their involvement can allow leaders to
focus, to get to know the causes they want to advance, and
to persuade their followers to get on board.
The most important message a busy nurse leader
should take away from this section is that various traits will
take center stage on different occasions. For example, a
nurse leader must be confident that his or her new triage
system is going to improve the accuracy of triage categorization. Ethical fitness will predominate when confronting a
physician or other provider about any ethical issues that
may arise. Courage would be forefront when defending
requests for additional funding to a hospital management
team that is focused on controlling costs.
COURAGE
In addition to a purpose, any leader also must possess courage. What is courage, exactly? There are several types of
courage. While physical courage is the willingness to risk
one’s life for a higher cause, natural courage causes an individual to just act. A leader in the nursing profession is most
likely to demonstrate moral courage, which Clancy 7
defined as being willing to risk shame and disapproval for
doing your duty and taking a stand, often while being
socially isolated. Moral courage requires leaders to hold
true to their beliefs and convictions.7 While courage itself
is important, a leader should avoid reckless courage, which
means to “shoot from the hip.”7 Those with reckless courage are not inhibited by fear when making difficult decisions. However, their luck eventually will dissipate and
they will fearlessly make the wrong decision.
ETHICAL FITNESS
Ethical fitness is another trait of sound leadership. Leaders
who are ethically fit have developed a deep sense of conviction for core values and morals.8 These individuals have an
intuitive sense of right and wrong, which helps provide the
courage to take a stand.8
A leader becomes ethically fit in much the same way
that a runner trains for a marathon. Becoming ethically
fit involves disciplined and progressive training, and for
some persons includes reflection on the morals and values
that underlie the decisions they have made. Furthermore,
leaders should evaluate their dedication to an issue constantly, questioning whether they are truly committed to
it. Kidder8 stated that leaders should ask themselves to what
extent are they willing to uphold their beliefs, to do the right
January 2010
VOLUME 36 • ISSUE 1
Styles of Leadership
Situational and transformational leadership are 2 styles that
are essential for effective leadership in the chaotic world of
the emergency department. Autocratic leadership may be
applied, although it should be limited to only crisis situations, such as a natural disaster. With this approach, the
leader assumes a command role in which he or she gives
directives to those in his or her charge. One important
point about these styles is that neither is perfect for every
situation. Therefore leaders should have the knowledge and
skills to apply them as needed. The appropriate style should
be chosen based on the job to be done, the leader’s base of
power, and the leader-follower relationship.9
SITUATIONAL LEADERSHIP
Situational leadership theory is built on a relationship
between a leader’s supportive and directive behavior and
WWW.JENONLINE.ORG
75
NURSE EDUCATOR/Grimm
the followers’ level of development. The leader’s supportive
ability involves the extent that leaders maintain a personal
association with the followers. This is done by maintaining open lines of communication and providing socioemotional support to the followers. The leader’s directive
behavior is the degree of direction given to the group in
terms of defining group roles, explaining the activities each
role must accomplish, and explaining how the tasks are to
be completed. The development level of the followers is a
product of their experience and their willingness and ability
to take on responsibility.10
The situational leadership model is depicted in a
square and represents the inter-relationship between leadership style and the development level of the followers 12. In
the lower right corner of the square is S1-directing, which
represents high directive and low supportive behavior. In
the upper right corner of the square is S2-coaching. This
style involves both high directive and high supportive behavior. S3-supporting is in the upper left corner of the square
and consists of both high supportive and low directive
behavior. S4-delegating is located in the lower left
corner and depicts the leader’s low supportive and low
directive behavior 12.
The four styles depicted in the square are intended to
correspond with a particular development level of the followers. For example, S1-the directing style, corresponds
with D1, a low level of development. As the follower(s)
development level progresses from D1 to D2 and then to
D3, moderate levels, then the leader’s style should change
from coaching to supporting. Finally, the leader should
take on a delegating role as the follower(s) reach D4-a high
level of development 12. They key point to remember
when determining the appropriate leadership style is that
the leader must do for the follower(s) the things they cannot do for themselves at that precise moment 12.
A nurse leader can apply this model when precepting
new nurses or clinical students in the emergency department. The leader’s approach in working with the mentee
is based on the mentee’s level of experience and confidence.
A new nurse or clinical student likely will have a base level
of clinical knowledge but may not have the experience in
performing certain tasks such as placing EKG leads on a
patient. Their lack of experience and confidence at this
point places them at M1. In this case, the leader would take
on a directive role with low relationship as reflected by S1
on the model. He or she would explain the correct order of
lead placement while positioning them on the patient. On
the next patient, the preceptor could encourage the student
place the leads while he or she observed. The preceptor
could gently correct the mentee or provide positive feedback during the process. As the mentee gained confidence
76
JOURNAL OF EMERGENCY NURSING
in lead placement, their maturity for this particular task
would move to M4. The preceptor’s behavior would simultaneously transition to S4, a low-task/low-relationship
behavior. He or she could then delegate future lead placements to the new nurse or clinical student. The delegation
role would be of benefit to nurses who have demonstrated
required clinical skills and are self-motivated.
TRANSFORMATIONAL LEADERSHIP
Transformational leadership is a style that is focused on
change. Those who use this style are regarded as change
agents who use qualities such as charisma to motivate their
followers. Transformational leadership is considered to
have a cascading effect; when practiced at the top, it is
reflected down the ladder of the organization.9 For transformational leaders to realize their vision for change, they
focus on building up their followers. Such leaders energize
and motivate their followers to achieve their goals, share
their visions, and embrace empowerment.
Leaders can enhance empowerment by embracing
several qualities, some of which were highlighted previously. First, they must build a bond of trust with their followers. This bond of trust can be developed by being open
and honest with the staff and by encouraging them to
become independent in their decision making. They must
envision several goals to achieve and use effective communication to transform them into goals shared by all.
In addition, managers and leaders must have a high sense
of self-esteem, believe in their vision, and have the courage
to see it through.9
The underlying goal of transformational leadership is
to bring about some type of change. A leader employing
this style of leadership should realize that change, in general, requires a great deal of effort and time. The leader
should be realistic when establishing the goals he or she
wants to achieve. It also is important to know the culture
of the unit, department, or organization in which they
work. The culture can be maintained when the environment is stable, when there is no need to bring about
change. When new demands are placed on the organization, cultural stability and the leader’s knowledge of the culture can both help to achieve successful results when
change is needed.
Another key point of this article is that nurse leaders
must be flexible in choosing the appropriate leadership
style. When I was a flight nurse in the Air National Guard,
the unofficial motto of aero-medical evacuation was to
always be flexible. Flexibility was critical to mission success
because plans and conditions were always sure to change.
The same is true for the emergency department; different
situations will call for different styles. A charge nurse may
VOLUME 36 • ISSUE 1 January 2010
Grimm/NURSE EDUCATOR
have to switch from a situational style when precepting a
new graduate nurse to an autocratic approach during a disaster and then back again to the situational style.
The leaders of an organization should recognize that a
variety of leadership styles is necessary to deal with varied
contingencies that arise within the organization. Organizational leaders should know the strengths and weaknesses of
different styles and develop ways to match the styles with
the appropriate situation.11 Particularly within health care
organizations, which are faced with seemingly constant
change, the leaders at the top should cultivate different
styles among the leaders below them. Subordinate leaders
and managers should be encouraged to develop and refine
their individual styles. One way to accomplish this goal is
by allowing them to take on a variety of responsibilities and
positions within the organization.11
To conclude, nurses are leaders by nature of the profession. Regardless of their level of practice or setting, nurses frequently are called upon to make decisions and act in ways
that can profoundly change the outcomes of their patients
and the organization of which they are a part. Different circumstances require different qualities and styles such as those
addressed in this article. On a historical note, the ancient
Romans were known to surround their young leaders with
paintings and sculpture in order to encourage them.
Beschloss12 noted that if America adopted this practice
to inspire future leaders, the objects surrounding them
would include artifacts from our nation’s presidential history that would remind them of the importance of courage.
If the aspiring leaders were not impressed, then they could
be taken to Mount Vernon to see the bed in which George
January 2010
VOLUME 36 • ISSUE 1
Washington died. They could then be told that while his
doctor was worried about the dying president’s prognosis,
Washington told him to not be afraid.12
Acknowledgment
The author wishes to acknowledge Tonya Appleby, RN, MSN, CPNP; Karen
Johnson, PhD, RN, CCRN; Valerie Sabol, RN, MSN, ACNP; and Kathryn
Von Rueden, RN, MS, FCCM.
REFERENCES
1.
2.
3.
4.
5.
6.
7.
Benton T. Air Force Officer’s Guide. 34th ed. Mechanicsburg, PA: Stackpole Books; 2005.
Tomey AM. Guide to Nursing Management and Leadership. 6th ed. St.
Louis, MO: Mosby; 2000.
McArthur DB. The nurse practitioner as leader. J Am Acad Nurs Practitioners.
2006;18:8-10.
Cook MJ. Improving care requires leadership in nursing. Nurs Educ
Today. 1999;19:306-12.
Kotter JP. What leaders really do. Harvard Bus Rev. 2001;79(11): 85-96.
Siegel ME. Probation and pretrial chiefs can learn from the leadership
styles of American presidents. Fed Probation. 2000;64: 27-33.
Clancy TR. Courage and today’s nurse leader. Nurs Admin Q. 2003;27:128-32.
8.
Kidder RM. How Good People Make Tough Choices. New York, NY:
Simon & Schuster; 1995.
9.
Murphy L. Transformational leadership: a cascading chain reaction.
J Nurs Manage. 2005;13:128-36.
10. Blanchard K, Zigarmi P, Zigarmi D. Leadership and the One Minute
Manager: Increasing Effectiveness Through Situational Leadership. New
York, NY: William Morrow and Company, Inc; 1985.
11. Lindholm M, Sivberg B, Uden G. Leadership styles among nurse
managers in changing organizations. J Nurs Manage. 2000;8:327-35.
12. Beschloss M. Presidential Courage: Brave Leaders and How They Changed
America. New York, NY: Simon and Schuster; 2007.
WWW.JENONLINE.ORG
77