- Email: [email protected]
Evidence-based leadership: Nursing's new mandate
Evidence-Based Leadership: Nursing’s New Mandate Holly A. De Groot, PhD, RN, FAAN
In its landmark report, “Keeping Patients Safe: Transforming the Work Environment of Nurses,” the Institute of Medicine (IOM) issued a startling wake-up call for nursing and health care leaders.1 Acknowledging the critical role of nurses in patient safety, this exhaustive study concluded that inherent in the work environment of nurses are serious threats to patient safety. The pervasiveness of these threats is evident in key areas of the organization.
While this report issued a stern indictment of the health care environment and the management practices of its leaders, it also recommended major patient safety defenses. The top safety strategy identified was to adopt evidence-based management (EBM) and evidence-based leadership (EBL) strategies. This article reviews the major recommendations in that study, as well as major leadership issues and best-practice elements associated with EBM. A new definition of EBL will be advanced, and a case for developing a personal leadership plan will be explored.
THREATS TO PATIENT SAFETY AND SAFETY DEFENSES The four major threats to patient safety identified by the IOM include poor management practices, unsafe workforce deployment, unsafe work and workspace deApril 2005
sign, and punitive organizational cultures that hinder error prevention and reporting. Four safety defenses against these threats also were discussed at length in this ground-breaking study: adopting transformational leadership and EBM practices, maximizing workforce capability, designing work structures and spaces to reduce error, and creating and sustaining a culture of safety. The fact that leadership is identified as the top defense for health care organizations is remarkable. For the first time, a prestigious national body affirms the key role of nursing executive management. It also means that nursing leaders must rise immediately to meet these serious challenges if our social mandate to ensure patient safety is to be met. Although the IOM report includes recommendations for other leaders, the main emphasis of this discussion is clearly on nursing and what nurse leaders must do to ensure patient safety and a positive work environment for Nurse Leader 37
Table 1. Leadership Assets Vital financial health Reputation and relationships Appropriate services, products, and tools Adapted from DePree M. Leadership is an art. New York: Doubleday; 1989.
Table 2. Leadership Legacy Clear statement of values Future leadership A sense of quality Openness to change New reference point New reference point
ture (learning and personal growth), and aging.4 The observation also has been made that not all leaders are managers and not all managers are leaders.5 Not surprisingly, the IOM report reflects the conceptual difference between management and leadership by identifying the need for transformational leadership as a precursor to EBM. In a remarkable move, the agency promoted the adoption of a particular research-based leadership strategy as the best way to solve the leadership problems in health care. This unprecedented recommendation came after an exhaustive review of the literature that demonstrated the superiority of transformational leadership over other approaches. The IOM asserts that transformational leadership is the essential precursor to patient safety, successful organizational change, and the organization’s competitive position. As such, transformational leadership offers clear promise and direction for nursing leaders.
Organizational improvement Adapted from DePree M. Leadership is an art. New York: Doubleday; 1989.
nurses. This article assumes the IOM conclusion that leaders frequently fail to follow management practices associated with patient safety and that transformational leadership and associated evidence-based practices are the top remedy for this leadership failure. This discussion is also based on the strong belief that EBL, if practiced to its full extent, will make certain the other three threats to patient safety are addressed and removed or minimized.
ISSUES IN MANAGEMENT AND LEADERSHIP The concepts of leadership and management are significant constructs in the IOM recommendations. Many definitions of these terms exist in the literature, and the difference between leadership and management has long been debated. However, a general consensus about the difference between these two crucial concepts has emerged over time. Most authors and researchers view leadership as a more strategic endeavor, focused on vision development, direction-setting, and coping with uncertainty and change. Managers, on the other hand, have a more tactical focus, dealing with organizational complexity as they implement plans, policies, and procedures to translate the vision and achieve organizational goals. Leaders are viewed as more tolerant of uncertainty, while managers seek more order and control.2 According to Kotter,3 “Managers promote stability, while leaders press for change.” Whether leadership is an innate or acquired ability has also been assessed, as well as the degree to which new skills can be retained over time. Studies have shown that leadership ability is a function of nature (genetics), nur38 Nurse Leader
TRANSFORMATIONAL LEADERSHIP Several common threads are evident in the various definitions of leadership, including the notion that leadership is relational and involves the ability to influence a group toward goal achievement. The source of this influence may be formal or informal, innate or acquired. While the transactional leader guides and motivates by clarifying role and task requirements, transformational leaders set aside their own self-interests for the greater organizational good. They tend to have a profound and extraordinary effect on followers.6 Transformational leaders engage with their followers in the joint pursuit of a goal in a mutually stimulating manner. Burns7 asserts the nature of transformational leadership and its elevating, inspiring effect on all parties. He also notes its potential to raise the level of human conduct and transform both leaders and followers alike.
THE LEADER-ORGANIZATION RELATIONSHIP Max DePree’s8 work provides further insight into the particular type of relationship required of transformational leaders in organizations. He believes that leaders are in a covenantal relationship with their organizations; there is an implied agreement, promise, and duty to perform in a particular way. This leadership covenant is formal, solemn, and binding. As such, leaders are both servants of and debtors in their organizations. This concept of stewardship in health care means that leaders owe their organization both assets and a legacy. The assets outlined in Table 1 include vital financial health in addition to reputation and relationships that allow financial health to continue. A sense of quality and organizational openness to change are also vital assets. Finally, leaders owe their organizations the appropriate products, services, and tools of production to be fully accountable. The legacy that leaders owe their organizations includes several key areas of focus (Table 2). First, leaders owe a clear statement of values that will ultimately shape individApril 2005
Table 3. Components of Emotional Intelligence
Table 5. Characteristics of Visionary
Self-awareness
Is creatively dissatisfied
Self-management
Leads by the power of the vision
Social awareness
Focuses on underlying problems
Relationship management
Remains radically open to new ideas Accepts multiple realities
Adapted from Goleman D, Boyatzis R, McKee A. Primal leadership. Boston: Harvard University Press; 2002.
Does not take credit for success Seeks insights from mentors Possesses capacity to hold the vision
Table 4. Characteristics of Vision Is value-directed Is future-oriented Involves hope Embodies an ideal Generates energy/excitement
are fundamental to successful transformational leadership, and ultimately, the reformation of health care. The fact that these competencies can be acquired or learned has particular implications for the professional growth and development of nursing leaders.
Implies action Involves continual change
ual and corporate behavior. In addition, they are responsible for succession planning and nurturing future leaders. DePree also asserts that leaders owe their organizations a new reference point or standard for how people can be and what they can accomplish in a caring, committed environment. Leaders are obligated to display maturity and leave their organizations better off than when they took office.
EMOTIONAL INTELLIGENCE Another significant factor that predicts leadership success is emotional intelligence (EI).9 Related to DePree’s notion of maturity, EI comprises leadership competencies and capabilities that influence ability to cope with organizational pressures and demands. Initially, five leadership competences were associated with EI, but further work by Goleman and colleagues9 has reduced the number to four interrelated domains: self- awareness, self-management, social awareness, and relationship management (Table 3). Self-awareness involves being aware of one’s emotions and how they affect others. The ability to self-assess accurately is also a key to this competency, as is self-confidence. Self-management includes self-control, transparent values and beliefs, adaptability, achievement, initiative, and optimism. Social awareness is evidenced by empathy, organizational astuteness, and a strong service orientation. Finally, relationship management is characterized by inspiration, influence, the ability to develop others and serve as a catalyst for change, and strong conflict management skills. Teamwork and collaboration are also emblematic of this capability. The point is that the competencies associated with EI April 2005
VISION AND LEADERSHIP Virtually every discussion of leadership acknowledges the critical role of vision to successful practice. Vision is the substance of leadership success and the blueprint for the future. The definition used here was offered by one of nursing’s greatest visionaries, Dr. Margretta Styles,10 who defined vision as “unusual discernment or foresight.” This seemingly simple definition is quite profound, because it captures the quintessence of vision so elegantly. The operative concepts in this definition imply not just the regular, garden-variety insight, but a significant and extraordinary prescience and comprehension of what is likely obscure, irrelevant, or meaningless to others. The characteristics of vision that have been described over the years are synthesized in Table 4. Vision is value-directed, and as such, discloses one’s will and innermost dreams and desires. Vision is also future-oriented. In fact, if a vision bears much of a resemblance to the current system or situation, it probably is not a vision in the way meant here. Vision also involves hope, the possibility of transformation, and attainment of new realities. Another important characteristic of vision is embodiment of an ideal. Vision represents, in its purest form, how one would have things in a perfect world. As such, it can be thought of as a preferred future. Vision also generates its own energy, excitement, and enthusiasm because of the promise it holds. In addition, vision always implies action and the need to take steps to translate it into reality. In this way, vision compels people to act. Finally, vision implies continual change. By its very nature, vision demands that the closer you get to attaining it, the more it needs to be revised and reformulated. Vision is in a constant state of becoming. While knowledge of these characteristics is helpful in understanding what it will take to transform health care, what we know of visionaries and the keys to their success Nurse Leader 39
also informs us. The attributes that definition of EBM and relating it to the distinguish visionaries from others are identification, assessment, and applicaConsideration of key depicted in Table 5. Visionaries are tion of empirical evidence from managecreatively dissatisfied with the current ment research in practice. The agency leadership state, implying a willingness to take acalso recommends five essential EBM characteristics and tion in a unique way. Visionaries lead practices: balancing the inherent tension by the power of the vision and focus between efficiency and reliability (safecompetencies on underlying problems rather than ty), creating and sustaining trust in the provides the foundation cosmetic fixes. Radically open to new organization, actively managing the ideas, visionaries at first may overprocess of change, involving workers in for a discussion of EBL. whelm others with their ideas. Howevwork design and workflow decisions, er, the application of transformational and creating a learning organization. leadership practices, combined with These five foundational practices add to EI, will allow others to embrace the vision as their own. our understanding of the type of empirical evidence and Visionaries more easily accept multiple realities, and as action required in leading and transforming health care ornoted earlier, tolerance of ambiguity and uncertainty are ganizations. defining characteristics of leaders. They do not need to What is still needed for health care leaders, however, is a take credit for the success of the vision; they simply are definition that incorporates leadership, vision, and the nosatisfied with knowing it became or is becoming a reality. tion of an evidence base. Such a definition must take into Visionaries also seek insight from mentors to clarify, focus, account the relational nature of leadership while asserting and sharpen their vision. Finally, they have the unique cathe application of sound theory in practice. The definition pacity to hold the vision, an attribute that sustains and enof EBL offered here is a transformational relationship incourages them along the way. volving organizational stewardship, decision-making, and Being a visionary is not for the faint-hearted, because vision translation through reasoned application of empirithe path to vision translation can be littered with obstacles cal evidence from management, leadership, and patient that require strength, endurance, persistence, and the care research. “four Cs”: This new definition acknowledges the transforming na• Conviction or an uncommonly strong belief in the vision ture of a leader’s covenantal relationship with the organizaand its potential to solve a problem or resolve a situation tion, while identifying the decision, vision, and application • Commitment to do what it takes to implement that vision. mandate associated with the role. This expanded definition Commitment requires an enduring, long-term focus that of EBL also has significant implications for nursing leaders. must be tended over time. Commitment is evidenced by First, the fundamental role of stewardship and the napersistent actions aimed at achieving the vision. ture of the leader’s covenantal relationship with the organ• Courage and the discipline to stay the course, even if ization must be fully understood and appreciated. How initially unpopular or misunderstood does one go about this process? Taking the time to read • Creativity, originality, and innovation are fundamental. and reflect on the particular assets and legacy that leaders To implement the IOM’s recommendations, a clear owe is the first step. The work of DePree and others who and compelling vision of nursing and care delivery write on leadership should inform and assist in this must exist if health care is to be transformed. process. An honest self-appraisal of one’s personal beliefs is also necessary to determine the degree of congruence with the expectations of organizational stewardship disEVIDENCE-BASED LEADERSHIP cussed here. This self-assessment should result in a clear Consideration of key leadership characteristics and compersonal belief statement that reflects conviction about petencies provides the foundation for a discussion of EBL. stewardship and the nature of the assets and legacy owed By linking transformational leadership and EBM to the to the organization. The end result of this process must be quest for patient safety and positive work environments, a firm commitment to those beliefs and the resolve to emthe IOM report lays the groundwork for a new definition body and employ their precepts. of EBL in nursing. Various definitions of evidence-based Second, this personal belief and commitment statepractice in the literature tend to focus on clinical practice ment will necessarily lead to a comprehensive self-assessdecision-making rather than on leadership or management of leadership strengths and areas for improvement. ment.11-13 Ingersoll14 offered a broader definition of eviThe evaluation focus should include, but not be limited dence-based nursing administration, calling it “the to, transformational leadership, EI, vision development conscientious, explicit, and judicious use of theory-derived, and translation, and the essential management practices research-based information in making decisions about care identified by the IOM. The outcome of this assessment delivery systems….” While this conception furthers our unprocess is a personal action plan to acquire or improve derstanding, the focus is on decision-making rather than the leadership knowledge and skill sets identified here. As leadership behaviors and practices. with any action plan, the goals and objectives should be The IOM addresses this omission by proffering its own 40 Nurse Leader
April 2005
Table 6. Keys to Successful Implementation of a Personal Leadership Plan Commitment Clarity
ates new opportunities and obligations for nursing leaders. By combining knowledge and skill building with conviction, commitment, courage, and creativity, nursing will be ideally positioned to fulfill its social mandate. In this way, evidence-based leadership will serve as the cornerstone of patient safety and nursing’s preferred future.
Coordination Education
References
Expertise
1. Institute of Medicine. Keeping patients safe: transforming the work environment of nurses. Washington (DC): The National Academies Press; 2003. 2. Zaleznik A. Managers and leaders. Are they different? Leadership insights. Boston: Harvard Business School Publishing; 2002. pp. 2-11. 3. Kotter JP. A force for change: how leadership differs from management. New York: Free Press; 1990. 4. Goleman D. What makes a leader? Leadership insights. Boston: Harvard Business School Publishing; 2002. pp. 93-102. 5. Mintzberg H. The manager’s job: folklore and fact. Harvard Business Rev 1990;68(3):75-88. 6. Robbins SP. Organizational behavior. Englewood Cliffs (NJ): Prentice Hall; 1996. 7. Burns J. Leadership. New York: Harper and Row; 1978. 8. DePree M. Leadership is an art. New York: Doubleday; 1989. 9. Goleman D, Boyatzis R, McKee A. Primal leadership. Boston: Harvard University Press; 2002. 10. Styles MM. On nursing. Toward a new endowment. St. Louis (MO): C.V. Mosby; 1982. 11. Sackett DL. Evidence-based medicine. Seminars in Perinatology 1997;21(1):3-5. 12. Stetler CB, Brunell M. Evidence-based practice and the role of nursing leadership. The Journal of Nursing Administration 1998;28(7-8):45-53. 13. Jennings BM, Loan LA. Misconceptions among nurses about evidence-based practice. Journal of Nursing Scholarship 2001;33(2):121-7. 14. Ingersoll GL. Evidence-based nursing: what it is and what it isn’t. Nursing Outlook 2000;48(4):151-2. 15. De Groot HA. Patient classification systems and staffing, II: practice and promise. JAMA 1994;24 :17-23.
Involvement Communication Evaluation
clearly identified, along with the particular strategies selected. Also included in this personal leadership plan is the projected start and expected completion date for each action item. Third, in order for the personal leadership plan to be actualized, eight keys to successful implementation should be kept in mind. These success strategies have been identified elsewhere15 and have particular relevance here (Table 6). The first four keys include the commitment to grow and develop as a leader, clarity of vision and the beliefs that drive it, coordination of personal growth and other organizational and life activities, and education appropriate to the plan. Seeking expertise, whether it is insight from mentors or other well-respected authorities, is also crucial, as is involvement in leadership-enhancing activities (professional meetings, seminars, retreats, etc.). Consistent communication with others about what has been learned and how it can be applied is also necessary because it shares your vision and allows others to grow with you. Finally, an annual evaluation of the progress made in the personal leadership plan will allow for any changes or refinements to be made. Often, life and work circumstances have a way of creating either the opportunity or requirement to adjust or refocus the plan. It is essential that the personal leadership plan stays flexible, adapting as organization and career goals change. It is clear from this discussion that the new view of EBL and the type of organizational stewardship it demands cre-
April 2005
Holly A. De Groot, PhD, RN, FAAN, is chief executive officer of Catalyst Systems, LLC, in Novato, California. She also serves as clinical faculty in the graduate program in nursing administration at the University of California, San Francisco. She can be reached at [email protected]. 1541-4612/2005/ $ - see front matter Copyright 2005 by Elsevier Inc. doi:10.1016/j.mnl.2005.01.004
Nurse Leader 41
In its landmark report, “Keeping Patients Safe: Transforming the Work Environment of Nurses,” the Institute of Medicine (IOM) issued a startling wake-up call for nursing and health care leaders.1 Acknowledging the critical role of nurses in patient safety, this exhaustive study concluded that inherent in the work environment of nurses are serious threats to patient safety. The pervasiveness of these threats is evident in key areas of the organization.
While this report issued a stern indictment of the health care environment and the management practices of its leaders, it also recommended major patient safety defenses. The top safety strategy identified was to adopt evidence-based management (EBM) and evidence-based leadership (EBL) strategies. This article reviews the major recommendations in that study, as well as major leadership issues and best-practice elements associated with EBM. A new definition of EBL will be advanced, and a case for developing a personal leadership plan will be explored.
THREATS TO PATIENT SAFETY AND SAFETY DEFENSES The four major threats to patient safety identified by the IOM include poor management practices, unsafe workforce deployment, unsafe work and workspace deApril 2005
sign, and punitive organizational cultures that hinder error prevention and reporting. Four safety defenses against these threats also were discussed at length in this ground-breaking study: adopting transformational leadership and EBM practices, maximizing workforce capability, designing work structures and spaces to reduce error, and creating and sustaining a culture of safety. The fact that leadership is identified as the top defense for health care organizations is remarkable. For the first time, a prestigious national body affirms the key role of nursing executive management. It also means that nursing leaders must rise immediately to meet these serious challenges if our social mandate to ensure patient safety is to be met. Although the IOM report includes recommendations for other leaders, the main emphasis of this discussion is clearly on nursing and what nurse leaders must do to ensure patient safety and a positive work environment for Nurse Leader 37
Table 1. Leadership Assets Vital financial health Reputation and relationships Appropriate services, products, and tools Adapted from DePree M. Leadership is an art. New York: Doubleday; 1989.
Table 2. Leadership Legacy Clear statement of values Future leadership A sense of quality Openness to change New reference point New reference point
ture (learning and personal growth), and aging.4 The observation also has been made that not all leaders are managers and not all managers are leaders.5 Not surprisingly, the IOM report reflects the conceptual difference between management and leadership by identifying the need for transformational leadership as a precursor to EBM. In a remarkable move, the agency promoted the adoption of a particular research-based leadership strategy as the best way to solve the leadership problems in health care. This unprecedented recommendation came after an exhaustive review of the literature that demonstrated the superiority of transformational leadership over other approaches. The IOM asserts that transformational leadership is the essential precursor to patient safety, successful organizational change, and the organization’s competitive position. As such, transformational leadership offers clear promise and direction for nursing leaders.
Organizational improvement Adapted from DePree M. Leadership is an art. New York: Doubleday; 1989.
nurses. This article assumes the IOM conclusion that leaders frequently fail to follow management practices associated with patient safety and that transformational leadership and associated evidence-based practices are the top remedy for this leadership failure. This discussion is also based on the strong belief that EBL, if practiced to its full extent, will make certain the other three threats to patient safety are addressed and removed or minimized.
ISSUES IN MANAGEMENT AND LEADERSHIP The concepts of leadership and management are significant constructs in the IOM recommendations. Many definitions of these terms exist in the literature, and the difference between leadership and management has long been debated. However, a general consensus about the difference between these two crucial concepts has emerged over time. Most authors and researchers view leadership as a more strategic endeavor, focused on vision development, direction-setting, and coping with uncertainty and change. Managers, on the other hand, have a more tactical focus, dealing with organizational complexity as they implement plans, policies, and procedures to translate the vision and achieve organizational goals. Leaders are viewed as more tolerant of uncertainty, while managers seek more order and control.2 According to Kotter,3 “Managers promote stability, while leaders press for change.” Whether leadership is an innate or acquired ability has also been assessed, as well as the degree to which new skills can be retained over time. Studies have shown that leadership ability is a function of nature (genetics), nur38 Nurse Leader
TRANSFORMATIONAL LEADERSHIP Several common threads are evident in the various definitions of leadership, including the notion that leadership is relational and involves the ability to influence a group toward goal achievement. The source of this influence may be formal or informal, innate or acquired. While the transactional leader guides and motivates by clarifying role and task requirements, transformational leaders set aside their own self-interests for the greater organizational good. They tend to have a profound and extraordinary effect on followers.6 Transformational leaders engage with their followers in the joint pursuit of a goal in a mutually stimulating manner. Burns7 asserts the nature of transformational leadership and its elevating, inspiring effect on all parties. He also notes its potential to raise the level of human conduct and transform both leaders and followers alike.
THE LEADER-ORGANIZATION RELATIONSHIP Max DePree’s8 work provides further insight into the particular type of relationship required of transformational leaders in organizations. He believes that leaders are in a covenantal relationship with their organizations; there is an implied agreement, promise, and duty to perform in a particular way. This leadership covenant is formal, solemn, and binding. As such, leaders are both servants of and debtors in their organizations. This concept of stewardship in health care means that leaders owe their organization both assets and a legacy. The assets outlined in Table 1 include vital financial health in addition to reputation and relationships that allow financial health to continue. A sense of quality and organizational openness to change are also vital assets. Finally, leaders owe their organizations the appropriate products, services, and tools of production to be fully accountable. The legacy that leaders owe their organizations includes several key areas of focus (Table 2). First, leaders owe a clear statement of values that will ultimately shape individApril 2005
Table 3. Components of Emotional Intelligence
Table 5. Characteristics of Visionary
Self-awareness
Is creatively dissatisfied
Self-management
Leads by the power of the vision
Social awareness
Focuses on underlying problems
Relationship management
Remains radically open to new ideas Accepts multiple realities
Adapted from Goleman D, Boyatzis R, McKee A. Primal leadership. Boston: Harvard University Press; 2002.
Does not take credit for success Seeks insights from mentors Possesses capacity to hold the vision
Table 4. Characteristics of Vision Is value-directed Is future-oriented Involves hope Embodies an ideal Generates energy/excitement
are fundamental to successful transformational leadership, and ultimately, the reformation of health care. The fact that these competencies can be acquired or learned has particular implications for the professional growth and development of nursing leaders.
Implies action Involves continual change
ual and corporate behavior. In addition, they are responsible for succession planning and nurturing future leaders. DePree also asserts that leaders owe their organizations a new reference point or standard for how people can be and what they can accomplish in a caring, committed environment. Leaders are obligated to display maturity and leave their organizations better off than when they took office.
EMOTIONAL INTELLIGENCE Another significant factor that predicts leadership success is emotional intelligence (EI).9 Related to DePree’s notion of maturity, EI comprises leadership competencies and capabilities that influence ability to cope with organizational pressures and demands. Initially, five leadership competences were associated with EI, but further work by Goleman and colleagues9 has reduced the number to four interrelated domains: self- awareness, self-management, social awareness, and relationship management (Table 3). Self-awareness involves being aware of one’s emotions and how they affect others. The ability to self-assess accurately is also a key to this competency, as is self-confidence. Self-management includes self-control, transparent values and beliefs, adaptability, achievement, initiative, and optimism. Social awareness is evidenced by empathy, organizational astuteness, and a strong service orientation. Finally, relationship management is characterized by inspiration, influence, the ability to develop others and serve as a catalyst for change, and strong conflict management skills. Teamwork and collaboration are also emblematic of this capability. The point is that the competencies associated with EI April 2005
VISION AND LEADERSHIP Virtually every discussion of leadership acknowledges the critical role of vision to successful practice. Vision is the substance of leadership success and the blueprint for the future. The definition used here was offered by one of nursing’s greatest visionaries, Dr. Margretta Styles,10 who defined vision as “unusual discernment or foresight.” This seemingly simple definition is quite profound, because it captures the quintessence of vision so elegantly. The operative concepts in this definition imply not just the regular, garden-variety insight, but a significant and extraordinary prescience and comprehension of what is likely obscure, irrelevant, or meaningless to others. The characteristics of vision that have been described over the years are synthesized in Table 4. Vision is value-directed, and as such, discloses one’s will and innermost dreams and desires. Vision is also future-oriented. In fact, if a vision bears much of a resemblance to the current system or situation, it probably is not a vision in the way meant here. Vision also involves hope, the possibility of transformation, and attainment of new realities. Another important characteristic of vision is embodiment of an ideal. Vision represents, in its purest form, how one would have things in a perfect world. As such, it can be thought of as a preferred future. Vision also generates its own energy, excitement, and enthusiasm because of the promise it holds. In addition, vision always implies action and the need to take steps to translate it into reality. In this way, vision compels people to act. Finally, vision implies continual change. By its very nature, vision demands that the closer you get to attaining it, the more it needs to be revised and reformulated. Vision is in a constant state of becoming. While knowledge of these characteristics is helpful in understanding what it will take to transform health care, what we know of visionaries and the keys to their success Nurse Leader 39
also informs us. The attributes that definition of EBM and relating it to the distinguish visionaries from others are identification, assessment, and applicaConsideration of key depicted in Table 5. Visionaries are tion of empirical evidence from managecreatively dissatisfied with the current ment research in practice. The agency leadership state, implying a willingness to take acalso recommends five essential EBM characteristics and tion in a unique way. Visionaries lead practices: balancing the inherent tension by the power of the vision and focus between efficiency and reliability (safecompetencies on underlying problems rather than ty), creating and sustaining trust in the provides the foundation cosmetic fixes. Radically open to new organization, actively managing the ideas, visionaries at first may overprocess of change, involving workers in for a discussion of EBL. whelm others with their ideas. Howevwork design and workflow decisions, er, the application of transformational and creating a learning organization. leadership practices, combined with These five foundational practices add to EI, will allow others to embrace the vision as their own. our understanding of the type of empirical evidence and Visionaries more easily accept multiple realities, and as action required in leading and transforming health care ornoted earlier, tolerance of ambiguity and uncertainty are ganizations. defining characteristics of leaders. They do not need to What is still needed for health care leaders, however, is a take credit for the success of the vision; they simply are definition that incorporates leadership, vision, and the nosatisfied with knowing it became or is becoming a reality. tion of an evidence base. Such a definition must take into Visionaries also seek insight from mentors to clarify, focus, account the relational nature of leadership while asserting and sharpen their vision. Finally, they have the unique cathe application of sound theory in practice. The definition pacity to hold the vision, an attribute that sustains and enof EBL offered here is a transformational relationship incourages them along the way. volving organizational stewardship, decision-making, and Being a visionary is not for the faint-hearted, because vision translation through reasoned application of empirithe path to vision translation can be littered with obstacles cal evidence from management, leadership, and patient that require strength, endurance, persistence, and the care research. “four Cs”: This new definition acknowledges the transforming na• Conviction or an uncommonly strong belief in the vision ture of a leader’s covenantal relationship with the organizaand its potential to solve a problem or resolve a situation tion, while identifying the decision, vision, and application • Commitment to do what it takes to implement that vision. mandate associated with the role. This expanded definition Commitment requires an enduring, long-term focus that of EBL also has significant implications for nursing leaders. must be tended over time. Commitment is evidenced by First, the fundamental role of stewardship and the napersistent actions aimed at achieving the vision. ture of the leader’s covenantal relationship with the organ• Courage and the discipline to stay the course, even if ization must be fully understood and appreciated. How initially unpopular or misunderstood does one go about this process? Taking the time to read • Creativity, originality, and innovation are fundamental. and reflect on the particular assets and legacy that leaders To implement the IOM’s recommendations, a clear owe is the first step. The work of DePree and others who and compelling vision of nursing and care delivery write on leadership should inform and assist in this must exist if health care is to be transformed. process. An honest self-appraisal of one’s personal beliefs is also necessary to determine the degree of congruence with the expectations of organizational stewardship disEVIDENCE-BASED LEADERSHIP cussed here. This self-assessment should result in a clear Consideration of key leadership characteristics and compersonal belief statement that reflects conviction about petencies provides the foundation for a discussion of EBL. stewardship and the nature of the assets and legacy owed By linking transformational leadership and EBM to the to the organization. The end result of this process must be quest for patient safety and positive work environments, a firm commitment to those beliefs and the resolve to emthe IOM report lays the groundwork for a new definition body and employ their precepts. of EBL in nursing. Various definitions of evidence-based Second, this personal belief and commitment statepractice in the literature tend to focus on clinical practice ment will necessarily lead to a comprehensive self-assessdecision-making rather than on leadership or management of leadership strengths and areas for improvement. ment.11-13 Ingersoll14 offered a broader definition of eviThe evaluation focus should include, but not be limited dence-based nursing administration, calling it “the to, transformational leadership, EI, vision development conscientious, explicit, and judicious use of theory-derived, and translation, and the essential management practices research-based information in making decisions about care identified by the IOM. The outcome of this assessment delivery systems….” While this conception furthers our unprocess is a personal action plan to acquire or improve derstanding, the focus is on decision-making rather than the leadership knowledge and skill sets identified here. As leadership behaviors and practices. with any action plan, the goals and objectives should be The IOM addresses this omission by proffering its own 40 Nurse Leader
April 2005
Table 6. Keys to Successful Implementation of a Personal Leadership Plan Commitment Clarity
ates new opportunities and obligations for nursing leaders. By combining knowledge and skill building with conviction, commitment, courage, and creativity, nursing will be ideally positioned to fulfill its social mandate. In this way, evidence-based leadership will serve as the cornerstone of patient safety and nursing’s preferred future.
Coordination Education
References
Expertise
1. Institute of Medicine. Keeping patients safe: transforming the work environment of nurses. Washington (DC): The National Academies Press; 2003. 2. Zaleznik A. Managers and leaders. Are they different? Leadership insights. Boston: Harvard Business School Publishing; 2002. pp. 2-11. 3. Kotter JP. A force for change: how leadership differs from management. New York: Free Press; 1990. 4. Goleman D. What makes a leader? Leadership insights. Boston: Harvard Business School Publishing; 2002. pp. 93-102. 5. Mintzberg H. The manager’s job: folklore and fact. Harvard Business Rev 1990;68(3):75-88. 6. Robbins SP. Organizational behavior. Englewood Cliffs (NJ): Prentice Hall; 1996. 7. Burns J. Leadership. New York: Harper and Row; 1978. 8. DePree M. Leadership is an art. New York: Doubleday; 1989. 9. Goleman D, Boyatzis R, McKee A. Primal leadership. Boston: Harvard University Press; 2002. 10. Styles MM. On nursing. Toward a new endowment. St. Louis (MO): C.V. Mosby; 1982. 11. Sackett DL. Evidence-based medicine. Seminars in Perinatology 1997;21(1):3-5. 12. Stetler CB, Brunell M. Evidence-based practice and the role of nursing leadership. The Journal of Nursing Administration 1998;28(7-8):45-53. 13. Jennings BM, Loan LA. Misconceptions among nurses about evidence-based practice. Journal of Nursing Scholarship 2001;33(2):121-7. 14. Ingersoll GL. Evidence-based nursing: what it is and what it isn’t. Nursing Outlook 2000;48(4):151-2. 15. De Groot HA. Patient classification systems and staffing, II: practice and promise. JAMA 1994;24 :17-23.
Involvement Communication Evaluation
clearly identified, along with the particular strategies selected. Also included in this personal leadership plan is the projected start and expected completion date for each action item. Third, in order for the personal leadership plan to be actualized, eight keys to successful implementation should be kept in mind. These success strategies have been identified elsewhere15 and have particular relevance here (Table 6). The first four keys include the commitment to grow and develop as a leader, clarity of vision and the beliefs that drive it, coordination of personal growth and other organizational and life activities, and education appropriate to the plan. Seeking expertise, whether it is insight from mentors or other well-respected authorities, is also crucial, as is involvement in leadership-enhancing activities (professional meetings, seminars, retreats, etc.). Consistent communication with others about what has been learned and how it can be applied is also necessary because it shares your vision and allows others to grow with you. Finally, an annual evaluation of the progress made in the personal leadership plan will allow for any changes or refinements to be made. Often, life and work circumstances have a way of creating either the opportunity or requirement to adjust or refocus the plan. It is essential that the personal leadership plan stays flexible, adapting as organization and career goals change. It is clear from this discussion that the new view of EBL and the type of organizational stewardship it demands cre-
April 2005
Holly A. De Groot, PhD, RN, FAAN, is chief executive officer of Catalyst Systems, LLC, in Novato, California. She also serves as clinical faculty in the graduate program in nursing administration at the University of California, San Francisco. She can be reached at [email protected]. 1541-4612/2005/ $ - see front matter Copyright 2005 by Elsevier Inc. doi:10.1016/j.mnl.2005.01.004
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