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Jackson
Paul T. Clements
Jennifer B. Averill
Kathie Zimbro
T
HE HEALTH SERVICES INDUSTRY
EXECUTIVE SUMMARY is a rapidly changing envi- and the increasing number of con-
ronment; subsequently, solidations have placed hospitals,
In a time of chaotic and unpre- innovative leadership char- health networks, managed care
dictable health care, it is vital for
nursing to employ a nursing acteristics and roles are required plans and other healthcare org a n i-
leadership theory that is specifi- for the nursing profession. Porter- zations under greater stress
cally applicable to nurses and OGrady and Malloch (2006) (ACHE, 2005).
will holistically, and comprehen- noted that the impact on nursing The Institute of Medicine
sively address and support both
the science and art of this hon- management and leadership is (IOM, 2004) published its re p o rt
ored profession. just beginning to be defined in this Keeping Patients Safe: Trans-
The authors propose that contemporary and unsettled f o rming the Work Environment of
Nursing Leadership Knowing health care arena. Furt h e rm o re, Nurses, noting a decline in chief
can address and impact the my r- changes resulting from enhanced nurse executives, directors of
iad issues confronting managers technology, proliferating inform a- nursing, and nurse managers, and
and administrators within the tur-
bulent health care industry, with tion available on the Intern e t , subsequently recommended the
the ultimate goals of quality com- i n c reasingly informed health care adoption of transformational lead-
prehensive patient care and consumers, ongoing constraints of ership and evidence-based man-
improved employee satisfaction. managed care, a worsening nurs- agement (EBM) to increase patient
They believe that Nursing ing shortage, and the ever evolv- safety and reduce errors in the
Leadership Knowing, grounded ing health care delivery systems work environment. Echoing the
in the realties of nursing experi-
ence, is a logical theoretical a re converging to create unpre c e- call for change, Sofarelli and
extension that can be translated dented challenges for nursing Brown (1998), Clegg (2000),
into nursing leadership practice leadership (Aiken, 2007; Ameri- Valentine (2002), and DeGroot
A particular and specific focus can College of Healthcare (2005) advocated transformational
on empirics and evidence-based Executives [ACHE], 2005; Arming leadership theory for nursing lead-
practice will not attend to the Health Care Consumers, 2006; ers.
robust and multidimensional
u n d e rpinnings of the lived ex p e- Dendaas, 2004). Additionally, B u rns (1978) seminal theory
rience that is so vital to nursing The number and magnitude of of transformational leadership
as a caring profession. challenges facing healthcare or- defined a process in which leader-
The ideal of nursing leadership ganizations are unprecedented. ship is transcendent, uplifting,
t h e o ry is not a single-focused G rowing financial pre s s u res, ris- moral, and often charismatic. It
shadow of its history, but a ri c h ,
inclusive, multi-faceted netwo rk
of knowing.
JANET P. JACKSON, MSN, RN, is Adjunct JENNIFER B. AVERILL, PhD, MSN, RN, is
As such, Nursing Leadership Faculty, School of Nursing, Old Dominion an Associate Pro f e s s o r, College of
Knowing provides a fo rum for University, Norfolk, VA. Nursing, University of New Mexico,
leaders to enhance their prac- Albuquerque, NM.
tice, as well as their relationship PAUL T. CLEMENTS, PhD, APRN, BC, is
with their employees, which ulti- an Assistant Clinical Pro f e s s o r, Dre x e l KATHIE ZIMBRO, PhD, RN, is Director,
mately translates into optimal University College of Nursing and Health Clinical and Business Intelligence,
care for the patients we serve. Professions, Philadelphia, PA. Sentara Healthcare, Norfolk, VA.
Empiric
L.K.
Outcome-Based
EMB, EBL
Sociopolitical Aesthetic
L.K. L.K.
Strategy, Culture Art, Vision
Emancipatory
Nursing Nursing
LK. Leadership
Knowing Staff
Transforming Ethical Personal
Workplace L.K. L.K.
Justice, Ethics Relationship
Unknowing
L.K.
Openness
f o rce in health care planning and replaces 80 RNs per year. The fronting managers and administra-
d e l i v e ry, including aware n e s s , minimum cost is $3.36 million per tors within the turbulent health
recognition, and utilization of the year, per facility. One approach c a re industry, with the ultimate
fifth pattern of knowing, sociopo- cited for hospitals to impro v e goals of quality compre h e n s i v e
litical knowing, which incorpo- quality and reduce costs is to patient care and improved
rates an understanding of society, i n c rease nurse staffing. Studies employee satisfaction.
politics, justice, and culture have demonstrated the reduction
(Chinn & Kramer, 2008; White, of adverse patient outcomes and The Patterns
1995). extra hospital days (Aiken, 2007), How do nursing leaders know
Another example of signifi- and additionally, that incre a s e d about leadership? An obvious
cant importance includes the eco- patient satisfaction will offset need exists for nursing leadership
nomic implications of the nursing i n c reased labor costs (Needleman, founded on plausible theory to
shortage that confronts and chal- B u e rhaus, Stewart, Zelevinsky, & amend and facilitate staff support
lenges nurse leaders, particularly Matte, 2006). Recruitment and and communication. We pro p o s e
since the current nursing short- retention are significant factors that Nursing Leadership Knowing,
age is a serious problem at all lev- with serious economic implica- grounded in the realties of nursing
els of nursing (Valentine, 2002, p. tions for facilities (Hnatiuk, 2006; experience, is a logical theoretical
1). Nurse experts presented data Milliken, Clements, & Tillman, extension that can be translated
on the value of nurses and the eco- 2007). Furt h e r, the additional lack into nursing leadership practice
nomics of the nursing shortage at a of nurse leaders exacerbates the (see Figure 1). Specific examples
c o n g ressional briefing on May 2, nursing shortage (Andrews & of such application follow.
2006 (Hnatiuk, 2006). It was noted Dziegielewski, 2005; IOM, 2004). Empirics. The first pattern,
that the cost of replacing one We propose here that Nursing re f e rred to as empiric leadership
nurse is $42,000 to $64,000, and Leadership Knowing can address knowing (empiric L.K.), is based
an average facility with 400 beds and impact the myriad issues con- on the science of nursing and
Empiric
L.K.
Outcome-Based
Sociopolitical Aesthetic
L.K. L.K.
Strategy, Culture Art, Vision
Emancipatory
Nursing Nursing
LK. Leadership Staff
Transforming Ethical Knowing Personal
Workplace L.K. L.K.
Justice, Ethics Relationship
Unknowing
L.K.
Openness
Transformational
Leadership
cipatory L.K.). Additional research brief descriptors of Patterns of a d d ress nursing leadership. The
is needed to determine the impact Knowing as leadership theory and study provides insight for leader-
of the other patterns of knowing related implications are pro v i d e d ship strategies that dovetail with
on nursing leadership, including in the Table 1. the foundational assertions of the
how those patterns can contribute leadership knowing theory; spe-
to evidenced-based practice and Implications for Nursing cifically, they re p resent the multi-
outcome measure s . Leadership Practice dimensional leadership appro a c h-
Nursing is a holistic pro f e s- A review of the extant litera- es inherent to use of the first six
sion; similarly, nursing leadership ture shows a paucity of re s e a rc h patterns in unison, simultaneous-
should also be holistic, dynamic, about applying the patterns of ly addressing the needs of both the
inclusive, flexible, and adaptable. knowing as leadership theory. leader and the employee. Add-
EBL, in and of itself and used in Schmidt and colleagues (2003) itional contemporary studies,
isolation, ignores the heart and applied Carpers patterns of know- identifying the facets of job satis-
soul the overall lived human ing to develop a successful clini- faction for nurses and subsequent
experience of leadership. This cal ladder program for Tampa responses sought by employees
will not serve the leader, the staff General Hospital. Staff interest in from management, can be easily
nurse, the patients, or the pro f e s- the program exceeded pro j ec t i o n s incorporated into the patterns of
sion of nursing. Nurse leaders and career advancement was knowing (see Table 2). Of note,
need to guide the nursing pro f e s- established. This ladder program most re s e a rchconcerning primary
sion into leadership theory that is is believed to be the first one to nursing and job satisfaction has
as comprehensive as the pro f e s- utilize Carpers work for program been based on the assumption that
sion. Foundational facets with development; however, it does not all nurses as professionals find job
satisfaction in intrinsic factors. emphasis on solely using EBL (the tencies, Jennings, Scalzi, Rodgers,
This assumption must be ques- empirical pattern of knowing) and and Keane (2007) concluded that
tioned in the contemporary era, t r a n s f o rmational theory is founda- inadequate distinction exists for
particularly when considering tional in nursing leadership differentiating the two sets of com-
methods of leadership that pro- approaches, it is suggested that petencies. The authors suggest
mote job satisfaction, which in nursing leadership will continue that the strength of using the pat-
turn can significantly enhance to fail its staff and patients by t e rns of knowing as nursing lead-
unit efficiency and optimize using borrowed and, subse- ership theory is they include both
patient care (Malkin, 2008). quently, inadequate methods. A the visionary qualities of transfor-
Current national re c o m m e n- comparison of Nursing Leadership mational leadership and objective
dations from the IOM (2004) Knowing to EBM/EBL (evidence- data of evidence-based practice,
include use of transform a t i o n a l based practice) and transform a- and they incorporate the addition-
leadership theory and EBM. tional leadership gives evidence al patterns which are so vital to
Horton-Deutsch and Mohr (2001) that although each approach has holistic leadership. For example,
articulated that nursing leadership value, they do not address the Scott and Caress (2005) indicated
is fading, and that nursing has uniqueness and totality of the new forms of leadership are
morally and ethically failed its nursing profession (see Figure 3). required to engage staff in deci-
patients (perhaps re p resentative of Tr a n s f o rmational theory may sion making and promote clinical
the empirical pattern having be ineffective for individuals effectiveness.
gone wild). People do not enter i n h e rently motivated by intrinsic
a hospital with the hope of being re w a rds as it does not address the Conclusion
cared for by EBM; rather, they science of nursing (see Figure 3). A particular and specific
want care from nurses practicing F u rt h e rm o re, in a recent detailed focus on empirics and evidence-
holistically, perhaps using all the l i t e r a t u re review of nursing man- based practice will not attend to
patterns of knowing? If the current agement and leadership compe- the robust and multidimensional