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Transformational leadership in nursing practice
Owen Doody and Catriona M Doody
Traditionally, nurses have been over-managed and led inadequately, yet today they face unprecedented challenges and opportunities. Organisations constantly face changes that require an increasingly adaptive and flexible leadership. This type of adaptive leadership is referred to as ‘transformational’; under it, environments of shared responsibilities that influence new ways of knowing are created. Transformational leadership motivates followers by appealing to higher ideas and moral values, where the leader has a deep set of internal values and ideas. This leads to followers acting to sustain the greater good, rather than their own interests, and supportive environments where responsibility is shared. This article focuses on transformational leadership and its application to nursing through the four components of transformational leadership. These are: idealised influence; inspirational motivation; intellectual stimulation; and individual consideration. Key words: Transformational leadership n Nursing n Motivation n Staff support n Personal qualities ffectivenursingleadershipisavehiclethroughwhich healthcare delivery and consumer demands can be fulfilled. Traditionally, nurses were over-managed andinadequatelyled;theynowfaceunprecedented challengesandopportunities(BowlesandBowles,2000). Thenotionofleadershipisconstantlychanging,withmany theoriesandframeworksavailable.Today’sorganisationsface ever-increasingchange,whichneedsamoreadaptiveflexible leadershipthatisbecomingincreasinglyimportantinthe21st century(Thyer,2003;Jooste,2004;Ralston,2005).Bass(1985) labelled this type of adaptive leadership as transformational, under which environments of shared responsibilities that influencenewwaysofknowingarecreated(Trofino,2000). TransformationalleadershipwasfirstdefinedbyDownton (1973) but it was the work of Burns (1978) that gained most currency. Burns distinguished between transactional and transformational leadership, feeling that one prohibits theotherandthattheyareatoppositeendsofacontinuum (Gellis, 2001; Judge and Piccolo, 2004). However, good
OwenDoodyisLecturer,DepartmentofNursingandMidwifery attheUniversityofLimerick,IrelandandCatrionaMDoodyis RegisteredIntellectualDisabilityNurseattheDaughtersofCharity Service,Ireland Accepted for publication: July 2012

Abstract

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leaders demonstrate both transactional and transformational characteristics(JudgeandPiccolo,2004),requiringamarriage of both styles complementing and enhancing each other (Bryant,2003;Rolfe,2011). Transformational leadership is a process that motivates followersbyappealingtohigherideasandmoralvalueswhere theleaderhasadeepsetofinternalvaluesandideasandis persuasiveatmotivatingfollowerstoactinawaythatsustains thegreatergoodratherthantheirowninterests(Burns,1978). Transformational leaders make it safe for staff to risk and extendtheboundariesofthinkinganddoing,creatingample conditions for energy, creativity and innovation to emerge (Porter-O’Grady, 1997), where supportive environments of sharedresponsibilityarecreated(Ward,2002;Bally,2007). Transformational leadership is viewed as the most effectivemodelofleadershipbecause,whileitrecognisesthe importance of rewards, it goes further to satisfy the higher needs of the follower by engaging this person emotionally andintellectually(Surakka,2008). This article focuses on transformational leadership and its application to nursing through the four components of transformational leadership identified by Bass (1995; 1998), Hall et al (2002) and Barbuto (2005): idealised influence; inspirational motivation; intellectual stimulation; andindividualconsideration.

Idealised influence
Idealisedinfluencebuildsconfidence,admiration,respectand trust(Bassetal,2003),providingemployeeswithasenseof mission (Northouse, 2010). For this to occur, nurse leaders needtoberolemodelswhotheirstaffseektoemulate(Hay, 2006;Iliesetal,2012).Whenaleaderisarolemodelforstaff, itbecomeslesslikelythattherewillberesistancetochangeor newinitiativesthataretobeimplemented(Wangetal,2011). Thisidealisedinfluencecanbeencapsulatedinthephilosophy andethosoftheservice/unitanditsmissionstatement.The leadershouldideallyinvolvestaff,familiesandserviceusersin thedesignandimplementationofthesestatements. However, even with this shared vision, leaders as role modelsmayfinditdifficulttoinvolveothersinthemission statement.Historically,staffwerepromotedontheirseniority, abilitytomirrorelementsofsupervisorsandtoconformto rules and regulations of the organisation (Porter-O’Grady, 1992).This historic selection process allowed for continuity and posed little threat to the viability of organisations; as mostmanagerswithinthissystemgainedtheirexpertiseand skill on the job, there was a tendency for them to reflect the existing hierarchical approach (Porter-O’Grady, 1992;

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PROFESSIONAL ISSUES
Murphy,2005).Tounderstandthepresentandfutureofnurse management, we need to understand its past and recognise someorganisationsareonlynowmovingbeyondtheeffects ofthishistoricprocess. Justasnursesneedtocontinuouslyupdatetheirknowledge andactfromanevidence-basedapproachratherthanpractice wisdom(DoodyandDoody,2011),thesameistruewhenit comes to nursing leaders. For nurse leaders to be effective, they have to be charismatic; charisma is based on personal attributessuchascharm,persuasiveness,self-confidenceand extraordinary ideas that arouse affection and commitment to the vision and goals to which the leader aspires (Ward, 2002; Sullivan and Decker, 2009). Nurse leaders should be admired for their high moral standing and sense of mission (Bass,1995;Northouse,2010).Thiscanbeexhibitedintheir approach and consistency in approach when managing staff andstaffissues. Within nursing, there are leaders at many levels, such as those in direct leadership roles at a unit level and those in higherleadershiprolesataservicelevel.Thiscanoftenleadto conflict and control-seeking, especially when final decisions need to be made.While staff ideas are transmitted through the direct leadership roles, it can place direct leaders in a vulnerablepositionwhentheyarestrivingtomeettheneeds ofstaffandclients,butarerestrictedbytheupperleaderswho have a greater emphasis on the strategic and organisational issues;thisoftenresultsinactionsanddecisionsbeingblocked due to budgetary constraints or other matters of which the directleaderisunawareof.Whiledirectleadersofferguidance and support to their staff, they are in a difficult position as theyhavetobalancethesupportrequiredbystaffwiththeir own vision and goals with how these fit with the overall organisation leadership style, vision and goals (Casida and Parker, 2011).They have to be confident and communicate their vision to staff while also identifying the constraints withintheirrolewhenasharedvisionrunsintodifficulty. theories(SullivanandGarland,2010).Contenttheoriesfocus on individual needs and what satisfies these needs. Perhaps the best known is Maslow’s (1954) hierarchy of needs, under which satisfaction of needs on one level activates a needatthehigherlevel.Organisationsthatofferpermanent, part-time and job-sharing roles to create a family-friendly workplaceincreasejobsatisfactionandhavestaffwhostrive for a connective relationship to the service (Sullivan and Decker, 2009). Process theories emphasise how motivation workstosteeranindividualintoperformance,helpingleaders to predict employee behaviour in certain circumstances. Examples include reinforcement theory, equity theory and goal-setting theory (Sullivan and Decker, 2009). Nurse leadersneedtosupportin-serviceeducationandtrainingfor alllevelsofstaffinvolvedincareprovision,basedonidentified needs and continuing education development relevant to areasofpractice.Also,nurseleadersshouldensurethatallnew membersofstaffaregivenanorientationperiodtotheunit, itsvision,goalsandexpectations. Theremaybenocorrecttheoryofmotivation,soleaders should combine theories so their effects complement each other (Moody and Pesut, 2006). Leaders should move out of the realm of pure staff motivation, adopting inspirational leadershipasitinfusesanintrinsicdrivefuelledbyahigher purpose, creating enthusiasm and passion, driving staff independently to achieve the goals of the organisation (Salanovaetal,2011).Tobeinspirational,nurseleadersneed to paint a flowery vision of the future that is more fantasy thanreality(Bass,1997),wherefollowersmaybepersuaded tosacrificetheirownvaluesforthebenefitoftheorganisation orleader(BassandSteidlmeier,2006). However, few nursing leaders are truly inspirational, as their leadership skills are formed on the basis of traditional hierarchical systems and practice wisdom (Bishop, 2009). Whiletheystriveforeffectivemotivation,leadershiptraining needstooccurtoresultinacascadingeffecttosubordinates (OshagbemiandGill,2004;BassandRiggio,2006).Employees inaninspiredservicefeelpassionateabouttheethosandthe significance of their work contribution (Moody and Pesut, 2006),wheredutybecomespleasureandpleasureismerged withduty(Maslow,2000;Salanovaetal,2011).

Inspirational motivation
Inspirational motivation involves encouraging others to achieve the goals and aspirations of the organisation while alsoachievingtheirownaims(Bally,2007). Motivation is, without doubt, an important element of healthcare, as motivation affects performance and client care (Sullivan and Decker, 2009). Leaders communicate high expectations to employees, inspiring them through motivationtosharethevisionoftheorganisation(Northouse, 2010;Carney,2011). Nurseleadersshouldensurefrontlinestaffarerepresented on committees where executive decisions are made in an organisation. There is a tendency in some organisations to equate direct leaders as representative of frontline staff; however, as identified earlier, these leaders have difficulties balancing all perspectives. Ensuring frontline staff are representedoncommitteesprovidesresponsibilitiesaswellas opportunities for learning new skills and to be empowered (Laschingeretal,2003;Scherbetal,2011). While many authors have examined motivation and have developedtheoriesaboutit,thesecanbegenerallybedivided into two distinct groups: content theories; and process

Intellectual stimulation
Intellectual stimulation encourages staff innovation, challenging the beliefs of staff, the leader and service (Northouse, 2010).Transformational leaders encourage the proposalofnewideasempoweringstafftoapproachproblems in new ways using evidence-based practice (Barbuto, 2005; Gheith,2010). Library, computer and IT facilities should be available, which will reinforce continuing learning to enhance client care and promote best practice. A central consideration of transformational leadership is the formal and informal education/learning of all staff (Dignam et al, 2012) to adjust and keep knowledge in line with service and client expectations(GovernmentofIreland,1998)andtoencourage stafftobeinnovative(Northouse,2010).Practiceneedstobe evidence-basedratherthan‘howwealwaysdidit’(AnBord Altranais,2000).

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Even though organisations may encourage and support further education informally or formally, there is often no onus on nurses to share their learning with other team members who are not in a position to undertake studies. Therefore, the direct nurse leader should ensure that staff who undertake studies and courses share their knowledge with the team and provide articles or leaflets to support evidence-based practice (Clegg, 2000).While this may be difficult to implement in practice, responsibility should be placedonnurseswhoreceiveformalsupporttodisseminate information and knowledge through presentations and methods.Thisisessential,orteammembersmayfeeldevalued in comparison with the‘elite’ nurse, who receives support; staffwillseethisdisseminationasameansofsupportingtheir advancementwithintheircareerpathway. While intellectual stimulation is desirable, in the long term, continuously striving to create new ways of doing things runs the risk of staff stress and burnout (Wang et al, 2011).Additionally, a high employee turnover can result in long-term staff being a part of a motivational chain that is continuously being broken by lack of continuity and familiarityofteammembers(Force,2005).

Individualised consideration
Within individualised consideration, leaders encourage and support individuals to reach higher levels of achievement, assisting full actualisation (Northouse, 2010), by the leader

Table 1. Leadership competencies
Sofarelli and Brown (1998) 1. Management of attention 2. Management of meaning 3. Management of trust 4. Management of self Contino (2004) 1. Organisational management Managing Managing ■ Managing ■ Managing ■ Managing
■ ■

time information human resources change revenue and expenses

2. Communication/communication skills Communicating Communicating ■ Communicating ■ Communicating
■ ■

vision organisational structure continuous learning change

3. Analysis and strategic planning Analysis of internal data Drawing up strategy for external opportunities ■ Drawing up strategy for effective decision-making ■ Analysis for change strategy and drawing this up ■ Drawing up strategy for a business plan
■ ■

4. Creation/vision Creating opportunity for employees Creating value for your customers ■ Creating quality through continuous improvement and error reduction ■ Creating relationships with strategic partners
■ ■

acting in an advisory capacity. However, self-actualisation is difficultandoftenunachievable(Northouse,2010). Leaderswithinorganisationsshouldcareforstaffandthere shouldbeastrongsenseoftheleaderactinginasupportive role,especiallyintimesofneed,asleadershaveadutyofcare fortheirstaff.Supportcantakeplacethroughregularpositive feedbackandstaffappraisals;ifthesearenotconducted,staff can become devalued and effective members can become tired of carrying other team members, leading to high absenteeism (Weberg, 2010). Leaders who provide positive feedback regarding performance increase self-esteem and performance (Riahi, 2011).Within the appraisal system, the nurse leader should look to draw up personal development plans,alongwithpeerreviewsand360°evaluations(Kerfoot, 2002). Compared to the traditional, singular, top-down method, 360° evaluations are believed to allow for a true evaluationofallteammembersinaconstructiveandeffective manner. However, they are time consuming, resourceintensive and should be treated with great caution.While thisformatisintendedtoalloweachmembertocontribute to the appraisal in an open manner and support open and effective teamworking, unless the aim, ground rules and appropriate facilitation mechanism are in place they can be counterproductive. Empowerment is one of the fundamental components of the transformational leader (Bowles and Bowles, 2000) whereby staff self-efficacy is increased, enabling them to completeworkmoresuccessfully(Tomey,2009).Productive leadersmustoperatethroughoutalllevelsoftheorganisation for empowerment to be effective (Laschinger et al, 2003). An empowerment strategy comprises many leadership competencies.Table 1listssomestrategiesintheliterature. Direct nurse managers can empower staff by holding team meetings regularly, where staff of each grade in the nursing team have the opportunity to voice their opinions and collectively create goals and strategies to deliver client care with greater effectiveness that is aligned with the organisation’s vision and mission. Duty rotas can become the responsibility of the team; this can make staff aware of the priority of the unit and the safe delivery of care with adequate staff levels.This empowers staff to take ownership fortheeffectivemanagementandefficiencyoftheunitfrom aday-to-dayperspective.Ithasbeensaidthatbecausedirect managersaremoreinvolvedinclientcarethantopmanagers, they have a greater knowledge of the goals and strategies that could improve care, contributing significantly to the aspirationsoftheorganisation(Dohertyetal,2010). The Royal College of Nursing (RCN, 2009) found an absence of agreed role definitions and role conflict existed because nurse leaders were constantly balancing different aspects of their role, while lacking formal preparation and skill development. While direct leaders have theoretical responsibility for the standard of nursing care, they lack authority to guarantee this (Bradshaw, 2010). The RCN (2009) recommended supernumerary status, titles that give clearidentity,anappropriateauthoritystructureandsupport, with the restoration of the traditional supernumerary, authoritative,ward-sisterrole. However,duetothehierarchyandbureaucracyinnursing,

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PROFESSIONAL ISSUES this may be difficult; nursing does not promote freedom or professional latitude and hence impedes innovation by nurse leaders (Clegg, 2001; Kuokkanen and Leino-Kilpi, 2001;Murphy,2005).Empowermentnecessitatesservicesto construct a supportive environment that values nurses and involves them in strategic, operational matters promoting opportunitiesforlearningandchanging,whichencompasses personalandserviceeffectiveness(DepartmentofHealthand Children,2004). Optimising team performance is a central matter for the transformationalleader(Riahi,2011).Nurseleadersneedto bemoreexpressive,forexample,throughwordsofthanksor praise, fair workload distributions, and individualised career planning,mentoringandprofessionaldevelopmentactivities tomotivatefollowersindividually(Simic,1998;Raffertyand Griffin,2004).

Table 2. Qualities of transactional nurse leaders
Sofarelli and Brown, (1998)
■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Contino (2004)
■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Conclusion
Overall, transformational leadership is favoured as leaders have the power to produce future generations of successful leaderswhohavetheproficiencytocreateeffectivesolutions tosomeoftheprofession’smostcrucialissues(Ward,2002). Balancing complex demands in unstable environments is attheheartofformulatinghealthierhealthcareorganisations that provide the quality of care that clients, families and communities deserve (Dixon, 1999). Leaders need to be knowledgeableandcompetentinstrategicplanning,sotheir efforts may be received and acknowledged at senior levels (Murphy,2005).Whiletransformationalleadershipiseffective regardless of culture, the level of effectiveness depends to some extent on cultural values (Spreitzer et al, 2005). Whereeffectivenessisseenastherelationshipbetweenone’s objectivesandoutputs,themoretheseoutputscontributeto theobjectives,themoreeffectivetheunitis(Surakka,2008) Whilemotivationandempowermentaredesirablewithin organisations, their level needs to be in line with the expertise of the workforce.Transactional leadership within nursing has to be considered in relation to the experience andcapabilitiesoftheindividual,astheremaybeoccasions wherealeaderisrequiredtointervenebeforemistakesoccur. This may be necessary to uphold best practice, safeguard clientsandcomplywithlegalresponsibilities;thisrecognises theleadershipthatenhanceseffectivenessmostisamarriage betweenbothtransactionalandtransformational(Stordeuret al,2000).Questionsarisewithinanorganisation,suchas:can we be highly orientated towards achievement while at the sametimebeinghighlyorientatedtowardsstaffwellbeing?It ispossiblethatmanyserviceprovidersviewthesetwogeneral domainsoforganisationalcultureasbeingadversarial(Hatton etal,1999).However,itmaybethatacultureofpromoting staff wellbeing would result in a greater willingness on the part of staff to aim to achieve a high-quality service. Future nurse leaders need to acknowledge and value staff contributions, within flexible work environments that are family-friendly. Continuingeducationneedstobeaccessibleandequitable forall.Performancereviewsshouldbealignedwithpersonal development plans for each staff member; these should acknowledgeeveryperson’scontributionsandareasforfuture

Clear purpose, expressed simply Value-driven Strong role model High expectations Persistent Self-knowing Perpetual desire for learning Love work Lifelong learners Identify themselves as change agents Enthusiastic Able to attract and inspire others Able to deal with complexity, uncertainty and ambiguity

Emotionally mature Courageous Risk-taker Risk-sharing Visionary Unwilling to believe in failure Sense of public need Listens to all viewpoints to develop spirit of co-operation Mentoring Effective communicator Considerate of the personal needs of employees Strategic

Sources: Tichy and Devanna (1986); Hall et al (2002); Stone et al (2004).

development that are aligned with the organisational vision andmission. Educationofleadersneedstooccurtoassistthechangeand developmentofleadershipwithinhealthcare,andanyaudits of practice should include leadership audits.It isimperative that creative, passionate, effective individuals with vision,  whowillchallengetheservice,arerecruitedanddeveloped withinservices. Although the four dimensions of transformational leadership are interdependent, they must coexist to yield performance beyond expectations (Hall et al, 2002; Kelly, 2003).Transformational leaders are people who can create significantchangeinbothfollowersandtheorganisationwith whichtheyareassociated(Griffin,unpublishedobservations, 2003).They lead changes in mission, strategy, structure and culture,inpartthroughafocusonintangiblequalitiessuch as vision, shared values and ideas, and relationship-building. They do this by articulating the vision in a clear and appealingmanner,explaininghowtoattainthevisions,acting with confidence and optimistically, expressing confidence in the followers, emphasising values with symbolic actions, leadingbyexample,andempoweringfollowerstoachievethe vision(Stoneetal,2004).Toachievethis,nurseleadersmust possessspecificqualitiesidentifiedinTable 2.  BJN Conflict of interest: none
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Key pOInTS n Transformational

leadership recognises the importance of rewards, but goes further to satisfy the emotional and intellectual needs of staff leaders create supportive environments where responsibility is shared and staff feel safe to take risks to become creative and innovate has four components: idealised influence; inspirational motivation; intellectual stimulation; individual consideration leaders have to be confident and communicate their vision to staff while acknowledging organisational constraints nurse leadership is now required by organisations, but this has been restricted by hierarchy and bureaucracy, and because nursing has not promoted professional latitude is needed to encourage the development of leadership

n Transformational

n It

n Transformational

n Adaptive

n Education

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