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Frontline nurses and transformational leadership

By: Kate Cook, DNP, RN

A key to quality and safety

In 2011, the Institute of Medicine called for nurses in all settings and levels of care to be prepared as leaders. In response, leadership development focused on nurses already in formal leadership roles, such as nurse executives and managers. However, less attention has been paid to promoting the leadership skills of nurses working in direct patient care, despite evidence indicating that when frontline nurses feel empowered to lead, patient outcomes improve, workflow functions more efficiently, and nurses report greater work satisfaction.

The tenets of transformational leadership theory—individualized consideration, intellectual stimulation, inspirational motivation, and idealized influence—align closely with the qualities needed for frontline nurses to meet the ever-changing demands of healthcare and to develop future formal leaders.

Individualized consideration

Individualized consideration means accepting each person’s differences when working toward a common goal. Frontline nurses engage in this behavior every day as they establish rapport with patients and construct individualized care plans. Expanding on this concept and encouraging nurses to get to know their peers on a personal level allows them to understand each team member’s strengths and weaknesses. Frontline nurses frequently take the lead in emergent patient situations when a formal leader isn’t present. When this occurs, a team that knows each other’s strengths can divide work in a way that benefits everyone.

Personal connections also help establish genuine concern and respect, which can motivate everyone to work to their fullest potential. Frontline nurses should be recognized for the skills and knowledge they bring to the unit. Formal recognition by management is always welcome, but peer acknowledgment can strength­en colleague ties. Organizations should establish opportunities (such as creating an area in the break room to post appreciations for each other or verbal kudos in staff meetings) for nurses to recognize each other’s accomplishments, which will strengthen bonds and promote a sense of teamwork. Nurse managers can then capture this information and add it to employees’ personnel files.

Intellectual stimulation

Thinking critically, increasing knowledge, and building skills are intellectually stimulating for frontline nurses. The same is true of professional behavior and leadership development. Once new nurses are comfortable with the routine tasks of their role, they should be encouraged to participate on committees and task forces. When direct care nurses have a seat at the table, they have an opportunity to share their perspectives on the organization’s current challenges. Mentors should encourage frontline nurses to express their concerns and opinions and to advocate for their coworkers and patients. Nursing research, journal clubs, and other scholarly endeavors also can benefit from the experience and perspectives of frontline nurses.

By design, these activities promote leadership development as direct care nurses experience professional communication and collaboration techniques. In turn, formal leaders connecting with these individuals can tap into their knowledge to gain a better understanding of frontline staff perceptions.

Inspirational motivation

Inspirational motivation involves cultivating a work environment where colleagues push each other to do their best and where everyone is encouraged to share ideas, concerns, and challenges without fear of blame. In a blameless safety culture, nurses listen to each other’s opinions, work together to solve problems, and communicate openly. Those in formal leadership roles should model these practices and encourage frontline nurses to use them when problem-solving during patient care. (See Nurses are prepared to lead.)

Nurses are prepared to lead

The core competencies of the Quality and Safety Education in Nursing Institute are embedded into the prelicensure curriculum of many U.S. nursing schools, so new nurses are coming into the workforce equipped with knowledge and skills related to teamwork, collaboration, quality improvement, and safety. They’ve been trained to consider quality and patient safety in all aspects of care, and many have participated in interdisciplinary projects. They anticipate that they’ll be treated as respected members of their nursing units from day one.

According to Press Ganey, nurses are most engaged on their units during the first 6 months of employment, and we know that a highly engaged nursing workforce leads to safer care. Formal nursing leaders must determine how to build a unit culture that encourages new nurses to put their leadership knowledge into practice immediately. For example, nurses at any level can lead a safety huddle or participate in interprofessional rounds.

Fostering a work environment where all nurses, regardless of level, are expected to engage in developing and evaluating workplace initiatives will help foster future nurse managers and administrators. When frontline nurses participate in shared governance of workplace initiatives, such as quality improvement projects, they’ll have a sense of ownership. In addition, informal leaders may emerge, team members who hadn’t felt empowered to share in the past may speak up, and all frontline nurses may feel more invested in the organization and inspired to support one another in achieving their goals.

Idealized influence

Transformational leaders use idealized influence to model their organization’s mission, visions, and values. Direct care nurses should feel connected to these ideals and understand how they apply to practice at the bedside. For example, every time a nurse speaks out to ensure a safety protocol has been performed correctly, they’ve aligned their work with the organization’s pledge to provide safe care. Likewise, every time a nurse advocates for the needs of a patient or family member, they’ve aligned their work with the organization’s promise to treat all patients with respect and dignity.

When frontline nurses sense the support of their organizations, they’ll feel more empowered to engage in these behaviors, such as advocating for their patients’ safety and speaking up when they have a concern on their unit. Professional education and training aimed at promoting transformational leadership among direct care staff will help nurses understand how the work they do every day enhances patient outcomes. Mentorship programs in which direct care staff work alongside leaders and administrators on quality improvement initiatives will provide them with the confidence of knowing they have the knowledge and skills to make a difference.

Develop a new generation of leaders

When frontline nurses have decision-making power and real opportunities to promote change in their work environments, they feel valued and trust is established throughout the nursing hierarchy. When this type of workplace environment exists, frontline nurses thrive, creativity increases, and stress levels fall. Empowerment leads to actions that result in improved care quality and safety and a new generation of nurses prepared to navigate our dynamic healthcare environment.

Kate Cook is an assistant professor in the RN to BSN online degree completion option at Chamberlain College of Nursing Chicago, Illinois.

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