Executive Leadership Meeting: Strategic Planning Report Administrator’s Instructions: Provide a response to each of the different areas below, ensure that each response provides sufficient details with supporting external evidence for the executive leadership team, as they will use this report as a starting point to begin working on next year’s budget and to update the facility’s strategic plan. Your identified factors and recommendations may influence the executive leadership team’s actions that may support your facility’s needs and daily operations. (Your supporting external evidence will need to be presented in APA format using in-text citations and remember to include a separate APA formatted Reference Page that your executive leaders may refer to in order to obtain additional information on your responses. Your references should be from the last five years, collected from the Week 3 to Week 5 course content, and you may include one additional resource outside of the weekly content from your own personal research.) Complete Section 1 Based on the Healthcare Setting and Role Options from the Assignment Prompt. Section 1: Your Facility and Role Administrator’s Name: Facility’s Location (City and State): Facility Characteristics: Urban or Rural Healthcare Location: Facility Type: Facility Size or Capacity Level: Average Daily Census or Number of Patient Visits Per Day: Provide a Summary, at least one paragraph long, of Your Patient Population and/or your ShortTerm/Long-Term Care Resident Population: Complete Section 2 based on the Healthcare Setting and Role Options from the Assignment Prompt for each of the factors provided below. Section 2: Specific Factors Influencing Your Facility Economic Factors Identify and discuss at least two economic factors that are influencing your facility. How do these economic factors influence your facility operations? Provide at least one recommendation to address one of the identified economic factors. (Economic factors that can be discussed but not limited to: housing, education, employment, income, community-based social services support, discrimination, governmental support, or any other economic factor that may impact your facility in the next year.) Financial Factors Identify and discuss at least two financial factors that are influencing your facility. How do these financial factors influence your facility operations? Provide at least one recommendation to address one of the financial factors. (Financial factors that can be discussed but not limited to: admissions, average daily census, average length of stay, risk-based agreements, value-based healthcare initiatives, reimbursement, specific risks, financial performance, organizational costs, competitive pricing considerations, capital needs, healthcare services expansion opportunities, technology costs, recruitment needs/costs, or any other applicable financial factor that may impact your facility within the next year.) Cultural and Workforce Management Factors Identify and discuss at least two cultural and workforce management factors that are influencing your facility. How do these cultural and workforce management factors influence your facility operations? Provide at least one recommendation to address one of the cultural and workforce management factors. (Cultural and Workforce Management factors that can be discussed but not limited to: or any other applicable cultural and workforce management factor that may impact your facility within the next year.) Regulatory Policy Factors Identify and discuss at least two regulatory policy factors that are influencing your facility. How do these regulatory policy factors influence your facility operations? Provide at least one recommendation to address one of the regulatory policy factors. (Regulatory policy factors that can be discussed but not limited to: Joint Commission Accreditation requirement, Centers for Medicare and Medicaid (CMS) rules/regulations, other federal regulations such as Occupational Safety and Health Administration (OSHA), privacy laws, state-based regulations, local regulations, or any other applicable regulatory policy factor that may impact your facility within the next year.) Quality Initiatives and Change Management Factors Identify and discuss at least two quality initiatives and change management factors that are influencing your facility. How do these quality initiatives and change management factors influence your facility operations? Provide at least one recommendation to address one of the quality initiatives and change management factors. (Quality initiative and change management factors that can be discussed but not limited to: Quality Assurance Performance Improvement (QAPI) goals, your facility’s change leadership style, your facility’s key quality measures, or any other applicable quality initiative and change management factor that may impact your facility within the next year.) Administrator Summary and Top 3 Recommendations Summarize the importance of each of these factors to the executive leadership team and share your top three recommendations that should be considered. Your executive leadership team will consider your top three recommendations as your facility’s top priorities for the strategic plan. FINANCIAL MGMT Physician compensation plan essentials for 2021 market forces By Mike Delmonico MBA, BSN, CMPE, RN Certified F or decades, the United States’ healthcare finance and delivery system has been in a state of ongoing change and evolution. Governmental bodies, licensing and regulatory agencies, accreditation organizations, health policy and clinical research institutes, and payers are continuously proposing and testing healthcare system enhancements toward optimizing: • How care delivery is organized • How care delivery is prioritized • How care delivery is paid for • How care delivery value is demonstrated. Amid all this change, the physician compensation plan must be dynamic and adaptable. A successful and enduring physician compensation plan is built to achieve organizational goals by translating healthcare system market forces into principles, variables, values and formulas (Design) that are assessed under test conditions (Model) through a collaboration of physicians and administrators (Engage) to create a program of achievement rewards (Implement) the results of which are continuously monitored, assessed and shared (Analyze) Figure 1. Physician Compensation Plan Entity to achieve the desired level of physician recruitment and retention (see Figure 1). The physician compensation plan is much more than a set of equations to calculate pay. It is an organized entity with a governance structure, responsibilities and functions necessary to align organizational goals with compensation plan principles and tactics. KEY MARKET FORCES To be dynamic and adaptable, the physician compensation plan must be attuned to present and evolving market forces that may impact the healthcare system and organizational goals. Some noteworthy U.S. healthcare system market forces to monitor and assess include: 1. The prevalence of physician burnout 2. The continuing evolution of value-based care initiatives 3. The Centers for Medicare & Medicaid Services (CMS) 2021 physician fee schedule (PFS) standards 4. The future of the Affordable Care Act (ACA) and the state of uninsured persons 5. The COVID-19-generated shifts in the U.S. economy and healthcare system. FIGURE 1. PHYSICIAN COMPENSATION PLAN ENTITY 8 4 | APRIL 2021 • MGMA CONNECTION Adverse work conditions and physician burnout Physician burnout is a market force that impacts physician supply and performance. The compensation plan needs to account for the impact that adverse work conditions have on physician burnout and adopt tactics that recognize and value such conditions. As defined by the Agency for Healthcare Research and Quality (AHRQ), burnout is “a long-term stress reaction marked by emotional exhaustion, depersonalization and a lack of sense of personal accomplishment,” and work conditions commonly found in healthcare — time pressure, chaotic environments and low control over work pace, among others — are “strongly associated with physicians’ feelings of dissatisfaction, stress, burnout and intent to leave the practice.”1 AHRQ-sponsored studies have found physician burnout increasing in prevalence, which intensifies other outcomes: Burned-out doctors are more likely to leave practice, which reduces patients’ access to and continuity of care. Burnout can also threaten patient safety and care quality when depersonalization leads to poor interactions with patients and when burned-out physicians suffer from impaired attention, memory, and executive function.2 To prepare for this market force, the physician compensation plan can acknowledge adverse work conditions that contribute to physician burnout by recognizing and valuing: • Physician time required to allow for organizational engagement (e.g., meeting attendance and participation on committees and teams) • Physician time required to allow for leadership, advisory and mentorship roles • Physician interest in flexible or part-time work schedules as opposed to the only alternatives being retirement, leaves of absence or seeking employment elsewhere. Requirements for success in value-based care The continuing evolution of value-based care initiatives is a market force that impacts how healthcare delivery is organized, prioritized and financed. The physician compensation plan needs to account for how value-based care requirements affect physician performance measures and adopt tactics that recognize and value such requirements. MEMBER RESOURCES Access an MGMA member-benefit analysis outlining pertinent provisions of the key revisions to the Stark Law, effective Jan. 19, 2021: mgma.com/stark-changes. MGMA members can access the MGMA 2021 E/M Coding, Billing and Auditing Toolkit, with tools to provide a comprehensive understanding of 2021 E/M coding changes, chart audits and elements of medical decision making (MDM): mgma.com/em-toolkit21. Governmental and commercial healthcare payers are driving the implementation of value-based care initiatives. Even with mixed results from some of its many value-based care programs, CMS is making changes to existing programs while also introducing new initiatives, such as the Primary Care First models. Recent federal action by the Department of Health & Human Services (HHS) Office of Inspector General (OIG) to revise the Physician Self-referral (Stark) Law and Anti-Kickback Statute provide some group practices with lower barriers and greater protections when entering care coordination arrangements.3 To prepare for this market force, the physician compensation plan can acknowledge value-based care requirements for physician success by recognizing and valuing: • Physician and staff time required to learn about governmental and commercial value-based care arrangements, Healthcare Effectiveness Data and Information Set (HEDIS) measures, Hierarchical Condition Category (HCC) coding and risk adjustment factor (RAF) scores • Physician and staff time required for collaboration on population health improvement initiatives, and the development of policies, procedures and workflows • Physician and staff time required for collaboration on new information systems, reports on care delivery, care management, care transitions and development of patient engagement tactics. The Medicare 2021 Physician Fee Schedule (PFS) The physician compensation plan should take into account the CMS 2021 PFS standards regarding measures of physician performance, as well as adopt tactics that recognize and value these standards. In brief, some of the 2021 Medicare PFS standards include: A P R I L 2 0 2 1 • M G M A C O N N E C T I O N | 85 1. The conversion factor set at $32.41, down from $36.09 in 2020; 2. Some E/M office work relative value units (wRVUs) have increased; 3. Nine services are added to the telehealth list; and 4. The performance threshold to avoid a negative adjustment under MIPS is being set at 60 points.4 According to analysis completed by SullivanCotter, CMS maintained reduced documentation requirements to save physicians 180 hours of paperwork per year and increased wRVUs for some E/M codes to acknowledge the length of office visits, electronic medical record documentation demands, and the introduction of new demands related to value-based care and population health initiatives.5 Some wRVU changes extracted from the final rule include:6 TABLE 1. NEW wRVUs FOR 2021 E/M OUTPATIENT VISIT CODES Code Current minimum minutes per visit Current wRVU for code 2021 minutes per visit 2021 wRVU for code Percentage increase in wRVU 99203 29 1.42 40 1.60 13% 99204 45 2.43 60 2.60 7% 99205 67 3.17 85 3.50 10% 99213 23 0.97 30 1.30 34% 99214 40 1.50 49 1.92 28% 99215 55 2.11 70 2.80 33% G2212* N/A N/A 15 0.61 N/A *An add-on code for every 15 minutes of extended visit time. The intention to increase wRVU weights for some E/M codes may be a factor in physicians generating more wRVUs in calendar year (CY) 2021 versus CY 2020. The intention to decrease the conversion factor may result in organizations generating less revenue in CY 2021 versus CY 2020. The overall impact of these new standards will be determined by physician services rendered, documentation, coding and whether commercial payers follow the CMS plan.7 To prepare for this market force, the physician compensation plan can acknowledge the impact of CMS 2021 PFS standards by recognizing and valuing: 8 6 | APRIL 2021 • MGMA CONNECTION • The “what-if” scenario of rising wRVU-based compensation with simultaneously decreasing practice revenue • The “what-if” scenario of rising wRVU-based compensation triggering conflicts with compliance and fair market value (FMV) standards • The “what-if” scenario of retaining existing physician compensation plan design elements and forgoing adoption of new CMS 2021 PFS standards. The ACA and demands of uninsured persons The ACA and the overall state of health insurance coverage in the United States is a market force that impacts access to, demand for and payment of healthcare services. The physician compensation plan needs to account for the impact that the ACA’s status and the demands of uninsured persons have on measures of physician performance, and adopt tactics that recognize and value the demands of uninsured persons. A decision from the U.S. Supreme Court on a challenge to the constitutionality of the individual mandate in the ACA is due this year.8 Based on CY 2020 ACA enrollment results, approximately 11.4 million persons selected or were automatically reenrolled in one of the state or federal insurance exchange plans.9 The number of uninsured persons in the United States may be between 29 and 30 million, but it’s fluid and impacted by many economic and social factors: • According to the Kaiser Family Foundation, the number of uninsured nonelderly was 28.9 million in CY 2019.10 • The 2019 National Health Interview survey projected that between 33 and 35 million were uninsured at different times during CY 2019.11 • A Commonwealth Fund health insurance survey in 2020 estimated the uninsured population to be 30 million at the start of 2020.12 Together, the ACA enrollment of approximately 11 million and uninsured estimates of approximately 30 million constitute a total population of 41 million people at risk for being uninsured if the ACA is deemed unconstitutional. Adding millions to the ranks of the uninsured lowers the likelihood those patients receive preventive care and services for major health conditions and chronic diseases,13 and the cost of care impedes follow-through on recommended prescriptions, tests, treatments, specialty care and sick care by uninsured persons.14 To prepare for this market force, the compensation plan can acknowledge the demands of uninsured persons by recognizing and valuing: • Physician and staff time required to address the complex economic, social and healthcare needs of uninsured persons who score low on social determinants of health (SDoH) assessments • Physician and staff time required to address the complex care management needs of uninsured persons who do not follow through on recommended prescriptions, tests, treatments and specialty care. COVID-19-generated shifts in the economy COVID-19 has been a societal event of significant scope and magnitude. It has been a healthcare system market force that no one anticipated and for which no one was prepared. The physician compensation plan needs to account for the impact that COVID-19 pandemic-generated shifts in the U.S. economy and healthcare system have on measures of physician performance and adopt tactics that recognize and value these shifts. Physicians have been impacted personally and professionally by the pandemic leading to introspection on their careers and care delivery in general. A survey by Jackson Physician Search found that two-thirds of responding physicians indicated that the COVID-19 virus has led them to look for a new job.15 A survey of physicians regarding the impact on their own well-being, their patients and the future of the healthcare industry by The Physicians Foundation found that loss of income, symptoms of burnout and concerns about health insurance coverage availability were the most common examples of the impact of COVID-19 on patients.16,17,18 To prepare for this market force, the physician compensation plan can acknowledge the impact of COVID-19 by recognizing and valuing: • Physician time required to participate in more frequent compensation plan governance committee and advisory group meetings • Physician productivity reductions resulting from reduced practice capacity and overall reduced demand for care. CONCLUSION “The next compensation plan will be the best compensation plan” might be a familiar saying in healthcare, but the accuracy of this statement depends on how an organization defines and manages its plan. An effective physician compensation plan plays a pivotal role in organizational success. It is not a static plan; it is a complex entity with a physicianadministrator partnership at its foundation with assigned responsibilities for and functions of design, model, engage, implement and analyze. As the U.S. healthcare system changes, the resilient physician compensation plan is built to consider and accommodate change (whether anticipated or unforeseen) in 2021 and beyond. Mike Delmonico, principal, Mike Delmonico Consulting LLC, mikedelmonicoconsulting.com. 1. AHRQ. “Physician Burnout.” Available from: bit.ly/34V1YKv. 2. Ibid. 3. HHS. “HHS Makes Stark Law and Anti-Kickback Statute Reforms to Support Coordinated, Value-Based Care.” Nov. 20, 2020. Available from: bit.ly/3bkbrz5. 4. CMS. “Final Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2021.” Dec. 1, 2020. Available from: go.cms.gov/38YD4e1. 5. SullivanCotter. 2021 Evaluation and Management CPT Codes: Understanding the Impact on Physician Compensation. Available from: bit.ly/38cWInl. 6. CMS. “Medicare Program; CY 2021 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment Policies.” Available from: bit.ly/3baKIoi. 7. Brady M. “Physician fee-schedule changes could upend compensation, experts say.” Modern Healthcare. Nov. 30, 2020. Available from: bit.ly/393YeY8. 8. MGMA. “The Affordable Care Act (ACA).” Available from: mgma.com/aca. 9. CMS. “Health insurance exchanges 2020 open enrollment report April 1, 2020.” Available from: go.cms.gov/3hDIu24. 10. Tolbert J, Orgera K, Damico A. “Key Facts about the Uninsured Population.” Kaiser Family Foundation. Nov. 6, 2020. Available from: bit.ly/3pOPax2. 11. Cohen RA, et al. “Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, 2019.” National Center for Health Statistics, CDC. Available from: bit.ly/2X8WTtD. 12. Collins SR, Gunja MZ, Aboulafia GN. “U.S. Health Insurance Coverage in 2020: A Looming Crisis in Affordability.” The Commonwealth Fund. Aug. 19, 2020. Available from: bit.ly/3b7UVC4. 13. Tolbert, et al. 14. Collins, et al. 15. Jackson Physician Search. “Physician Recruitment Amid the Pandemic — Keeping Your 2021 Staffing Plan on Track.” July 24, 2020. Available from: bit.ly/355GZEz. 16. “The Physicians Foundation 2020 Physician Survey: Part 1.” The Physicians Foundation. Aug. 18, 2020. Available from: bit.ly/3bfreyK. 17. “The Physicians Foundation 2020 Physician Survey: Part 2.” The Physicians Foundation. Sept. 17, 2020. Available from: bit.ly/359eDJX. 18. “The Physicians Foundation 2020 Physician Survey: Part 3.” The Physicians Foundation. Oct. 22, 2020. Available from: bit.ly/3n7sdDG. A P R I L 2 0 2 1 • M G M A C O N N E C T I O N | 87 Copyright of MGMA Connection is the property of MGMA and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written permission. However, users may print, download, or email articles for individual use. Third Edition TRANSFORMATIONAL LEADERSHIP in NURSING From Expert Clinician to Influential Leader Marion E. Broome Elaine Sorensen Marshall EDITORS Register Now for Online Access to Your Book! Your print purchase of Transformational Leadership in Nursing, Third Edition, includes online access to the contents of your book—increasing accessibility, portability, and searchability! Access today at: http://connect.springerpub.com/content/book/978-0-8261-3505-6 or scan the QR code at the right with your smartphone and enter the access code below. 3K3DWF6L If you are experiencing problems accessing the digital component of this product, please contact our customer service department at cs@springerpub.com The online access with your print purchase is available at the publisher’s discretion and may be removed at any time without notice. Scan here for quick access. Publisher’s Note: New and used products purchased from third-party sellers are not guaranteed for quality, authenticity, or access to any included digital components. SPC View all our products at springerpub.com Marion E. Broome, PhD, RN, FAAN, is dean of the School of Nursing, vice chancellor for nursing affairs, and Ruby Wilson Professor of Nursing at Duke University, as well as associate vice president for academic affairs for nursing at Duke University Health System, Durham, North Carolina. Prior to joining Duke, Dr. Broome was dean of the Indiana University School of Nursing and associate vice president for nursing at Indiana University Health, where she was awarded the rank of distinguished professor. Widely regarded as an expert, scholar, and leader in pediatric nursing research and practice, Dr. Broome was funded externally by the American Cancer Society, the National Institutes of Health, and various foundations for two decades. Dr. Broome’s research is published in more than 121 papers in 58 nursing, medicine, and interdisciplinary journals. She also has published seven books and 20 chapters. Dr. Broome is editor in chief of Nursing Outlook, the official journal of the American Academy of Nursing and the Council for the Advancement of Nursing Science. She completed a variety of leadership training courses while serving in the Army Nurse Corp, a Management and Leadership in Education Certificate from Harvard University, and the Center for Creative Leadership’s Leading for Organizational Leadership Course. Elaine Sorensen Marshall, PhD, RN, FAAN, is former Castella Distinguished Professor and chair of the Department of Health Restoration and Care Systems Management at the University of Texas Health Science Center School of Nursing, San Antonio, Texas; former professor and Bulloch Endowed Chair at the School of Nursing at Georgia Southern University, Statesboro, Georgia; and professor and dean emerita of the College of Nursing at Brigham Young University, Provo, Utah. She has served in national elected and appointed leadership positions for the American Association of Colleges of Nursing, the American Association for the History of Nursing (AAHN), and the Western Institute of Nursing (WIN). Dr. Marshall has published two books and more than 50 articles and book chapters. She received the New Professional Book Award from the National Council on Family Relations, the Lavinia Dock Award from the AAHN, and the Jo Eleanor Elliott Leadership Award from the WIN. TRANSFORMATIONAL LEADERSHIP IN NURSING From Expert Clinician to Influential Leader Third Edition Marion E. Broome, PhD, RN, FAAN Elaine Sorensen Marshall, PhD, RN, FAAN Editors Copyright © 2021 Springer Publishing Company, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Springer Publishing Company, LLC, or authorization through payment of the appropriate fees to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400, fax 978-646-8600, info@copyright.com or on the Web at www.copyright.com. Springer Publishing Company, LLC 11 West 42nd Street New York, NY 10036 www.springerpub.com http://connect.springerpub.com/home Acquisitions Editor: Adrianne Brigido Compositor: Amnet Systems ISBN: 978-0-8261-3504-9 ebook ISBN: 978-0-8261-3505-6 Instructor’s PowerPoints ISBN: 978-0-8261-3542-1 DOI: 10.1891/9780826135056 Qualified instructors may request supplements by emailing textbook@springerpub.com 20 21 22 23 24 / 5 4 3 2 1 The author and the publisher of this Work have made every effort to use sources believed to be reliable to provide information that is accurate and compatible with the standards generally accepted at the time of publication. The author and publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance on, the information contained in this book. 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Description: Third edition. | New York, NY : Springer Publishing Company, LLC, [2021] | Author’s names reversed on the previous edition. | Includes bibliographical references and index. | Identifiers: LCCN 2019046706 (print) | LCCN 2019046707 (ebook) | ISBN 9780826135049 (paperback) | ISBN 9780826135056 (ebook) | ISBN 9780826135421 (Instructor’s PowerPoints) Subjects: MESH: Nurse Administrators | Leadership | Nursing, Supervisory Classification: LCC RT89 (print) | LCC RT89 (ebook) | NLM WY 105 | DDC 362.17/3068—dc23 LC record available at https://lccn.loc.gov/2019046706 LC ebook record available at https://lccn.loc.gov/2019046707 Contact us to receive discount rates on bulk purchases. We can also customize our books to meet your needs. For more information please contact: sales@springerpub.com Publisher’s Note: New and used products purchased from tird-party sellers are not guaranteed for quality, authenticity, or access to any included digital components. Printed in the United States of America. CONTENTS Contributors vii Foreword Patricia Reid Ponte, DNSc, RN, FAAN, NEA-BC ix Preface xi PART I: CONTEXTS FOR TRANSFORMATIONAL LEADERSHIP 1. Frameworks for Becoming a Transformational Leader   3 Elaine Sorensen Marshall and Marion E. Broome 2. Transformational Leadership: Complexity, Change, and Strategic Planning  35 Marion E. Broome and Elaine Sorensen Marshall 3. Current Challenges in Complex Healthcare Organizations and the Quadruple Aim   67 Katherine C. Pereira and Margaret T. Bowers 4. Practice Models: Design, Implementation, and Evaluation   99 Mary Cathryn Sitterding, Christy Miller, and Elaine Sorensen Marshall 5. Collaborative Leadership Contexts: It Is All About Working Together  155 Marion E. Broome and Elaine Sorensen Marshall PART II: BECOMING A TRANSFORMATIONAL LEADER 6. Shaping Your Own Leadership Journey   183 Marion E. Broome and Elaine Sorensen Marshall 7. Building Cohesive and Effective Teams   213 Marion E. Broome and Elaine Sorensen Marshall PART III: LEADING THE DESIGN OF NEW MODELS OF CARE 8. Creating and Shaping the Organizational Environment and Culture to Support Practice Excellence   237 Megan R. Winkler and Elaine Sorensen Marshall v vi • Contents 9. Economics and Finance of Healthcare   277 Brenda Talley 10. Leading Across Systems of Care and in the Larger Community   319 Marion E. Broome and Elaine Sorensen Marshall Index 345 CONTRIBUTORS Margaret (Midge) T. Bowers, DNP, RN, FNP-BC, AACC, FAANP Associate Professor Duke University School of Nursing Durham, North Carolina Marion E. Broome, PhD, RN, FAAN Dean and Ruby Wilson Professor of Nursing Duke University School of Nursing Vice Chancellor for Nursing Affairs, Duke University Associate Vice President for Academic Affairs for Nursing Duke University Health System Durham, North Carolina Elaine Sorensen Marshall, PhD, RN, FAAN Castella Distinguished Professor and Department Chair (retired) University of Texas Health Science Center School of Nursing San Antonio, Texas Bulloch Endowed Chair (retired), School of Nursing, Georgia Southern University Statesboro, Georgia Professor and Dean Emerita, College of Nursing, Brigham Young University Provo, Utah Christy Miller, MSN, RN, CPN Clinical Program Manager Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio Katherine C. Pereira, DNP, RN, FNP-BC, ADM-BC, FAAN, FAANP Professor Director, Doctor of Nursing Practice Program Duke University School of Nursing Durham, North Carolina vii viii • Contributors Mary Cathryn Sitterding, PhD, RN, CNS, FAAN Vice President, Patient Services Center for Professional Excellence Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio Brenda Talley, PhD, RN, NEA-BC Clinical Associate Professor The University of Alabama in Huntsville Huntsville, Alabama Megan R. Winkler, PhD, RN, CPNP-PC Researcher, Division of Epidemiology and Community Health University of Minnesota School of Public Health Minneapolis, Minnesota FOREWORD I am so pleased to be writing the foreword for the third edition of Transformational Leadership in Nursing: From Expert Clinician to Influential Leader. As a seasoned health services nurse leader, I know much about the complexities and challenges of healthcare delivery, and I appreciate the importance of effective leadership in advancing excellence in this important domain. This book provides readers with a vibrant and up-to-date view of these complexities and challenges. It imparts a plethora of knowledge, both theoretical and empirical, that positions readers to develop their own effectiveness as people and leaders so that they can ultimately positively influence healthcare delivery in the future. This book is perfectly geared toward nurses who are interested in becoming more effective and more influential people and leaders as they carry out their professional roles in healthcare delivery. When I first read the second edition of Transformational Leadership, I knew immediately that this was the book I would use to teach nurses to be effective leaders. I recently transitioned from my health services role to teaching DNP students full time. I was designing the leadership course for a new DNP program and looking for just the right book. When I found the second edition, I was immediately taken with the usefulness of the entire book. Every chapter was filled with the content I knew I needed to prioritize for our new course. When I reached out to Marion Broome and Elaine Marshall about my interest in knowing if a third edition would be coming out soon, I was so delighted to hear that, in fact, the plan for that was well underway. Both Marion and Elaine have incredible depth in their own expertise and experience in leading in the academic setting. They could not be better suited to be editors for this important text. That was evident to me as I read the second edition. In this current edition, a comprehensive overview of leadership theory sets the stage in the first chapter, but it does not stop there. The book encourages readers to personalize the knowledge imparted in the book to their unique characters and roles in the healthcare setting. This book is written with application in mind. It highlights key challenges that leaders face and provides ideas and strategies based in evidence that can guide their planning, implementing, and evaluating tactics and strategies to ensure excellence in all they do. There are personal vignettes, cases, reflective questions, and a robust set of references for even further exploration. ix x • Foreword What is most valuable about this particular nursing leadership book is that it addresses the current healthcare system. It is rich with what is real today. In this new third edition, several chapters were revised to add or update key priorities within healthcare delivery today. For instance, a chapter on the design, implementation, and evaluation of innovative practice models is provided. Additionally, the growth of population health initiatives and the importance of recognizing, improving, and innovating care delivery across the continuum are fully addressed. Information technology, use of machine learning, and the possibilities of future technology for personalizing and guiding care are also addressed. Nurse faculty, nursing students, practicing nurses, and APRNs alike will find this third edition extremely helpful in their quest to improve care delivery while improving their own effectiveness as people, nurses, and leaders. The authors use the term transformational as less about ascribing to a particular leadership theory and more about helping transform practice settings and people who work in them through recognition of the benefits of diversity, by encouragement of creativity, innovation, and professional development. They also stress how important it is to recognize the importance of standards, policies, guidelines, recognition, governance, regulations, structures, and processes that ensure that excellence is always present. The authors also advance the idea that leadership is personal, it is a lifelong journey, and it is about serving others and self with compassion, humility, and kindness. That said, the book emphasizes execution and outcomes. In this way, Transformational Leadership in Nursing: From Expert Clinician to Influential Leader is very practical but also philosophical and clearly provides readers with a set of values, principles, and evidence by which to start down the road of making a tremendous difference in people’s lives. Patricia Reid Ponte, DNSc, RN, FAAN, NEA-BC Associate Clinical Professor William F. Connell School of Nursing Woods College of Advanced Studies Master of Health Administration Program Boston College, Chestnut Hill, Massachusetts Professor of Practice—Adjunct College of Natural, Behavioral, and Health Sciences Simmons University, Boston, Massachusetts PREFACE This book is for nurse leaders of the future. It speaks to clinicians who are experts in patient care and are now on a path toward leadership. Several clinician leaders offer their insights in their chapters, while other scenarios and examples drawn from practice are placed throughout the book. This book is offered as a resource as you embark on your own journey toward transformational leadership. You are needed to lead in the setting where you practice: from a solo practice clinic in the community to the most complex healthcare system. From an isolated rural community to an urban health sciences center, it is clear that nurse leaders like yourself are needed to forge new and innovative models of care that can meet the challenges of patients and families with whom we work. If you are reading this book, you are likely already prepared for clinical practice. You may be an expert in patient care, you may work as a manager in administration, or you may teach clinical nursing. Your challenge now is to enhance your skills and stature to become an influential leader. If that “becoming” is not a transforming experience, it will not be enough to prepare you to lead in a future of enormous challenges. The future of healthcare in the United States and throughout the world requires leaders who are transformational in the best and broadest sense. It requires a thoughtful, robust sense of self as a leader. It requires an intellectual, practical, and spiritual commitment to improve clinical practice and lead others toward their own transformation in their professional journey. It requires courage, knowledge, and a foundation in clinical practice. It requires an interdisciplinary fluency and ability to listen, understand, and influence others across a variety of disciplines. Transformational leadership requires vision and creativity! Many who use this book are students in programs of study for a clinical practice doctorate, for example, the DNP. A decade ago, the DNP emerged as the credential for leaders in clinical practice. The DNP Essentials and the position statement on the DNP of the American Association of Colleges of Nursing (AACN, 2004) called for a “transformational change in the education required for professional nurses who will practice at the most advanced level of nursing” (AACN, 2006, p. 4) and “enhanced leadership skills to strengthen practice and health care delivery” (AACN, 2006, p. 5). Such transformational leaders focus not only on settings of direct patient care but also on healthcare for entire xi xii • Preface communities. The 2020 version of the DNP Essentials is being developed as we send this book to press. But the core values of doctoral education—knowledge translation, leadership, and practice excellence—serve as core concepts in this book. This work is neither a comprehensive encyclopedia for healthcare leadership nor a traditional text in nursing management. Rather, its purpose is to identify some key issues related to leadership development and contexts for transformational leaders in healthcare. The book is meant to introduce you, as a clinical expert, to important issues in your own aspirations toward becoming a leader. It is offered as a text and supplement to your own study of the literature, experts, and important experiences in the transition to leadership. It is meant to accompany and guide you to more focused current literature and experts on a variety of issues that healthcare leaders face. It is an aid to launch or guide you on your own journey to become a leader. You will read about transformational leadership, which needs some clarification. Although there are some formal theories and definitions of transformational leadership, this work refers to the concept in its best and broadest sense without adhering only to a specific theoretical perspective. This book is heavily referenced not only to provide citation but also to lead you to a vast range of literature—both seminal and contemporary. In this third edition, we have made some changes to update the messages for present-day and future readers. We provide more opportunities for students of leadership to access contemporary thinking of leaders from a variety of fields through links to TED Talks, blogs, and other media. Because a global view of healthcare is essential to today’s leader, global perspectives have been added throughout the book. The focus on the context of complex healthcare organizations has been sharpened, with attention given to current legislation and concepts such as the Quadruple Aim to increase access, decrease costs, and improve quality; seamless care delivery; and competencies of the American Organization of Nurse Executives. There is also increased attention to national patient safety benchmarks, issues in health disparities, workforce issues, and patient and consumer satisfaction. We have invited experts to contribute on important issues of interprofessional collaboration, creating and shaping diverse environments for care, healthcare economics, and other significant areas of leadership development. The messages of this book are to be taken personally. Your journey toward transformational leadership is a deeply personal one, and it requires courage and creativity. Throughout the book, we provide cases of “Leadership Action” for you to read about and see how nurses just like you played to their strengths, sought out mentors, and solved complex problems. Finally, you will find discussion questions and occasional personal stories and opportunities to guide your own personal reflection. We hope you enjoy reading this text and using Preface  • xiii what content and activities resonate with you as you continue your leadership journey! Marion E. Broome Elaine Sorensen Marshall REFERENCES American Association of Colleges of Nursing. (2004). AACN position statement on the practice doctorate in nursing. Washington, DC: Author. American Association of Colleges of Nursing. (2006). The essentials of doctoral education for advanced nursing practice. Washington, DC: Author. Qualified instructors may obtain access to supplementary PowerPoints by emailing textbook@springerpub.com. PART I CONTEXTS FOR TRANSFORMATIONAL LEADERSHIP CHAPTER 1 Frameworks for Becoming a Transformational Leader Elaine Sorensen Marshall and Marion E. Broome A leader takes people where they want to go. A great leader takes people where they don’t necessarily want to go but ought to be. —Rosalynn Carter OBJECTIVES • To consider the challenges facing today’s leaders in healthcare systems and the need for leaders who can transform these challenges into opportunities • To review foundational historical and theoretical contexts for leadership • To discuss the evolution and envisioned role of doctorally prepared nurses in healthcare systems and how they can exert positive influence as leaders within these systems • To explore theoretical contexts in the discipline of leadership to guide transformational leadership • To use activities within this book to develop leadership skills, assess current and preferred future environments to make a difference, and shape the future of nursing and healthcare HEALTHCARE ENVIRONMENTS: OPPORTUNITIES FOR NURSE LEADERS The world needs visionary, effective, and wise leaders. Never has this statement been truer than it is in the world of healthcare today. Leadership matters. It matters in every organization, not only for nurses to thrive in their careers but for them to advance effective healthcare for society. The current state and pace of healthcare change continue to create unprecedented challenges for individuals, families, and communities of the nation and the world. Healthcare continues to grow more 3 4 • I: CONTEXTS FOR TRANSFORMATIONAL LEADERSHIP complex, corporate, costly, and expansive. In the United States, we face urgent problems of system complexity, financial instability, and poor distribution of resources; shortages of clinicians and provider expertise; issues of patient safety; and controversy about who will pay for what, at what level of quality, and at what cost for services (Institute of Medicine, 2010; Siwicki, 2017). Furthermore, leaders face a host of health problems and disparities, such as greater incidence of chronic illnesses, comorbidities, new epidemics of infectious diseases and opioid use, and growing numbers of vulnerable, underserved, and aging populations. Important issues of artificial intelligence, cybersecurity, disaster preparedness, drug prices, and patient experiences add further challenges to today’s leaders (Siwicki, 2017). Meanwhile, society impatiently waits with waning confidence in the current healthcare system. Dialogue becomes more strident, and positions become more polarized in legislatures, the federal government, among private insurers, and within health systems themselves. Where are the transformational leaders who can take us through these turbulent times? The healthcare professions of past decades focused on clinical practice and educational preparation for practice (Broome, 2019). Society demanded clinical experts to master the burgeoning body of knowledge, research, clinical information, and skill sets. Nurses, physicians, and other health professionals across disciplines responded to that challenge, as they became highly specialized clinical experts. They devoted years of learning and practice to achieve clinical excellence. Despite years of intermittent shortages, the nursing profession continued to provide registered nurses at the bedside, advanced clinical specialists who worked in acute care settings providing and managing care for patients, APRNs who practiced in primary care to provide health promotion and management of chronic conditions, and administrators who led health systems through difficult demands of society. These professionals effectively met healthcare needs for thousands of individuals and families. If you are reading this book, you are among those nursing professionals who have made major contributions to care delivery. The profession and society will continue to need expert clinicians like you. The context of health and healthcare has changed dramatically in the past decade. We now recognize that patients spend most of their time living with their illness outside clinics and inpatient units. Our care delivery models of the past heavily focused on highly technical inpatient settings. Care is now, more than ever, expanded into the community and the homes of patients. Our need now is for leaders who can work within and across systems and settings. Your clinical expertise, whether it is in direct patient care, clinical education, research, or administration, is needed as a foundation for your emerging leadership in changing healthcare environments. We need nurse leaders who can draw from their roots in clinical practice to collaborate with leaders in other disciplines, with policy makers, and with members of the community to create new solutions to the problems facing all of us, to improve quality of life, to transform healthcare systems, and to inspire the next generation of leaders. 1: FRAMEWORKS FOR BECOMING A TRANSFORMATIONAL LEADER • 5 REFLECTION QUESTIONS 1. Think about your current practice environment. Is it organized in such a way that patients and staff feel safe, cared for, and able to express problems? 2. Are you ready to think of your practice in a different way? 3. What are the areas in your practice where you notice a need for a new kind of leadership? 4. What new challenges do you face in your practice? Preparation at the highest level of practice must include preparation for leadership. The world needs expert clinicians to become transformational leaders. The world needs you to become a leader to transform healthcare for the next generation. HERITAGE AND LEGACY: HISTORICAL PERSPECTIVES ON LEADERS IN NURSING The story of modern Western nursing began with little noted but great leaders, and it traditionally starts with Florence Nightingale. Although her contributions are not usually described from a purely leadership perspective, the inspiration and effectiveness of her leadership have been celebrated for over 150 years. Her work in Scutari, Turkey, designing safer healthcare environments and hospital structures, training nurses, and using epidemiological data to improve health, can only be described as “transformational.” The list of other transformational leaders in the history of nursing practice is daunting, including some who are unrecognized today. Well-known charismatic leaders in nursing of the 19th century include Clara Barton, who founded the American Red Cross; Dorothea Dix, who championed advocacy for patients and prisoners and who ruled her staff nurses with an iron fist; and, perhaps, even Walt Whitman, the celebrated poet who was a volunteer nurse during the American Civil War. Best-known and revered models in our heritage of leadership in nursing include the handful of women in North America at the dawn of the 20th century who are credited with the vision of professional nursing: Isabel Hampton, Mary Adelaide Nutting, Lavinia Lloyd Dock, and Lillian Wald (see Keeling, Hehman, & Kirchgessner, 2018 for a comprehensive history of nursing). • Hampton led nurse training at Johns Hopkins in Baltimore and was the first president of what became the American Nurses Association. “Her vision of nursing . . . required a transformation of . . . accepted norms. [Her work] demonstrated her ability to effectively lead change and inspire others toward her cause” (Keeling et al., 2018). 6 • I: CONTEXTS FOR TRANSFORMATIONAL LEADERSHIP • Nutting was Hampton’s student at Johns Hopkins and was among the first visionaries to foresee academic nursing education, rather than apprentice nurse training solely in hospitals. She led efforts to develop the first university nursing programs at the Teachers College of Columbia University and to secure funding for such programs (Gosline, 2004). • Dock was a strong woman who was involved in many “firsts” that influenced the profession for years. She firmly believed in self-governance for nurses and called for them to unite and stand together to achieve professional status. She was among the founders of the Society for Superintendents of Training Schools for Nurses, which later became the National League for Nursing (2019), and an author of one of the first textbooks for nurses and history of nursing. She encouraged nurses and all women to become educated, to engage in social issues, and to expand their views internationally (Lewenson, 1996). She was known as a “militant suffragist” and champion for a broad range of social reforms, always fighting valiantly for nurses’ right to self-governance and for women’s right to vote. • Wald, who modeled the notion of independent practice a century before it became a regulatory issue, founded the first independent public health nursing practice at Henry Street in New York. She not only devoted her life to caring for the poor people of the Henry Street tenements but also was the first to offer clinical experience in public health to nursing students. She worked for the rights of immigrants, for women’s right to vote, for ethnic minorities, and for the establishment of the federal Children’s Bureau (Brown, 2014). Many other leaders of the 20th century valiantly promoted the development of the profession of nursing. Among them was Mary Elizabeth Carnegie, who established one of the first baccalaureate programs in nursing in 1943 at Virginia’s Hampton University (American Association for the History of Nursing, 2018). She became the first African American nurse to be elected to a board of directors of a state nurses association (Florida). She was on the editorial staff of the American Journal of Nursing, was senior editor of Nursing Outlook, and the first editor of Nursing Research. Carnegie was a president of the American Academy of Nursing and was awarded eight honorary doctorates over the course of her career. Her legacy of leadership included making the contributions of African American nurses visible in the professional literature (see Carnegie, 2000). Ildaura Murillo-Rohde was a Panamanian American nurse, academic, and organizational administrator. She came to the United States in 1945 and studied at Columbia University. She was the first Hispanic nurse awarded a PhD from New York University. Her specialty was psychiatric–mental health nursing, and she was an outstanding advocate for mental health needs of Hispanics. MurilloRohde was an associate dean at the University of Washington and the first Hispanic dean at New York University. She founded the National Association of Spanish-Speaking Spanish-Surnamed Nurses in 1975 and served as its first 1: FRAMEWORKS FOR BECOMING A TRANSFORMATIONAL LEADER • 7 president. She was named a living legend in the American Academy of Nursing (National Association of Hispanic Nurses, 2019). Modern leadership for advanced practice in the mid-20th century ultimately led to the development of the DNP degree. The vision, courage, and leadership qualities of Loretta Ford and Henry Silver at the University of Colorado are evident in their pioneer work in establishing the first nurse practitioner program in the United States in 1965. By the 1990s, preparation for advanced nursing practice had moved to the master’s degree. Now, in the face of increasing complexity of healthcare, trends among other healthcare disciplines toward doctoral preparation, and the urgent need for knowledge workers and wise leaders, the practice doctorate is becoming the required preparation for advanced practice nursing. Today’s healthcare leaders inherit courage, vision, and grit that must not be disregarded. We stand on the shoulders of valiant nursing leaders of the past who left a foundation that cries for study of its meaning and legacy for leadership today. They were visionary champions for causes that were only dreams in their time but today are essential. They dared to think beyond the habits and traditions of the time. These leaders were truly transformational. You are among the pioneer leaders to move healthcare forward to better serve society. REFLECTION QUESTIONS Lurking in the archives of your own institution, community, or state are the stories of other exemplary leaders in nursing and healthcare. 1. Who were/are they? 2. How have they changed healthcare? 3. What can you/we learn from them? FOUNDATIONAL THEORIES OF LEADERSHIP Although the theme of this book is transformational leadership, it is important to understand that the purpose, content, and principles of this book are not confined to the tenets of a specific theory of transformational leadership. To become a full citizen of the discipline, it is important that the transformational leader in healthcare understands the history, culture, and theoretical language of the science and practice of the discipline of leadership. Here we explore several leadership frameworks of the past and present with the expectation that some might resonate with you in your own career. The popularity of any particular theory for leadership may wax or wane, but some leadership principles are timeless. Any truly transformational leader will have a solid foundation of understanding of the value of a theoretical approach to leadership in practice. 8 • I: CONTEXTS FOR TRANSFORMATIONAL LEADERSHIP The first principle for leadership is that leaders be grounded in a set of ethics or core values that guide human behaviors and actions. No matter how brilliant the strategy or how productive the actions, if leaders do not hold the trust and act in the best interests of those they serve, they are not competent. Leaders in today’s healthcare and academic settings deal with a variety of ethical issues and must ground themselves in values that enable them to lead with grace and effectiveness. Nurse leaders have a responsibility to shape ethical cultures (Broome, 2015) using the knowledge of ethical standards in the discipline (American Nurses Association, 2015) and expert guidelines (Johns Hopkins Berman Institute of Bioethics, 2014). More than a decade ago, YoderWise and Kowalski (2006, p. 62) outlined the following principles for ethical leadership: respect for others, beneficence (promoting good), veracity (telling the truth), fidelity (keeping promises), nonmaleficence (doing no harm), justice (treating others fairly), and autonomy (having and promoting personal freedom and the right to choose). Such principles continue to be reflected in leadership today. Historical Overview of Leadership Theories It is beyond the scope of this text to provide a comprehensive history of leadership theories. A brief review is offered to give a sense of how traditional theories continue to influence leaders. Early management theories were developed during the industrial revolution and, thus, reflect the factory environment of worker productivity. Such theories included classic and scientific management theory that emphasized formal processes of the organization rather than the characteristics or behaviors of the individual. Primary concepts included hierarchical lines of authority, chain-of-command decision-making, division of labor, and rules and regulations. Such theories were originated by early 20th-century industrial thinkers such as Max Weber, Frederick W. Taylor, F. W. Mooney, and Henri Fayol. Approaches focused on organization and processes. They included time-and-motion studies, mechanisms, and bureaucracy. Advantages of such theories were clear organizational boundaries and efficiency. Disadvantages included rigid rules, slow decision-making, authoritarianism, and bureaucracy (Garrison, Morgan, & Johnson, 2004). Behavioral and Trait Theories In the mid-20th century, management focus turned away from the organization and moved toward people within the organization. Theories that emerged may be referred to as behavioral or trait theories. Even with a new focus on people rather than organizations, early behavioral theories promoted linear thinking, compartmentalization, functional work, process orientation, clear 1: FRAMEWORKS FOR BECOMING A TRANSFORMATIONAL LEADER • 9 and fixed job requirements, and predictable effects (Capra, 1997; Cook, 2001; Wheatley, 1994). WORKER STYLE THEORIES Other early behavioral theories moved the focus from people, or even leaders themselves, to an emphasis on the concept of leadership. Thus, the ideas of leadership styles emerged. Styles were considered people based, task based, or a combination of both. Such styles include authoritarian, democratic, and laissez-faire (Lewin, Lippitt, & White, 1939). Leaders were expected to determine objectives, initiate action, and coordinate the efforts of workers. These early theories set the stage for modern theories of management by objectives (Williams, 2017). Problems with behavior or style theories are related to the issue of context. For example, in the heat of a crisis, such as pandemic influenza, which style is most effective? Theory X or Theory Y? Do the styles describe all aspects of the personality, character, motivation, or behavior of the leader? Do the behavioral styles account for all situations? Which, if any, style is uniquely applicable to leaders in healthcare? Another important question is, “Do all individuals respond to certain styles or do followers require some tailoring or combination of styles?” LEADER TRAIT THEORIES Current trait theories seem, in some respects, to return to an old “great person” approach as they target the intellectual, emotional, physical, and personal characteristics of the leader. Trait theories propose that desirable characteristics of successful leaders may be learned or developed. Trait theories continue to be popular. Just pass by a bookstore in any airport to find shelves full of business or leadership self-help books based on some list of qualities, behaviors, or habits marketed for success. The notion of successful leadership traits cannot be denied, but the science of predicting optimal traits under differing circumstances has still not matured. Emotional intelligence is increasingly recognized as an important characteristic of effective and successful leaders. It may be considered here among trait theories. It includes self-awareness, self-management of emotions, empathy, and effective communication and relationship management. These characteristics allow leaders to deal with the daily challenges in healthcare organizations by understanding how they respond to stress, how to regulate emotions such as anger and resentment, and how to make decisions and communicate their rationale to others. Since Goleman’s original work on emotional intelligence in 1995, his work continues to influence leaders in many areas, with growing use in nursing and medicine (see Carragher & Gormley, 2017; Goleman, Boyatzis, & McKee, 2002; Heckemann, Schols, & Halfens, 2015; Johnson, 2015; Lewis, Neville, & Ashkanasy, 2017). See Table 1.1 for examples of behavioral and trait theories over time. 10 • I: CONTEXTS FOR TRANSFORMATIONAL LEADERSHIP TABLE 1.1 Examples of Behavioral and Trait Theories for Leadership THEORY Theory X MAJOR PRECEPTS CONTRIBUTIONS TO OUR KNOWLEDGE ABOUT LEADERSHIP Theory X is a directive style, wherein the leader makes decisions, gives directions, and expects compliance. The leader is a motivator and role model for follower behavior. Follower productivity is related to incentives and punishments. Theory Y (McGregor, 2006) Theory Y is a participative style, wherein the leader seeks consensus. Followers focus on quality and productivity and are rewarded for problem-solving. Theory Z (Ouchi, 1981) The theory Z leader promotes employee– follower well-being on and off the job to promote high morale, satisfaction, stable personnel employment, and high productivity. Leadership attributes (Gardner, 1989) Leadership attributes include physical vitality and stamina, intelligence and action-oriented judgment, eagerness to accept responsibility, task competence, understanding of followers and their needs, skill in dealing with people, need for achievement, capacity to motivate people, courage and resolution, trustworthiness, decisiveness, selfconfidence, assertiveness, and adaptability. This promotes less “theory,” with associated concepts and propositions, and more “lists” of preferred characteristics or activities. Eight habits (Covey, 1989, 2004) Eight habits of successful leaders: • Be proactive and take goal-directed action rather than reacting to circumstances • Begin with the end in mind—goal oriented • Put first things first—distinguish important versus urgent • Think win–win—negotiate to mutually benefit • Seek first to understand, then to be understood—listen • Synergize—engage in activities that amplify most effective aspects of all leadership habits The first seven habits codified commonsense principles in a national bestseller of the popular business literature. Later Covey added the eighth habit of “finding your voice.” (continued) 1: FRAMEWORKS FOR BECOMING A TRANSFORMATIONAL LEADER • 11 TABLE 1.1 Examples of Behavioral and Trait Theories for Leadership (continued) THEORY MAJOR PRECEPTS CONTRIBUTIONS TO OUR KNOWLEDGE ABOUT LEADERSHIP • Sharpen the saw—attend to personal maintenance and renewal • Find and express your voice in vision, discipline, passion, conscience Leadership attributes (Shirey, 2006, 2009, 2017) Leadership attributes: genuineness, trustworthiness, reliability, compassion, believability Provides another list of commonsense effective characteristics. Leadership competencies (American Organization of Nurse Executives, 2005) Leadership competencies: • Communication and relationship-building • Knowledge of the healthcare environment • Leadership • Professionalism • Business skills Provides a list of specific skills related to nursing leadership. Situation/Contingency and Constituent Relationship Theories Situational theories grew largely as a reaction to trait theories, proposing the opposite premise that the characteristics of the situation, rather than personal traits of the person, produced the leader (see Table 1.2). Theorists called for a repertoire of leadership traits or styles and defined the appropriate style for specific types of situations. Building on the work of Lewin et al. (1939), situational theory would propose that authoritarian leadership may be required in a time of crisis, a democratic style in situations for team or consensus building, and laissez-faire style in traditional single-purpose, well-established organizations. REFLECTION QUESTIONS 1. What do you think are ideal conditions under which one learns successful leadership traits? 2. What leadership traits might be needed in a leader of a state public health department? Are these similar to those needed by the chief nursing officer of a large hospital system? If different, which ones are needed and why? 3. What leadership traits do you think would be most predictive of effectiveness in a particular role? 4. Which theory best “fits” your perception of effective leadership? 12 • I: CONTEXTS FOR TRANSFORMATIONAL LEADERSHIP TABLE 1.2 Examples of Situational and Constituent Interaction Theories for Leadership THEORY MAJOR PRECEPTS CONTRIBUTIONS TO OUR KNOWLEDGE ABOUT LEADERSHIP Path–goal theory (House, 1971) Leader responds to follower motives in working relationships. Leader influences followers’ perceptions of work and goals and creates paths to attain these goals and expectancies for goal attainment. Leader identifies and removes barriers, gives support and direction, secures resources, and facilitates goal or task achievement of followers. Leader focuses on followers’ needs for affiliation and control by promoting clarity of expectations and supportive structure. Describes transactional leader behaviors as achievement oriented, directive, participative, or suppressive. These are connected to environmental and follower factors or situations. Situational leadership theory (Hersey & Blanchard, 1977; Hersey, Blanchard, & Johnson, 2008) Four leadership styles and associated situations: • Telling, or giving direction • Selling, or participatory coaching • Participating, or sharing decision-making • Delegating, or assigning responsibility for task or goal achievement Expands scenario in which leadership occurs to include follower and situational needs. Leader in context of quanta and chaos theory (Porter-O’Grady & Malloch, 2011) Recognition of phenomena of disequilibrium, disorganization, or chaos to lead a natural course to new orders. Constant change is a way of being. Leadership and organizations can thrive on the paradox that order can emerge from disorder. Application of “New Age” theories from physics to leadership. Allowance for phenomena beyond the control of the leader to evolve and emerge. Principles: • Partnership • Accountability • Equity • Ownership (continued) 1: FRAMEWORKS FOR BECOMING A TRANSFORMATIONAL LEADER • 13 TABLE 1.2 Examples of Situational and Constituent Interaction Theories for Leadership (continued) THEORY Emotional intelligence (Goleman et al., 2002) MAJOR PRECEPTS CONTRIBUTIONS TO OUR KNOWLEDGE ABOUT LEADERSHIP Monitoring of emotional perceptions of self and others. Expands concepts of social–emotional aspects of human relationships to complement traditional business management/leadership competencies. Domains: • Self-awareness • Self-management • Social awareness • Relationship management Five steps to advance as leader: • Identify “ideal self” • Identify “real self” • Create a plan to build on strengths • Practice the plan • Develop trust and encourage others Servant leadership (Van Dierendonck, 2011) Leader’s motivation is to serve and meet the needs of others. Rather than directing followers, the leader inspires, motivates, influences, and empowers. Servant leaders combine their motivation to lead with a need to serve others. Ten characteristics: • Humility • Empathy through framing questions • Authenticity • Awareness • User of persuasion • Interpersonal stewardship • Foresight • Provide distraction • Commitment to the growth of people • Co-builder of learning/working communities Thus, the leader would adjust behaviors according to circumstances of worker experience, maturity, and motivation. Less-motivated workers would require a directive task focus, and highly motivated workers would require a focus on support and relationships. See Table 1.2 for examples of situational and constituent theories. 14 • I: CONTEXTS FOR TRANSFORMATIONAL LEADERSHIP Situational/contingency theories represented attempts to consider both the leader and the situation. However, studies over the past few decades were most often done in typical American, middle-class, male organizations with little regard for situations or styles that considered gender, culture, political climate, or specific types of organizations such as those of healthcare. Relationshipbased theories, which evolved more recently, paved the way for more transformational theories in the 21st century that are believed to be critical to the success of any organization and leader. They also expanded thinking to incorporate the notion that engaged followers are an essential part of any leader’s effectiveness. WHAT IS TRANSFORMATIONAL LEADERSHIP? As you thought about your answers to the earlier reflection questions, did you think of certain individuals who were more effective than others as leaders in your own experience? Or did you ask yourself some basic questions such as, “What is leadership?” or “Who are the leaders we need?” Leadership is one of those difficult concepts that is sometimes readily identified but never easily defined. Simply put, leadership is the discipline and art of guiding, directing, motivating, and inspiring a group or organization toward the achievement of common goals. It includes the engaging and management of people, information, and resources. It requires energy, commitment, communication, creativity, and credibility. It demands the wise use of power. Leadership has been defined by many people over the years. Leadership is the ability to guide others, whether they are colleagues, peers, clients, or patients, toward desired outcomes. A leader uses good judgment, wise decision-making, knowledge, intuitive wisdom, and compassionate sensitivity to the human condition—to suffering, pain, illness, anxiety, and grief. A nursing leader is engaged and professional and acts as an advocate for health and dignity. You might also ask at this point, “But what does a leader do?” Leaders “are people who have a clear idea of what they want to achieve and why” (Doyle & Smith, 2009, p. 1). They are usually identified by a title or position and are often associated with a particular organization—but not always. Leaders are the resource for confidence, assurance, and guidance. Renowned leadership guru Peter Drucker (2011) listed the following things leaders must do to be effective: • Ask what needs to be done. • Ask what is right for the enterprise. • Develop action plans. • Take responsibility for decisions. • Take responsibility for communicating. • Focus on opportunities, not problems. • Run productive meetings. • Think and say “we” not “I.” 1: FRAMEWORKS FOR BECOMING A TRANSFORMATIONAL LEADER • 15 These are pragmatic but highly effective strategies to motivate others, improve the organization, and empower followers to achieve excellence. Not a single item on the list is easy or straightforward, but each provokes thinking and action. All can be learned behaviors if one is open to that learning. Leaders are seldom born, made, or found by luck, but rather they emerge when preparation, character, experience, and circumstance come together at a time of need. Those leaders build on strong leadership characteristics they always had. Leaders are most often ordinary people demonstrating extraordinary courage, skill, and “spirit to make a significant difference” (Kouzes & Posner, 2007, p. xiv). So, you can prepare yourself and learn to be a leader. That is one reason you seek additional education. Others in your environment can and will support, coach, and mentor you as you learn to know yourself and your strengths, try on new behaviors, and own your future. The purpose of this book is to help you as an advanced clinician to prepare to become a transformational leader. Transformational Leadership Simply defined, transformational leadership is a process through which leaders influence others by changing the understanding of others of what is important (Broome, 2013). An operative word here is process. It is not just a list of attributes or characteristics but a dynamic and ever-evolving style that is focused on self, others, the situation, and the larger context. Transformational leaders inspire others to achieve what might be considered extraordinary results. Leaders and followers engage with each other, raise each other, and inspire each other. Transformational leadership includes value systems, emotional intelligence, and attention to each individual’s spiritual side. It connects with the very soul of the organization and honors its humanity. It raises “human conduct and ethical aspirations of both the leader and the led and, thus has a transforming effect on both” (Burns, 1978, pp. 4, 20). Transformational leaders are energetic, committed, visionary, and inspiring. They are role models for trust. Their leadership is based on commitment to shared values. For over a decade, nurses have discussed the need for transformational leaders. Where and how leadership is truly “transformational” in nursing and healthcare may still not be clear, but there is no question that such leadership is much needed. The original concept and foundational theory for transformational leadership are attributed to James MacGregor Burns, who proposed the idea in 1978. Other leadership scholars continue to build on the principle. Bass (1985) developed the concept of a continuum between transactional and transformational leadership. As noted earlier, Goleman further advanced the perspective to include aspects of emotional intelligence, such as self-awareness, self-­management, social awareness, and relationship management (Goleman et al., 2002; Heckemann et al., 2015). Bass, Avolio, and Jung (2010) created an instrument to measure transformational leadership, and many studies have 16 • I: CONTEXTS FOR TRANSFORMATIONAL LEADERSHIP been conducted in diverse settings and disciplines to examine leadership among various groups. Since this book does not embrace a sole theoretical perspective, transformational leadership is considered here in its best and broadest sense, as a context and backdrop for leadership development. Components of Transformational Leadership Though we refer to transformational leadership in its broadest sense, without strict adherence to a specific theoretical framework, it is important to recognize and review the foundational seminal work on the concept. Some of the core concepts of transformational leadership, as developed by theorists Burns and Bass (Bass, 1985, 1990; Bass, Avolio, Jung, & Berson, 2003; Bass et al., 2010; Bass & Riggio, 2006; Burns, 1978), are outlined in the following paragraphs. CHARISMA OR IDEALIZED INFLUENCE A transformational leader is a role model of values and aspirations for followers. He or she inspires trust and commitment to a cause. Charisma refers to the ability to inspire a vision. Unlike the individual with narcissistic charisma, who focuses on self, the person with charisma of idealized influence finds effectiveness stemming from a strong belief in others. Charisma is the ability to influence others, to inspire not only a willingness to follow, but also an expectation of success, an anticipation of becoming part of something greater than self. Charismatic leaders know who they are and where the organizational unit they are leading has the potential to go. They have themes and personal mantras in their lives. One leader keeps a file called “Dream” that holds ideas about future opportunities, or another keeps a hand-drawn diagram of her “Tree of Life” showing the roots, trunk, and branches of her life and future. Charismatic leaders, grounded in a commitment to values, influence others to make a positive difference in the world. Healthcare needs such leaders. Indeed, one study demonstrated higher satisfaction and greater happiness among workers who follow a charismatic leader (Erez, Misangyi, Johnson, LePine, & Halverson, 2008). On the other hand, other researchers found that leaders too high in charisma may be less effective because they are not able to engage in operational demands. Their conclusion was that too little charisma brings less strategic thinking and behavior, while too much may not get the job done (Vergauwe, Wille, Hofmans, Kaiser, & DeFruyt, 2018). Charismatic leaders often emerge in times of crisis. They exhibit personal qualities that draw people to believe and follow them. If they are wise, they inspire followers in a synergistic manner that provides safety, direction, beliefs, and actions that exceed the expectations of either follower or leader. To be charismatic does not mean to be flamboyant. Indeed, the most successful leaders “blend extreme personal humility with intense professional will” they are often “self-effacing individuals who display the fierce resolve 1: FRAMEWORKS FOR BECOMING A TRANSFORMATIONAL LEADER • 17 to do whatever needs to be done to make the [organization] great” (Collins, 2001, p. 21). In their early seminal study of 28 elite companies (i.e., those who moved from “good to great”), Collins and colleagues found that level 5 (transformational) leaders channeled their ego away from themselves to the larger goal of building a great company. They were ambitious—but more for their organization than for themselves. One charismatic leader shared, “I want to look out from my porch at one of the greatest companies in the world someday and be able to say, ‘I used to work here’” (Collins, 2001, p. 26). Collins also later confirmed that the steady commitment to move forward, such as “turning a flywheel,” creates momentum toward success for the entire enterprise (Collins, 2019). Charisma may refer to a quality of authenticity, transparency, and trust that draws others to you to share the vision and the will to work toward the goal. Kouzes and Posner (2012) noted that such leaders may be ordinary people who accomplish extraordinary results by being role models, being examples, and leading by behavior that authentically reflects the behaviors expected of and admired by others. INSPIRATION AND VISION Transformational leaders also create a compelling vision of a desired future. Kouzes and Posner (2007, p. 17) explained, “Every organization, every social movement, begins with a dream. The dream or vision is the force that invents the future.” Thompson (2019) outlined how successful leaders create a shared vision: Be clear about the desired destination, dream big, communicate a strong purpose, and set strategic goals. Transformational leaders influence others by high expectations with a sight toward the desired future. They set standards and instill others with optimism, a sense of meaning, and commitment to a dream, goal, or cause. They extend a sense of purpose and purposeful meaning that provides the energy to achieve goals. They inspire from a foundation of truth. INTELLECTUAL STIMULATION The transformational leader is a broadly educated, well-informed individual who looks at old problems in new ways. He or she challenges boundaries, promotes creativity, and applies a range of disciplines, ideas, and approaches to find solutions. This involves fearlessness and risk-taking. The transformational leader in healthcare reads broadly, takes lessons from many disciplines beyond clinical practice, and engages as an interested citizen in public discourse on a full range of topics. Such a leader may find strategies from the arts and literature, humanities, business, or other sciences. He or she consults experts from a variety of fields and settings to weigh in on complex problems faced by the organization. Such leaders ask questions. Asking questions about problems, large and small, allows leaders to understand the landscape in which the 18 • I: CONTEXTS FOR TRANSFORMATIONAL LEADERSHIP problem “lives,” and they can pull together teams to work on the problem and encourage, expect, and nurture independent and critical thinking. The transformational leader assumes that people are willing and eager to learn and test new ideas. INDIVIDUAL CONSIDERATION The transformational leader has a kind of humility that looks beyond self to the mission of the organization and the value of the work of others as individuals. He or she uses many professional skills including listening, coaching, empathy, support, and recognition of the contributions of followers. The transformational leader enables others to act toward a shared vision. The effective leader recognizes and promotes the contributions of others and creates a culture of sharing, celebration, and unity within the entire team. Who gets the credit is less important than how team members affirm each other’s work. Transformational leaders effectively build on these characteristics and integrate principles from a variety of leadership theories and pragmatic approaches to advance, enhance, and expand clinical expertise from a focus on direct individual patient care to a focus on the care of groups, aggregates, and entire populations in a variety of environments. They consider the individual and the aggregate at once. Recently, in addition to a plethora of reviews about transformational leadership and leadership in general, there have been some studies on how leaders in nursing demonstrate transformative leadership and influence followers. Fischer (2016) found transformational leadership in nursing to include “high-performing teams and improved patient care,” but it is not considered to be a set of skills or competencies that can be taught. Masood and Afsar (2017) found a relationship between transformational leadership and innovative work behavior when combined with knowledge sharing of best practices and mistakes. Lin, Maclennan, Hunt, and Cox (2015) identified a relationship between transformational leadership and nurse job satisfaction and organizational commitment. Yet, we know little beyond the description of actions of such leaders (Broome, 2013; Disch, 2017a; Disch, Edwardson, & Adwan, 2004; Giddens, 2018). Hutchinson and Jackson (2013) confirmed that there is little applicable research or critical review of transformational leadership in nursing literature. We still know little about how transformational leadership works, or what it ultimately means to followers and patients. Such research and role models must emerge from the next generation of leaders. It is your job to envision and articulate the prototypes for transformational leadership in healthcare for the future or to test their effectiveness. The transformational leader must make a conscious decision to lead. Often, competent nurses are given opportunities to supervise or manage, but successful leaders choose to lead. And some individuals find they learn a great deal very quickly and go on to build on that experience and become transformational leaders, while others find the emotional costs and 1: FRAMEWORKS FOR BECOMING A TRANSFORMATIONAL LEADER • 19 BOX 1.1 LEADERSHIP IN ACTION: PERSONAL REFLECTION ON LEADERSHIP Elaine Sorensen Marshall, PhD, RN, FAAN I remember the first “official” day I was required to be a leader. I had been out of nursing school for less than a year, working at a job I loved as a staff nurse on a medical–surgical unit in a large flagship hospital. The nurse manager, then referred to as the team leader, called in sick. One by one, calls to all the other usual suspects to take her place were in vain. The house supervisor came to me and said, “You are it today. You are in charge. I will be available if you need anything.” I was left in charge of a unit staff of one other registered nurse, two practical nurses with more bedside experience than I had in years of life, two nursing assistants, and 22 very sick patients. My heart raced simultaneously with the surge of excitement and panic. I will not violate privacy regulations here to tell you all the near-death adventures that day, but I can say that it was probably not the ideal first step on a path toward transformational leadership. I did learn, almost immediately, what worked and what did not work to inspire or influence others. Eventually, over a lifetime, I gained knowledge, insight, and experience as a transformational leader, but I always return to that summer day when I learned the “sink or swim” theory of leadership. I learned that my heart was in the right place, that I wanted to care for others, that I had some innate abilities to influence others for good, that I was a natural goal setter, that I had fairly good judgment in making decisions, and that others trusted me. But I had no specific knowledge of how to lead, no preparation for leadership, no coach or mentor, little confidence, and not much insight on organization of resources to meet what came next. I knew only that I was in a situation that needed a leader, and on that day, I was recruited and stepped up to it. Since that day, I have had the benefit of advanced education, professional leadership training, and years of experience in academic leadership. I have led teams in private and public settings as well as a large academic health center. My joy has been to help others to grow and watch them flourish. BOX 1.2 LEADERSHIP IN ACTION: PERSONAL REFLECTION ON LEADERSHIP Marion E. Broome, PhD, RN, FAAN I spent my early career learning how to be a competent nurse, then nursing educator, and then nurse researcher—always focused on improving the care of children and their families. Twelve years after I graduated with my BSN, and 2 years after completing my PhD, I assumed my first administrative role, as an associate dean for research. For the first time in my nursing career I found myself on the (continued) 20 • I: CONTEXTS FOR TRANSFORMATIONAL LEADERSHIP BOX 1.2 LEADERSHIP IN ACTION: PERSONAL REFLECTION ON LEADERSHIP (continued ) “side” of hearing the complaints, issues, and needs of nurses in the organization, in this case related to support for faculty research development. I must admit I was not entirely prepared for the responsibility of “fixing the problems” the faculty brought to me. However, once I began to reframe the issues—as problems to be solved, systems to be put in place so faculty could be successful—and honed my listening skills to focus intently on what a person was really asking for, my enthusiasm for the job increased. I began to see myself as a problem solver and someone who needed to have a vision for how things could be. To my amazement, I enjoyed solving problems, and I enjoyed thinking about how to make the systems we had in place work better. I also learned quickly that while you could tell others their issue was solved, it was not until they actually worked with the office (to submit a grant, to develop an institutional review board [IRB] proposal, or to hire personnel), and things went smoothly, that they became true believers. It seemed so easy (and fun). For me, the real satisfaction of leadership was seeing others be able to achieve their goals with the least amount of hassle and the most amount of perceived support. Then they could dream bigger and better and move the whole organization ahead! time investment of leadership not to be congruent with where they see themselves making a contribution. In Boxes 1.1 and 1.2 we share our personal leadership stories. MANAGEMENT AND LEADERSHIP: IS THERE REALLY A DIFFERENCE? In their zeal to promote charismatic transformational leadership, some writers make unfortunate distinctions between managers and leaders, as though managers are undesirable, and leaders are more effective across all situations. Jennings, Scalzi, Rodgers, and Keane (2007) reviewed the literature to find a growing lack of discrimination between nursing leadership and management competencies. Traditionally, managers are thought to control and maintain processes with a focus on the short term, relying on authority rather than influence, while leaders are visionary, insightful, and influential. Managers minimize risk, and leaders maximize opportunity. In reality, most leaders will tell you it is important to know enough about processes in one’s organization to be able to decide what new directions to take and how to assess the efficiencies of a unit to preserve or redirect resources. It is likely a matter of balance between the two sets of competencies of manager or leader that is crucial to master. 1: FRAMEWORKS FOR BECOMING A TRANSFORMATIONAL LEADER • 21 Transformational leadership theorists refer to the manager style as transactional leadership (Bass et al., 2010). Transactional leaders primarily motivate others by systems of rewards and punishments. Their power lies largely in the authority of their position. A manager may be referred to as the “laissez-faire” supervisor who provides little direction or motivation for change, leaving most decision-making to the followers. Transformational leaders, on the other hand, develop, innovate, focus on developing others, inspire and create trust, and hold a long-term, big-picture, futuristic view. The reality is that anyone in charge of a group of people working toward effective goal achievement needs the wisdom to develop and use the qualities of both manager and leader in different situations. Williamson (2017, p. 4) asserted that “nurses are called to leadership” regardless of the position title of leader or manager. Thus, the terms manager and leader may be used interchangeably, as appropriate, in this book, not for lack of precision, but with the view that the characteristics of each are needed in effective leadership. Effective leaders (and managers) rely on a broad repertoire of style, rather than specialization of techniques. And neither should rely on their position to motivate or reward others. You must be able to distinguish when incentive/punishment motivation is needed versus when charismatic inspiration will achieve the desired results, or even when “well enough” is left alone. The next generation of leaders will be required to blend techniques of artistic management and wise leadership, all “on the run,” in a rapidly changing healthcare environment (Bolman & Deal, 2013). Indeed, early studies of military platoons in combat (the ultimate fast-paced and stressful environment) showed both transformational and transactional leadership to be positively related to group cohesion and performance (Bass et al., 2003). Researchers have compared the effects of transformational leadership with other leadership styles and have found high correlations among all styles with organizational outcomes, employee satisfaction, and change management (Fischer, 2016; Lin et al., 2015; Molero, Cuadrado, Navas, & Morales, 2007), confirming the idea that a variety of leadership styles and approaches can be effective in differing roles and circumstances (Burke, 2017). ROLE OF THE DNP IN ORGANIZATIONAL AND COMPLEX SYSTEMS LEADERSHIP You have taken a step toward assuming leadership for the profession by pursuing the DNP degree. From the beginning of the development of the degree, leadership development has been a high priority (Lenz, 2005). Indeed, the need for leaders prepared in advanced clinical practice was a precipitating factor in the earliest discussions of the DNP. Since the inception of the DNP, leadership roles have been studied and promoted as essential to healthcare practice and education (see Gosselin, Dalton, & Penne, 2015; Malloch, 2017; Morgan & Tarbi, 22 • I: CONTEXTS FOR TRANSFORMATIONAL LEADERSHIP 2016; Smith, Hallowell, & Lloyd-Fitzgerald, 2018; Tyczkowski & Reilly, 2017; Walker & Polancich, 2015; ). Broome (2012) proposed that doctorally prepared nurses will bring unique expertise to several areas, including innovative educational approaches, patient management knowledge and expertise, theoretical expertise, research methods expertise (both qualitative and quantitative), statistical and analytical expertise, and political awareness. They will also open doors to new roles and positions to gain entry to care for specific patient populations at the highest levels. When leaders in nursing education developed DNP programs in the early part of the 21st century, we joined other practice disciplines, such as medicine, optometry, pharmacy, physical therapy, and audiology, which had elevated their practices and leadership by preparing practitioners with the highest professional academic degree. The American Association of Colleges of Nursing (2004, 2015) affirmed the fundamental need for DNP-prepared leaders, noting that “the knowledge required to provide leadership in the discipline of nursing is so complex and rapidly changing that additional or doctoral level education was needed.” One of the competencies listed in the Essentials of Doctoral Education for Advanced Nursing Practice (DNP Essentials) (American Association of Colleges of Nursing, 2006, p. 10) is “Organizational and systems leadership for quality improvement and systems thinking.” Specifically, DNP graduates should be prepared to: • Develop and evaluate care delivery approaches that meet the current and future needs of patient populations based on scientific findings in nursing and other clinical sciences, as well as organizational, political, and economic sciences. • Ensure accountability for the quality of healthcare and patient safety for populations with whom they work. • Use advanced communication skills/processes to lead quality improvement and patient safety initiatives in healthcare systems. • Employ principles of business, finance, economics, and health policy to develop and implement effective plans for practice-level and/or system-wide practice initiatives that will improve the quality of care delivery. • Develop and/or monitor budgets for practice initiatives. • Analyze the cost-effectiveness of practice initiatives accounting for risk and improvement of healthcare outcomes. • Demonstrate sensitivity to diverse organizational cultures and populations, including patients and providers. • Develop and/or evaluate effective strategies for managing the ethical dilemmas inherent in patient care, the healthcare organization, and research. (American Association of Colleges of Nursing [AACN], 2006, pp. 10–11) 1: FRAMEWORKS FOR BECOMING A TRANSFORMATIONAL LEADER • 23 Although early in its development, the DNP was met with controversy within the discipline of nursing (see Chase & Pruitt, 2006; Dracup, Cronenwett, Meleis, & Benner, 2005; Joachim, 2008; Otterness, 2006; Webber, 2008). Some leaders proclaimed that “the question facing the nursing community is no longer whether the practice doctorate is ‘future or fringe’” (Marion et al., 2003), but rather how do we move forward together (O’Sullivan, Carter, Marion, Pohl, & Werner, 2005). As of 2017, there were 135 PhD programs in nursing with enrollment of 4,698 (AACN, 2017). As of 2018, there were 348 DNP programs with enrollment of 32,678 (AACN, 2018). Clearly, the DNP degree has been embraced by many nurses in practice who want to take their careers as practitioners to a new level and provide leadership and expertise to shape care delivery. Clearly, new models of care are needed, designed by nurses prepared at the highest levels of practice and education (see Mason, Martsolf, Sloan, Villarruel, & Sullivan, 2019). Graduates of DNP programs are fulfilling the hope for a new, more effective advanced practitioner and healthcare leader. Taken together, the complexity of healthcare systems, emphasis on ­evidence-based practice and information management to improve patient outcomes, information explosions in science, advances in technology, and a new world of ethical issues only amplify the need for new leadership grounded in expert clinical practice. It is the hope of the profession that the DNP-prepared leader will offer the highest level of practice expertise and have the skills to translate knowledge into evidence, as well as practice-based evidence into better outcomes for patients and families (Zaccagnini & White, 2017). As a DNP-prepared leader, you will be expected to guide and inspire organizational systems, quality improvement, systems and analytical evaluations, and policy development and translation, and to forge intra- and interdisciplinary collaborations to improve patient health outcomes (Broome, 2012). Much of this important work is done in context and collaboration with interprofessional teams. We elaborate more on this later, but at the outset of considering yourself a leader, it is critical to understand the style, dynamics, and climate of interpro­ fessional collaboration (Agreli, Peduzzi, & Bailey, 2017; Disch, 2017b) and teambased care. Prepared at the highest level of practice, you will understand the broad perspective of resource management in a sociopolitical environment to influence policy decisions and use your influence to lead teams to develop and test new care models. There is every reason to hope that you will be able to invent systems of care yet unknown that will strengthen, correct, and transform healthcare systems as we know them today. You will work with teams from various disciplines and various levels of preparation and backgrounds even in nursing. The success of teamwork is the goal and responsibility of the transformational leader. Transformational leaders in nursing include those with preparation at a variety of levels. 24 • I: CONTEXTS FOR TRANSFORMATIONAL LEADERSHIP ROLE OF THE PhD-PREPARED NURSE IN PRACTICE AND LEADERSHIP Many hospitals throughout the United States, especially those in academic health centers, employ nurses prepared with the Doctor of Philosophy (PhD) degree to lead various sectors of the enterprise, including education, professional development, and research. PhD-prepared nurses are also most commonly employed in academic institutions. You might ask, “What is the difference between the two degrees and their preparation? How will we work together?” The PhD is not a professional degree but rather the highest research-focused academic degree given across a variety of disciplines. The PhD program and degree require the student to understand the philosophy of science and the nature of knowledge, and to master, extend, and generate knowledge for the discipline through research. PhD programs provide graduates with an understanding of the environment within which nurses practice and prepare graduates to advance the science of the discipline (Broome & Fairman, 2018). The core of the PhD program is an understanding of nursing and the development of competencies to expand science that supports the discipline and practice of nursing (AACN, 2010). Since the mid-1990s, hospitals and health systems have employed nurse scientists to engage in the development and testing of interventions designed to impro…


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