for a patient by communicating important information, writing a letter to a member of the state legislature regarding legislation that negatively impacts patient care, alerting a supervisor about a concern that may adversely affect patient safety, or serving as a preceptor for a newly hired nurse. These opportunities for leadership are all important, regardless of work location or specialty.
The impact of leadership in nursing can be far-reaching by influencing change in practice and improving patient outcomes. Initiating change at the bedside can be accomplished in a variety of ways such as advocating for important issues and inspiring fellow nurses through role modeling, idea sharing, and mentoring. It is important to remember that leaders do not have to be in management roles to lead others. For example,   between nursing management and bedside nurses, also known as  , can provide opportunities to produce positive change at the bedside. Effective leaders can promote quality care in many settings. Kouzes and Posner (2017) researched specific practices and commitments of exemplary leaders that, when applied, assist the   to inspire  and motivate others.
Table 5.1
Practices and Commitments of Exemplary Leaders

Five Practices

Ten Commitments

Model the Way

1. Clarify values by finding your voice and affirming shared ideals.
2. Set the example by aligning actions with shared values.

Inspire a Shared Vision

3. Envision the future by imagining exiting and ennobling possibilities.
4. Enlist others in a common vision by appealing to shared aspirations.

Challenge the Process

5. Search for opportunities by seizing the initiative and by looking outward for innovative ways to improve.
6. Experiment and take risks by constantly generating small wins and learning from experiences.

Enable Others to Act

7. Foster collaboration by building trust and facilitating relationships.
8. Strengthen others by increasing self-determination and developing competence.

Encourage the Heart

9. Recognize contributions by showing appreciation for individual excellence.
10. Celebrate the values and victories by creating a spirit of community.

Note. Adapted from  The Leadership Challenge (6th ed.), by J. M. Kouzes & B. Z. Posner, Hoboken, NJ: John Wiley & Sons, Inc. 2017.
Real-Life Leadership Experiences
Leadership means thinking outside of the silo of day-to-day work. By looking at a broader picture of health and identifying areas that need improvement, I can then establish ways to meet those needs by utilizing available resources. Leadership is about finding passion and purpose in your own life and incorporating that into advocating for others.
Amberlee Kendrick ADN, RN
Staff Nurse
Joplin, MO
Nurses play a critical role in health care, health policy, and society at large. In my 36 years as a nurse, I have seen this role grow in traditional health care settings, holistic community care, and beyond. Nurses are leaders in health care through the various characteristics they possess, and there are many characteristics intertwined in making one a competent leader. Leaders communicate and listen, all the while advocating for the needs of others. One of the many components to be a leader is knowledge through education. Knowledge is a powerful asset and allows nurses the ability to communicate, educate, and advocate in order to problem solve for physical, emotional, and spiritual needs. Having knowledge assists the nurse to utilize the skills that she/he has learned to communicate, educate, and advocate for all individuals, community, and society, both locally and globally.
Lynne Chamallas MSN, RN
Department of Health and Human Services
Somerville, MA
Challenges/Barriers to Improving Practice
Challenges and barriers to improving practice are multifactorial. With any change there is a significant amount of apprehension and fear amongst staff. People become comfortable and set in their ways, and it can be difficult to persuade them that another way may work just as well, if not better. Leadership should take this knowledge and help foster a sense of reassurance and comfort in their employees. They should provide statistical data related to the proposed changes and their impact on patient outcomes, allowing the employees to see tangible reasoning for instituting change. Leadership should also be available for questions, concerns, feedback, and guidance and be willing to use feedback to make further alterations when needed. Additionally, leaders should consistently exemplify positive attitudes and model the behaviors they want to see blossom in their staff (Kouzes & Posner, 2017).
Check for Understanding
1. What ways can nurses impact the health care system to create positive change?
2. What leadership activities can you identify in your day-to-day practice as a nurse?

Making an Impact
Nurses such as Florence Nightingale, Clara Barton, and Lillian Wald are well known for their impact on the nursing and health care professions. They are considered nursing leaders and have made a long-lasting impact on society. Nurses today may wonder, “How can leadership be exhibited in daily practice?” Consider the examples of Mary Pappas and Roxana Reyna and the impact they have made as nurse leaders:
· Mary Pappas, BSN, RN, was the diligent school nurse who notified public health officials of the swine flu outbreak at the St. Francis Preparatory School in Queens, NY. Her quick assessment and surveillance of illness presented at her office allowed for quicker public health response by the Centers for Disease Control and Prevention (Gaskell, 2009).
· Roxana Reyna MSN, RN, FNP came up with a creative solution to promote healing for neonatal omphalocele patients by creating specialized wound dressings. These dressings improved healing to allow earlier surgical intervention for repair (Reyna, 2018).
Through informed decision making and internal motivation, these nurses were able to create positive change in health care.
Empower Each Other
Successful leadership has been associated with job satisfaction and retention (Mosadeghrad & Ferdosi, 2013). When employees feel supported and cared for, they are more likely to feel valued and have a desire to stay in their position (Mosadeghrad & Ferdosi, 2013). Just as the values and behaviors of organizations originate with its leadership, influential leaders can be relied upon for their professional responsibility and accountability (Azaare & Grosse, 2011). Successful leadership and   are interconnected; a successful leader must learn self-reflection, accept feedback, and make necessary changes in order to be an effective leader. Conscious awareness of personal values, goals, motivations, and skills through self-awareness enables leaders to develop self-regulating and role-modeling behaviors (Mosadeghrad & Ferdosi, 2013). This awareness helps the leader become more relatable and encourages staff to exhibit positive attributes and strive for improvement.
Opportunities to inspire fellow nurses as a role model, preceptor, or mentor occur frequently in nursing.   is an intentional, long-term relationship between and expert and novice nurse. This kind of relationship can often inspire the novice nurse to support and encourage other novice nurses as they advance in their nursing career. The educational component of mentoring can include empowering opportunities in the form of listening and empathizing, which can be of great benefit to both the mentor and mentee. Mensik (2017) stated that it is important to ask for a preceptor and seek out a mentor to help navigate the politics of complex, multilevel organizations.
There are many benefits when nurses encourage each other in the professional nursing environment, including creating a positive and collaborative environment that leads to improved patient care and positive patient outcomes. Additionally, the fostering of such a work environment can lead to staff contentment and job retention. Encouragement and positive work relationships make going to work much more enjoyable for employees, and everyone benefits from having happy employees regardless of the work environment (Drake, 2017).
Motivated coworkers are often goal-driven regardless of obstacles. While individuals often have unique internal motivations, the creation of a cohesive unit motivation is essential to provide excellent patient care. While one individual nurse may be motivated to provide excellent discharge education, it behooves the patient more if the unit as a whole is motivated to improve patient discharge education. Resources and interdisciplinary staff can be involved in making improvements to patient education, making it a collaborative effort to improve patient care and outcomes (Drake, 2017).
Clark (2018) stated that employees want meaningful work that matters to them, personally, societally, and organizationally—registered nurses are no different. When the nursing staff feels supported by leadership, encouraged by colleagues, and motivated by the collaborative efforts of everyone caring for patients, they find meaning in their work.
The following steps can be used by nurse leaders to empower  their fellow nurses:
· Lead with optimism.
· Create a positive and healthy work environment.
· Be visible and available to others.
· Foster interpersonal and organizational trust.
· Cultivate relationships with others.
· Set goals and provide feedback when necessary.
· Produce meaningful work.
· Encourage autonomy and individual growth.
· Communicate and be transparent.
· Use powerful but simple strategies to keep others engaged (Clark, 2018).
Real-Life Leadership Experiences
After two years of being a school nurse, I had the opportunity to move into the current school nurse leader role I am in. I was hesitant to take this new position, as I had only been in school nursing for two years, but I was excited at the same time. Accepting the leadership position with colleagues I had worked alongside for two years was also a bit intimidating. I was concerned about how to maintain professional relationships and also be their supervisor. Concerns of acceptance and being taken seriously as their leader were daunting.
I decided I wanted to be the best leader I could be as well as ensure that our nursing staff felt well supported. I focused my efforts on knowing our district policies from the start. This would be beneficial in ensuring that our nursing staff was providing health care services in accordance with the district policies, as well giving the nursing staff the foundation they needed to feel comfortable in their setting. School nursing is a specialty area of nursing, and most nurses who come to school nursing feel more comfortable knowing their boundaries.
Data retrieval is also important for the school nurse leader to utilize within daily practice. Data collection offered the avenue to achieve important goals for our department. As the nurse leader, I collected data and presented it to our school board, which provided our department with additional staff, the development of our electronic health record (EHR), and positive outcomes for other department initiatives that have been developed over the years.
As a nurse leader, I think it is important to be a servant leader. Helping staff with professional development is essential. School nurses have a tremendous knowledge base. Placing them in a position to teach others what they know provides them a sense of leadership and further supports the district and department goals. We have many school nurses who are effective leaders, and they should be recognized for their knowledge and expertise.
Dana Fifer BSN, RN
School District Nursing Supervisor
North Kansas City, MO
I think nurses are leaders whenever they do what is right. We are leaders every day, every time we act with integrity. We come across people when they are their most vulnerable, and we help them cope rather than take advantage of them. We teach them to be their own advocates. I think of all the teachable moments we have as nurses: wound care, medication knowledge, good health habits, and safety. Then, we are lucky enough to orient or mentor a new nurse or have a student shadow us—leadership!
Peggy Karleskint BSN, RN
St. Louis MO
Leadership Competencies
Nurses are life-long learners. As nurses continue to learn throughout their careers, they simultaneously gain valuable leadership skills. Leaders cannot be effective without acknowledging the need for continued development along the course of their professional career. The American Nurses Association (ANA) believes that leadership is an integral part of the nursing profession and supports the development of leadership competencies, also known as a competency model framework, to advance to the next level of leadership. The competency model embraces the idea that competency should be evaluated individually by self-assessment, nurse peers, and those in formal leadership roles such as a nurse manager. Competencies assessed include flexibility, creativity, leadership, organization, and ethics, all of which are crucial elements to being a leader, whether in a clinical role or leadership role (Kevas, Seljak, & Stare, 2013). The Leadership Institute offers a professionally developed, evidence-based curriculum for nurses who wish to advance their leadership skills. The leadership curriculum emerged from foundational components of the nursing profession, including the ANA and the scope and standards of practice for nursing. The three domains included in the program include leading yourself, leading others, and leading the organization. These domains include competencies created by the ANA that are specific for advancing nurse leadership (American Nurses Association, 2018). Competencies can be evaluated subjectively through self-assessment; by professional colleagues, such as nurse managers or supervisors, mentors, preceptors, and co-workers; and objectively with tools developed to measure the nurse’s knowledge base. Table 5.2 shows the competencies needed for nurses to lead in the identified domains.
Table 5.2
ANA’s Nurse Leader Competencies and Domains

Leading Yourself

Leading Others

Leading the Organization



Business Acumen

Executive Image

Conflict Management

Change Management



Decision Making


Employee Development


Learning Capacity


Problem Solving


Systems Thinking

Vision and Strategy

Project Management

Note. Adapted from “ANA Leadership: Competency Model,” by the American Nurses Association, 2018, p. 6.
Advancing leadership skills are important because nurses are currently under-represented in leadership positions. Cook and Glass (2014) stated that women in particular are under-represented in top leadership positions, leading to the notion that a glass ceiling exists and poses an invisible barrier for women. Nurses should not be waiting to be placed in positions of leadership based on gender because, as a discipline, nurses are already leaders in their own right. Advancing leadership skills ensures that nurses can better advocate for patients, be better decision makers, and contribute to the legislative process.
Check for Understanding
1. In what ways do you motivate and inspire others?
2. What motivating goals and desires do you possess as a leader?
3. Are you self-aware of your own moral values, emotions, strengths, and weaknesses?
Be a Leader for the Future
As a leader for the future, it is every nurse’s professional responsibility to be aware of the Robert Wood Johnson Foundation and the Institute of Medicine’s 2010 response to the need to transform the nursing profession. The  Future of Nursing: Leading Change, Advancing Health report identified a call for nurses to lead, stating that “nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States” (Institute of Medicine [IOM], 2010, p. 221). The report (IOM, 2010) explains why nursing leadership is necessary:
Strong leadership is critical if the vision of a transformed health care system is to be realized. Yet not all nurses begin their career with thoughts of becoming a leader. The nursing profession must produce leaders throughout the health care system, from the bedside to the boardroom, who can serve as full partners with other health professionals and be accountable for their own contributions to delivering high-quality care while working collaboratively with leaders from other health professions. (p. 221)
Reflective Summary
Every nurse, regardless of role in the health care system, is a leader. Nurses have an essential role in health care and should understand the value of their contributions to patients and the health care system. Nurses should be initiating change in professional culture to acknowledge the impact of nursing leadership through contributions each day caring and advocating for patients. Successful leadership is impacted by the ability to be self-aware and have control over interactions with others. Advancing leadership skills is important to be better patient advocates, decision makers, and change agents.
Key Terms
Advocacy: The action of supporting or pleading for a cause or proposal.
Collaboration: Two or more people working together toward a common goal; in a health care setting, this work is meant to provide safe, quality care to patients in a nonthreatening environment.
Nurse Leader: Nurses who develop trusting relationships with colleagues, foster accountability, take action to improve their own nursing practice, and encourage others to improve their own nursing practice.
Mentorship: An intentional, long-term relationship between a nurse, who is considered an expert in the field, and a novice nurse desiring expert status.
Self-Awareness: Understanding one’s self by recognizing strengths and weaknesses, moral values, thought processes, character, emotions, motivations, desires, and goals.
Shared Governance: A partnership between bedside nurses and nursing managers and leaders that involves decision making and empowers nurses by giving them a voice.
American Nurses Association. (2018). ANA leadership: Competency model. Retrieved from
Azaare, J., & Grosse, J. (2011). The nature of leadership style in nursing management.  British Journal of Nursing,  20(11). doi: 10.12968/bjon.2011.20.11.672
Clark, C. (2018). 10 tips to boost employee engagement.  American Nurse Today,  13(1), 12-14. Retrieved from
Cook, A., & Glass, C. (2014). Women and top leadership positions: Towards an Institutional Analysis.  Gender, Work and Organization,  21(1), 91-103. doi: 10.1111/gwao.12018
Drake, K. (2017). The motivation to stay motivated.  Nursing Management 48(12), 56. doi: 10.1097/01.NUMA.0000526921.77464.16
Gaskell, S. (2009). Mary Pappas is a true flu hero: School nurse spotted first swine flu case in New York.  New York Daily News. Retrieved from
Institute of Medicine. (2010).  The future of nursing: Leading change, advancing health. Retrieved from
Kouzes, J. M., & Posner, B. Z. (2017).  The leadership challenge (6th ed.). Hoboken, NJ: John Wiley & Sons, Inc.
Kevas, A., Seljak, J., & Stare, J. (2013). The use of competency models to assess leadership in nursing.  Iranian Journal of Public Health,  42(9), 988–995.
Mensik, J. (2017).  Lead, drive & thrive in the system. Silver Spring, MD: American Nurses Association.
Mosadeghrad, A. M., & Ferdosi, M. (2013). Leadership, job satisfaction and organizational commitment in healthcare sector: Proposing and testing a model.  Materia Socio-Medica,  25(2), 121–126. doi: 10.5455/msm.2013.25.121-126
Reyna, R. (2018). “I’ve always considered myself a ’MacGyver’ nurse”: how one woman is propelling healthcare forward. Retrieved from


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