THE CALL to advance leadership capacity and competence in nursing has never been louder or more urgent than it is today.1-4 The Future of Nursing Report notes,
Although the public is not used to viewing nurses as leaders, and not all nurses begin their career with thoughts of becoming a leader, all nurses must be leaders in the design, implementation, and evaluation of, as well as advocacy for, the ongoing reforms to the system that will be needed. Additionally, nurses will need leadership skills and competencies to act as full partners with physicians and other health professionals in redesign and reform efforts across the health care system.1(p221)
To address this call for increasing nursing's leadership contribution in health care, the profession must evaluate current strategies in both education and practice. While many new graduates dream of becoming a nurse practitioner or nurse anesthetist, few transition into practice with the goal of becoming a nurse leader.
To increase the number of nurses capable of leadership, the profession must address 2 critical issues. First, effort must be made to augment faculty and students' conceptualization of nursing such that leadership is seen as a dimension of practice for all nurses, not just those in formal leadership roles. In so doing, leadership identity development would be seen as a part of becoming an expert nurse. A good deal of nursing literature on leadership is devoted to leader development rather than leadership development.5-7
While administrative leaders are needed, so are informal and formal leaders at every level and department. Without embracing leadership as a collective action and the redistribution of authority throughout the organization, healthcare delivery will remain burdened by adverse events and randomized care.8(p86)
If nurses are to make an impact on the advancement of patient care and the promotion of patient safety, then leadership must be considered an integral dimension of nursing education across the continuum.
Second, a comprehensive conceptual framework for lifelong leadership development of nurses needs to be designed. This framework should allow for baseline leadership capacity building in all nurses and advanced leadership development for those in formal administrative and advanced practice roles. Defining what leadership knowledge and skills are essential for nurses across the educational continuum is a critical priority for nursing.9 The knowledge and skill requirements for quality improvement and patient safety have been explored and recommendations made for Quality and Safety Education for Nurses, but parallel work needs to be done to outline educational content, objectives, and effective pedagogy for advancing leadership development in nursing students at all levels.10
EVERY NURSE A LEADER
Readying an adequate leader workforce in nursing first requires acknowledging that "all nurses must be leaders, but they certainly do not need to choose management to make a critical, positive difference in our world."11(p6) Modern, postindustrial leadership theory focuses on leadership development as an "integration strategy" promoting collaboration, communication, and achievement of common goals.12,13 In the new Knowledge Age, leadership development must be designed to foster competent leaders in formal roles and must translate leadership knowledge and skills in a way that followers can also use.14 In the Industrial Age, the leader might possess full knowledge of the processes and structures within the organization where they were employed; however, the Knowledge Age requires that leaders access the knowledge, creativity, and participation of the followership if goals are to be accomplished.15
Developing leadership aptitude in all nurses is an ambitious task-one that challenges both academic programs and health care systems. Despite an international call for embracing leadership as a central component of nursing practice, the discipline suffers from ambivalent definitions of leadership, disciplinary confusion about management versus leadership, and a lack of evidence-based strategies for teaching leadership.16,17 The most prevalent evidence of the need to make leadership education a priority is found in the international call for clinical leadership. Clinical leadership is a direct response to the complexity of managing patient care across organizations, within economic constraints, and in a manner that promotes continuous improvement and patient safety. Clinical leadership has been characterized as having 5 dimensions: clinical expertise, effective communication, collaboration, coordination, and interpersonal understanding.18 At minimum, all nurses should be equipped with these core competencies. In contrast, nurses entering leader roles need this foundation of skills but they must also develop proficiency in creating a shared vision, organizing, delivering, and evaluating patient care systems, advancing clinical excellence, demonstrating strategic and financial acumen, thinking wisely, and maximizing managerial effectiveness and efficiency.5,9,19,20 The call for leadership education for all nurses is an old call, but one that must receive increasing attention if the preferred future for nursing is to be realized.21,22
Current realities in nursing require the use of collective wisdom to innovate, promote patient safety, improve quality, and reduce cost. Tapping collective wisdom requires leadership that is relational and shared.23 Emergent literature stresses leadership as participative with terms such as "shared leadership" and "collective leadership."24 In contrast, most nursing literature stresses leadership as a role.
Thus, essential to expanding nursing's leadership capacity is the adoption of the philosophy that leading is a relational process that can be learned and that the leadership process is a critical dimension of practice for all nurses. Second, nursing must adopt a perspective that supports collective leadership capacity building. Leadership is a set of knowledge, skills, and attitudes that can be used by anyone to accomplish goals and connect effort. Moving to adopt leadership in nursing as both a process and a role promotes the potential for development of leadership competency and capacity in all nurses, not just those who take on administrative functions in organizations and groups. As more nurses perceive themselves as being able to lead, more will be inspired to become leaders in formal roles as well.
LEADERSHIP DEVELOPMENT FRAMEWORK
Expanding leadership development in nursing requires designing a comprehensive framework upon which education, research, and practice can be developed. No consistent definition of leadership in nursing exists, nor does a consistent framework for nursing leadership education.22 The new documents on baccalaureate and master's essentials support the development of leadership competencies in all nurses. In the baccalaureate essentials, a need for "knowledge and skills in leadership, quality improvement, and patient safety" necessary for the provision of high-quality health care is required.2 Another essential stresses communication and collaboration, 2 core leadership competencies. In addition, of the 6 outcome expectations for master's prepared nurses, 2 contain the word "lead" and most imply the use of leadership knowledge, skills, and attitudes.3 Yet, no comprehensive category of the knowledge and skills for leadership education has been developed.
In 2005, the leadership education model was developed with 6 modules: leader as achiever, communicator, critical thinker, expert, mentor, and visionary.22 This model was framed using general systems theory and took an approach that leadership knowledge and skills were developed over time and occurred at varied levels in nurses. While dimensions of this model are relevant for all nurses, its intent was the development of formal nurse leaders. Models have been proposed both for RN-BSN programs and for doctoral programs,7,25 and there are multiple frameworks for developing nurse leaders in practice.6,26
In contrast to the efforts in the United States, the National Health Services has designed a comprehensive framework for both leadership and clinical leadership competency.27 Both of these models are generalized across health care disciplines and are not unique to nursing. Nova Scotia addressed the call for leadership as an attribute of all nurses in 2006. The concept of leadership, as defined by the College of Registered Nurses of Nova Scotia, is:
being involved, open to new ideas, having the confidence in your own capabilities and a willingness to guide and motivate others. Leadership is action, not a position and is not limited to formal leadership roles. Leaders have influence through their position, behavior, experience, knowledge and development. Nursing leadership at all levels in an organization and in all areas of practice is essential to the provision of safe, effective and ethical nursing practice and maintenance of public trust.28
The Nova Scotia model has 6 core leadership competencies and is modeled after the National Health Services framework.
LIFELONG LEADERSHIP DEVELOPMENT
Leadership ability develops across the life span of an individual and can occur at varied intervals in one's life.29 Leadership development can be the result of "life span trigger events" or from intentional efforts to mobilize leadership potential.30 While leadership knowledge and skills can be taught in educational venues, leadership aptitude varies by individual and is influenced by parental style, exposure to leadership training and roles, and educational and work experiences.30,31
Leadership identity development
The optimal time for learning to lead is from early childhood through young adulthood when the self-concept is being developed.30 As the self-concept evolves, individuals try on and ultimately integrate multiple identities. For example, a person may perceive him- or herself as a good student, a good athlete, a sibling, and a basketball team leader. Identity development moves to the forefront in late adolescence and young adulthood, making the educational journey of future nurses an optimal time to focus on the expansion of future leaders.32 Leadership identity, perceiving oneself as having the capacity to lead, is a precursor to being motivated to learn to lead.33 And, individuals who perceive themselves as leaders are motivated to seek experiences that allow them to practice leadership skills and behaviors.34 Komives et al35 studied leadership identity development in college students and found varying levels of leadership capacity in students ranging from simple awareness of the concept to total integration and synthesis of leadership in their identities. This longitudinal study confirms that students' leadership identities develop over time.
Hannah36 designed a leadership emergence developmental model that highlights the components that influence whether or not a person identifies him- or herself as able to lead (Figure). In the Hannah model, developmental readiness is conceptualized as having "the self-regulation, motivation, goal orientation and efficacy necessary for emerging adults to approach leadership roles."30(p187)
When nursing students enter the educational system, they arrive with varying degrees of developmental readiness for leadership. The first contributor to this readiness is self-regulation, often described by other leadership theorists as self-leadership or management.37 Self-regulation that contributes to leadership development includes approaching the world with aspirations and making attempts to achieve them. Motivation to lead and learning goal orientation are 2 more contributors to readiness because individuals who are motivated to lead and want to learn from their experiences are often more willing to try leading and reflect on their interactions in order to better relate to others. Lord and Hall38 note that to develop leadership capacity, individuals must possess self-knowledge, identification with the role of leader, and self-assurance to practice leading. Positive experiences with practicing leadership and relating to others contribute to the building of confidence and the belief that one can lead. If educational programs are to support the development of future leaders, then evaluating where nursing students are in their development of a leadership identity is critical.
Leadership self-efficacy
Leadership self-efficacy is defined as the "level of confidence in the knowledge, skills, and abilities associated with leading others."39(p669) Popper and Mayseless40 found that self-confidence was the most prevalent characteristic used in defining a leader. Further analysis revealed that individuals with high self-confidence have limited stress in changing situations, belief in their ability to be successful, and an internal locus of control. This self-confidence and belief in one's ability to lead, or leadership efficacy, is a powerful determinant of long-term leadership development. Efficacy beliefs
affect whether individuals' think in self-enhancing or self-debilitating ways, how well they motivate themselves and persevere in the face of difficulties, the quality of their well-being and their vulnerability to stress and depression, and the choices they make at important decision points.41(p87)
The concept of how efficacy is developed in individuals has been well researched. Bandura42 found 4 effective techniques: mastery experiences, vicarious learning, social persuasion, and arousal. Nursing education needs to include opportunities for students to develop desire for and participate in successful leadership experiences. Faculty and nurses in practice must recognize and label leadership as a dimension of nursing practice, thus providing role models of competent leadership for students. Nurses already use persuasion to entice nurses to take on leadership roles. Often the path leading to an administrative position in nursing is begun when managers tell nurses they think they would be good in leadership. Faculty and nurses in practice must be alert to students who exhibit leadership qualities and encourage those behaviors and practices. Finally, students need to be exposed to nurses who are passionately addressing issues in health care in both formal and informal roles of leadership, so they are aroused to consider leadership as a course of action for resolving challenges in health care.
CONCLUSION
If nursing is going to maximize its leadership capacity and avoid a leader shortage, a comprehensive conceptual framework for lifelong leadership development of all nurses must be designed in addition to developmental frameworks for those in formal administrative and advanced practice roles. Educational initiatives must then be developed and researched for generating more nurses with leadership identities and leadership self-efficacy.
REFERENCES