1. Raso, Rosanne MS, RN, NEA-BC, FAAN

Article Content

Leadership underlies nearly every organizational model we embrace as nurses. Healthy work environments (HWEs), high reliability organizations, Magnet(R) recognition or Pathway to Excellence(R) designation, and safety cultures, to name a few, all include leadership as foundational elements. In our roles, we're constantly striving to improve our leadership skills to achieve these, or other, improvements in our healthcare environments.

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

One of the relational leadership styles, authentic leadership is rooted in positive psychology-the scientific study of the strengths that enable individuals and communities to thrive. The values of honesty, trust, and integrity are the underpinnings of authentic leadership. The importance of these values is as old as Greek philosophy and as relevant today as it was centuries ago. Authentic leadership's important relationship to HWEs impacts staff well-being and patient outcomes. With growing nursing literature on authentic leadership, we see its positive effects on nurses and patients nationwide and globally.


In a healthcare environment of value-based care and high performance expectations, leadership that influences outcomes is vital. This article explores authentic leadership and its relevance to practice and HWEs.


Relational leadership styles

In the nursing literature, relational leadership styles have emerged as consistently resulting in beneficial outcomes.1,2 What do we mean by relational styles? We mean leadership styles that focus on relationships with people, the most common being transformational, authentic, and servant leadership. These styles may also be referred to as positive leadership.3 Positive leadership is practiced by individuals who are genuine, trustworthy, reliable, and believable, helping employees connect to themselves and others.3-5


There are differences in the three styles, although all are clearly positive and founded in relationships. (See Table 1.) Transformational and servant leadership styles tend to be more ubiquitous in the literature than authentic leadership. The transformational style is focused on inspiration by a charismatic and confident leader. It's one of the domains in the Magnet Recognition Program(R) due to the transformational nature of creating a culture of nursing excellence.6 Servant leaders concentrate on others and the work environment, with unwavering caring and support. Their focus is "primarily on the growth and well-being of people...putting the needs of others first."7

Table 1: Relational ... - Click to enlarge in new windowTable 1: Relational leadership styles

Then we have authentic leadership, one of the six essential elements of an HWE in the American Association of Critical Nurses' (AACN) model.8,9 (See Figure 1.) In fact, although authentic leadership was just beginning to appear in the literature in 2005 when the AACN published its landmark Standards for Creating and Sustaining Healthy Work Environments, it's noteworthy that authentic leadership was included as a standard, stating "nurse leaders must fully embrace the imperative of a healthy work environment, authentically live it, and engage others in its achievement."8,9 The HWE model is grounded in authentic leadership's positive effects on patient safety, clinical outcomes, and staff recruitment and retention.

Figure 1:. AACNs HWE... - Click to enlarge in new windowFigure 1:. AACN's HWE model: Interaction between authentic leadership, work environment, and outcomes

Authentic nursing leadership expert Maria Shirey's systematic review of current literature on leadership practices for an HWE concluded that relational leaders contribute to higher nurse satisfaction and better work environments, boosting employee health and well-being.2 Other researchers have also found evidence of the correlation between relational leadership styles and nurse satisfaction. The benefits of positive leadership and relationships seem irrefutable and, of course, desirable.


A broad overview

Authentic leadership is relatively new, primarily noted within the past 15 years in management and nursing literature. Historically, its origins are based on multiple business scandals occurring in the early 2000s, which led to interest in a shift from "arrogant" leadership to genuine leaders who instill hope, optimism, and resiliency.10 Authentic leaders act in alignment with their personal values, building credibility, respect, hope, and trust with direct reports. This type of leader is seen as genuine, resulting in positive effects such as satisfaction, motivation, and performance. Of course, contextual factors are also influential, such as organizational culture, politics, and structure.2,10 (See Figure 2.)

Figure 2:. Shireys m... - Click to enlarge in new windowFigure 2:. Shirey's model of best practices for creating and sustaining HWEs

Shirey states that the most desirable leadership attributes require authenticity, and authentic leaders are genuine and true to themselves.2 Different from the two relational styles described earlier, authentic leadership focuses on character, not charisma or service. If you've been referred to as a "straight shooter" or a "nurse's nurse," you probably have authentic leadership traits.


When you look at conceptual models of authentic leadership, you'll find four constant characteristics: self-awareness, internalized moral perspective, relational transparency, and balanced decision-making.11-13 Let's break these characteristics down to understandable attributes and relate them to leadership effectiveness. (See Table 2.)

Table 2: Authentic l... - Click to enlarge in new windowTable 2: Authentic leader characteristics

Self-awareness in today's jargon simply means "Do you have a clue?" You've probably worked with or for people who literally have no clue how they act and their effect on others. The authentic leader self-reflects often and knows his or her strengths, weaknesses, values, and beliefs. This type of leader seeks feedback regularly to improve. Ed Koch, New York City's mayor in the 1980s, frequently asked his constituents: "How am I doing?" It's this type of ongoing process that's essential to authenticity. Focusing on your strengths, passions, and self-development is key.


Internalized moral perspective refers to a strong ethical foundation and acting in accordance with your values, even under pressure. In nursing, this is considered the "nursing compass" and has also been called moral courage.13 When decision-making and actions are grounded in your values, you have authenticity. Sometimes the basic value of patient-centeredness is sacrificed in the complexity of our organizations. If this happens, internalized moral perspective has been lost.


Relational transparency refers to the ability to connect with others easily and the open sharing of thoughts, feelings, and beliefs. There's no hidden agenda. Being able to develop relationships by being yourself and consistent in your words and actions is fundamental to authentic leadership. This is leading with the heart, most likely resulting in a followership of engaged employees.


Balanced decision-making is when the leader objectively seeks, and listens to, all stakeholders' perspectives. Decision-making and conflict resolution are handled in a rational manner without emotional stakes getting in the way. The balanced authentic leader is also behaviorally consistent and there's an absence of workplace drama. Refreshing, isn't it?


You may see some or all of these characteristics in yourself. Look for and develop them because authentic leadership has significant relevance to our work as nurse leaders.



From a healthy workplace standpoint, authentic leadership is relevant to everyone. For example, an authentic leader would take on a patient experience organizational goal because it's the right thing to do (moral perspective), proceed to listen and involve all stakeholders in discussing and determining interventions (balanced decision-making), share concerns and updates (relational transparency), and reflect on performance and process to improve moving forward (self-awareness). This type of leadership fosters "authentic followership," a concept important to any leader's success.


Early work on authentic leadership stressed this point and we all know from experience that our success is dependent on our teams and their engagement and development. The trust gained through transparency, balance, moral compass, and even vulnerability provides a foundation for the leader-follower dynamic.14 Other researchers continue to identify the importance of authentic leadership for advancing direct reports' intrinsic work motivation and subsequent improved work performance.15 The interplay of leaders and their employees clearly affects outcomes. This is why authentic leadership is an essential element of building high-performing teams and developing others.


Most identified outcomes of authentic leadership are related to staff engagement-the holy grail of leadership and organizational success, and the precursor to high performance. Alilyyani and colleagues from Canada published a systematic review of healthcare outcomes, predominantly in acute care settings.16 Associations with 43 outcomes were grouped into two major themes: healthcare staff outcomes and patient outcomes. Staff outcomes included five subthemes: personal psychological states, such as optimism and trust; satisfaction with work, including work engagement; work environment factors, including structural empowerment and workplace behaviors; health and well-being; and performance. There was one patient outcome study related to fall reduction.16 We also see evidence of authentic leadership positively affecting safety culture.17 The positive outcomes in Table 3 are important to any nurse leader's sustained success.

Table 3: Positive ou... - Click to enlarge in new windowTable 3: Positive outcomes of authentic leadership

Of concern is an identified dichotomy in the nursing leadership literature. Nurses have reported declining HWEs while the evidence of a positive impact on staff and patient outcomes is growing.1,18 In a recent systematic review of nurse work environments, it was concluded that nurse leaders are anchors for HWEs; however, another HWE study demonstrated a lack of consistent leadership practice across the US.1,19 This isn't ideal for the nursing profession or patients and a main reason why the development of authentic, positive leadership attributes is relevant today.


Currently, mindfulness is a hot topic reminding us to be present, focused, and nonjudgmental both in our personal lives and as leaders.20 With the authentic leadership characteristics of self-awareness and balanced decision-making, we see that mindfulness and authentic leadership are entwined-you can't be self-aware and listen to others without being mindful. The potential of leaders is grounded in authenticity and "checking in with their own humanity" using mindful practices.21


Another current leadership topic is burnout and its opposites, joy and resilience. Is authentic leadership an antidote to burnout? With HWEs, optimism, engagement, and empowerment as outcomes of authentic leadership, it seems possible that joy at work may be advanced and burnout moderated. There's evidence that authentic leadership enhances nurses' "thriving at work," clearly an element of joy.22


What about our millennial workforce? Does authentic leadership resonate with them? We have a lot to learn about this question, a topic ripe for inquiry and research. From experience, it seems that our younger generation generally does look for approachable leaders and the ability to participate in decision-making-hallmarks of authentic leadership.


Can it be learned and measured?

One of the big questions is whether authentic leadership, or any leadership style, can be learned. Alexander studied the leader behaviors nurse executives use to create and sustain HWEs, providing evidence that authentic leadership can be learned and simulated in leadership development programs in the academic and practice setting.13 This study is one of only a few on authentic leadership development, and we still have a lot to learn about how to cultivate authentic leaders.


Shirey describes the process of becoming an authentic leader as a personal journey of self-discovery, self-improvement, and self-reflection rather than a destination.3 That makes sense for many of our professional journeys, whether it be leadership, clinical excellence, or any other. To be authentic, you must be in touch with yourself and reflect often. After all, self-awareness is one of the basic tenets. The journey includes practicing and repeatedly learning in continuous cycles. Using resources such as books, courses, programs, team retreats, coaching, and mentors is obviously important to both authentic leadership and overall competency development.


You can work on developing this effective relational style. Don't forget there's always more to learn to be an effective leader, such as business skills, emotional intelligence, and conflict management. There's a growing body of evidence that formal leadership programs have positive outcomes in terms of competencies, retention, and transition to new roles; more development programs are clearly needed.23


As for measurement, historical authentic leadership instruments, such as the Authentic Leadership Questionnaire, measure the four attributes mentioned earlier from the leader's perspective.24 Interestingly, nurse researcher Marie Giordano-Mulligan recently developed a new measurement tool for authentic leadership that's grounded in nursing and from the staff perspective. Positively correlated with nurse engagement, the Authentic Nurse Leadership Questionnaire includes caring as a domain, using Watson's Caring Theory as a theoretical base. Giordano-Mulligan notes that the concept of authentic leadership was developed in other disciplines and didn't include components that reflect the unique characteristics of nursing. She also states that nurse leaders who incorporate authentic leadership into their practice are positioned to influence nurses' work-life environment and engagement, supporting the significance of authentic leadership for HWEs.25


Call to action

This article explored some, but certainly not all, of the nursing literature on authentic leadership. Authentic leaders are anchored by their own inner core values and deep sense of self; they know where they stand on important issues. Their positive relationships with employees lead to positive individual and organizational outcomes. We've seen nursing research evidence that both authentic leadership and HWEs contribute to staff engagement and improved patient outcomes. In the context of nursing management, it's the patient and staff outcomes of authentic leadership that are most important to our practice.


One caution is not to get caught up in the label. Authentic leadership is a distinct style of relational leadership that you may find yourself relating to or even admiring. Openness and honesty are hallmarks of authenticity and much needed in our workplaces. Developing your leadership skills and those of others is important whether it's authentic leadership, another relational style, or a combination. We have to learn how to create sustainable, meaningful, and effective leadership development and succession planning programs to combat the perceived deterioration of leadership practice noted earlier and the impending loss of a large part of the nurse leader workforce in the next few years.18,19,26 As Shirey asserted during a 2018 regional research conference, it's a call to action to learn, grow relationships, and commit to leadership excellence.27


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