1. Porter-O'Grady, Tim DM, EdD, APRN, FAAN, FACCWS
  2. Malloch, Kathy PhD, RN, FAAN

Article Content

For complex organizations, the core of the new paradigm for leadership is a focus on the intersection of relationships necessary to sustain the connection between people and the organization.1 Because of our growing understanding of the array of dynamics that occur at the myriad interfaces operating constantly in organizations, the leadership necessary for success must now be reconceptualized.

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

A new understanding of leadership

In traditional industrial organizations, leadership science and research has been mostly focused on the leader as a person and the right combination and configuration of personal skills and behaviors to ensure both the leader's and organization's success.2 Goodness-of-fit between person, place, and relationships enables synergy, with the goal of honing the leader's personal insights and skills to better lead others and help sustain the success of the enterprise.3 As a result of focusing on the leader's aptitude and personal capacity to excel, an entire body of research and literature has grown up around these concepts, demonstrating various leadership models that claim to make the leader more or less effective.4,5


An emerging understanding of complex adaptive systems/networks has challenged this approach to leadership, creating a different foundation for the role and capacity of the leader.6-8 In complex adaptive systems/networks, the environment is constantly in the throes of change, transformation, or deconstruction, or all three. They thrive because they're adaptive, immediately changing as required to ensure long-term viability. And they're adaptive because their employees' individual and collective behavior can mutate and self-organize consistent with any change at the macro and micro level. Every part is interdependent and positively or negatively influences the action of the whole. The better the "fit" of the shared synthesis of collective action, the more likely the system/network and its people will thrive.9-13


In this new understanding of human work and systems/networks, leadership operates through the viewfinder of a new lens. Adaptive leadership is no longer about the person; instead, it's about the dynamic ability to successfully respond to continual uncertainty by coping with new conditions, creatively responding to new situations and circumstances, and resonating with an emerging reality that's different from the past.14 Leadership is embedded in the response and is itself adaptive. This means that leaders emerge where and when they're needed, expressed in ways that best facilitate understanding, competence, and action rising from a particular demand or requisite for change.15 Leadership effectiveness is directly related to the demand for change and the specific responses and actions that make it happen in a way that enables the life of the system/network and its members. Leader skills, behaviors, and practices are malleable and themselves dynamic, evolving and adapting to the changes they're facilitating and either extended or extinguished as the change is completed or a new adaption is required.16


With this understanding, anyone can or may be a leader. Depending on the circumstances, a person may be called to inform, guide, influence, challenge, or lead others in a direction advised by the need for a specific adaptation.17 Once the demand is met, leadership may move into the hands of a different person with a unique talent set. In this scenario, the demand for leadership skill and competency is deeply ensconced in the vortex of the dance of change, emerging in form and function in ways that best fit a positive response on the trajectory of growth and sustainability. Here, the leader discerns the necessary mix of skills and talents, draws on them in a way that best demonstrates a positive response to a particular demand, and exercises the creativity to best meet that demand.


This notion of leader as more role than person, called agency, is critical to understanding leadership expression and effectiveness. We've become so familiar with the leader-as-person approach that it's immediately uncomfortable to separate our understanding from this concept. Yet, our complex systems/networks are now dependent on our capacity to understand and apply leadership in a fundamentally new way. This new understanding doesn't suggest that there aren't specific skills for good leadership, but rather those essential skill sets are available to all who will inevitably, by location or demand, assume the role of leader at any given time. Keep in mind that leadership is always a learned skill. As this reality becomes more fundamentally a part of role expectation in a complex system/network, mechanisms for learning and developing the related skill sets will become more easily accessible.


Appreciative leadership

A beginning foray into this new concept of leadership, appreciative leadership is a positive mental model and framework for leadership practices that are an expression of the response to complexity. Practically, the appreciative leader understands that every person in an organization plays a specific and definitive role in the system's/network's ability to thrive. In fact, everyone in a system/network should be clear about the role they play. Everyone's role is appreciative in that it's consciously and concretely related to the life of the work community. No role is superfluous-it's either adding value or taking it away. We know a role's value by the degree of goodness-of-fit between the role and its specific contribution to the dynamic and prospering life of the work community. The leader's role is appreciative to the extent that it enables and advances the role contribution of everyone who participates in the life of the work community, adding value to the system/network.


There are five guiding principles that underpin the expression of appreciative leadership. The leader demonstrates:


* relational capacity to mobilize accountability


* a significant level of self-awareness and self-confidence


* exceptional skills in the expression of leadership language and leader role obligations


* authoritative competence and performance in the role that results in a definitive and intentional impact


* consistent and continuous integrity and inclusion.1



Rather than being identified with the leader's personal characteristics, these appreciative characteristics are embedded in the role, not the person. This leads to the emergence of new patterns, skills, and behaviors at all points of intersection for decision-making and action in any system/network. An appreciative leader is recognized by his or her behaviors and expressions in the leadership role. These expressions reveal the leader's commitment to the advancement of the work he or she leads and the essential facilitation of the skills and efforts of others who own the work and directly influence its outcome and impact. Consider the following appreciative leader behaviors that are foundational to the appropriate expression of the leadership role.


Everyone counts. The appreciative leader knows that every role in a workspace contributes to the essential goals and products of the work. It's important that individuals are clear about their role's value and function, and the specifics of their contribution to the mosaic of effort necessary for the work and its outcomes. For example, the iPhone may have been the idea of a single individual, but as a real product is the consequence of the collective convergence of all the skills of everyone necessary to create it. The leader recognizes this and ensures each contributor knows his or her contribution, understanding that all contributors work through an essential conjunction (community) of effort to create the product. In this way, the leader facilitates, coordinates, and integrates the effort necessary to produce the best outcome.


Clarity of accountability. Every worker owns his or her effort. In complex work, the outcome is always the result of a convergence of complex effort. Each contributor depends on the contribution of others from conception to design to impact. Individuals must know what they bring to the table that specifically contributes to the collective effort of the team. They must also be clear about what part their unique contribution plays in producing an outcome.


Everyone makes their own decisions. Ownership is an important notion in appreciative leadership. The leader knows that he or she facilitates the work of others and that they own the work they do. This ownership is an essential element of accountability, which demands understanding and respect from the leader in a way that doesn't impede the owners' full engagement and participation in decisions and actions that relate to what they do and the contributions they make. Participation is a basic part of the value that the individual brings to the work and the workplace. Individual contribution and collective collaboration are vital correlates; each is necessary to the other to ensure competence, integration, and effectiveness.


It's never about me. The leader is never the center of the enterprise. In fact, the leader should never be the center of anything. The appreciative leader is always an agent of the enterprise and the integrity of the worker and the work. The leader inherently acts as a facilitator of the effort, innovation, process, or product. The leadership effort is directed at ensuring an effective convergence of relationships, communication, decisions, actions, and challenges in the interest of the right success and/or outcome. The measure of success isn't found in the leader's actions but is instead demonstrated by the achievement of collective effort. In short, the wise and appreciative leader lives in the reflection of success, not at its center.


Success is the convergence of effort. For good or ill, all outcomes are the result of the convergence of effort necessary to achieve them. The appreciative leader is aware that this reality operates in all circumstances. Knowing this, the leader appreciates each contributor and contribution, the consonance of their work and collective effort, and the precise alignment of all effort to produce the just-right outcome. The leader wants each member to know and appreciate his or her specific contribution and to equally value the goodness-of-fit of all contributors that's represented in both process and product. A patient doesn't heal simply because of the deft skill of the surgeon; healing happens because each caregiver did the part that was theirs to do and the collective synergy of their individual efforts converged to create the just-right circumstances for healing to occur. The appreciative leader ensures that all the necessary pieces come together to achieve effectiveness.


A case for the appreciative leader

To illustrate both the nature and power of appreciative leadership and provide a pragmatic application, a situation related to the restrictions on family presence that occurred during the COVID-19 pandemic is presented here. Using appreciative principles and leadership applications, we propose a critical reflection on this patient care challenge using inquiry to learn more about the situation, illuminating the evidence to support new decisions, including healthcare workers at multiple positions in the organization, emphasizing connections across the organization, and inspiring others to move forward with new ideas.1 The goal isn't to negate the work of the past, but rather to appreciate the applied science of what worked well; build on the evidence; integrate new science; and consider alternatives based on appreciation, evidence, and the interconnected events in a complex environment.


As we know, public agencies and healthcare systems were highly reactive to the COVID-19 pandemic. The response was focused on controlling the spread of the virus as quickly as possible, and community and health systems went into lockdown. However, the decision to shut down healthcare organizations and fully restrict visitors removed patients' family as an essential member of the care team, negatively affecting their clinical and emotional care.


To be proactive and learn from the pandemic, the appreciative leader looks through a different lens regarding managing patient-family interactions, seeing in it the need to address the competing priorities at the intersection of safeguarding families and healthcare personnel from a serious infection, protecting limited resources, ensuring family-centered care, and carrying out end-of-life care. The appreciative leader raises the following questions to develop specific actions that are consistent with the science of caring and the essential humanity of patient-family relationships:


* What changes need to be made to patient care practices to ensure that the patient's own caregiver support system is never left out of the caring equation and the patient's needs are fully integrated into the care plan? Can the leader link competing demands and seek common solutions? Can leadership behaviors demonstrate the use of evidence-based choices driving decision-making? Can formal leaders ensure that point-of-service accountability and authority are exercised by the right people (ownership) when needed?


* How was fear of COVID-19 analyzed and effectively managed during the pandemic and how can it be mediated in the future?


* How effective were the CDC's infection control guidelines? Was handwashing and gloving and gowning (universal precautions) believed to be of value? Did we trust the underlying science behind appropriate infection control methods?


* Did leaders fail to support professional nursing governance during the pandemic? How can professional governance activities advance better critical decisions and a more integrated approach to caregivers and patients?


* Were there negative outcomes of the pandemic that could be reversed or diminished? Can organizations value the experiences (both positive and negative) garnered during the pandemic, learn what did and/or didn't work, and construct better solutions?



Reflecting on the impact of family restrictions during the pandemic and reengaging with the research related to loneliness and supportive relationships provide a logical and legitimate foundation for moving forward.18 The appreciative leader values intention and facilitates actions to integrate science and humanity as the goals driving next steps in a way that supports both critical patient needs and decreased risk of virus spread. Appreciative leadership principles provide guidance to begin the journey, specifically relational capacity to mobilize accountability, renewed self-awareness, and confidence to move the work forward, using the language of ownership, accountability, and facilitation. The appreciative leader advances consistency in the construction and application of standards, engaging the accountable individuals to establish these standards in the organization.


The appreciative leader moves forward using established relationships across the organization to mobilize accountable healthcare workers to examine the science of caregiver-patient relationships as a fundamental element of the care plan. In addition, new relationships are formed throughout the organization, centered on point-of-service caregivers. Engaging teams across the organization is complex and multifaceted but critical to generate emerging evidence-based knowledge throughout the system. Appreciative leaders demonstrate self-awareness of the risks, challenges, and ultimate value of changes in managing family and caregivers. In the case of patient-family care support, the appreciative leader understands both the support for relevant processes and the reluctance of some individuals to eliminate nonevidentiary restrictions, reflecting effective relational capacity with accountable members of the organization. Using facilitative, rather than directive, leadership techniques will further support team member engagement and sustainable solution-seeking.19 The appreciative organization learns and succeeds together, with regular validation and demonstration of new competencies in caregiver-supportive patient care.


Our case study demonstrates the need for rethinking the role of families and patient caregivers in healing. A significant other care partner is defined as "an advocate for a loved one's needs" who "supports them in managing their health, healthcare, long-term care, and overall well-being."20 Care partners require physical presence because they're uniquely attuned to subtle changes in the patient's behavior or status, which is important for reducing the risk of preventable harm and harnessing the patient's own internal resources for hope and healing. The appreciative leader "pushes the walls" of the organization when its practices conflict with prevailing research and evidence, such as the limitation or elimination of the presence of essential care partners at a time of the patient's greatest need. Confronting apparent opposing demands between patient need (aloneness and isolation) and human safety (disease risk and infection control) and arriving at a viable and sustainable solution defines the landscape of the appreciative leader's work.


The shift to appreciative leadership accelerates the value of accountable healthcare workers in the system and recognizes the impact of social determinants of health, such as economic stability, social and community context, neighborhood and environment, access to healthcare, and education. Healthcare leaders can indeed learn from the myriad unintended consequences as outlined in this case, confronting restrictive visitation policies for adults, children, and families during periods of heightened anxiety such as a pandemic.


Planning for the future

Appreciative leaders manage the movement of the system, including its people and resources, toward an unending unfolding of a more desirable future-one that's healthier, stronger, and more sustainable. They coordinate and integrate the confluence of forces between people and systems on a trajectory that's intentionally better, always leading across rather than down and recognizing that everyone in the enterprise is a dynamic team member with a crucial contribution to make. For the appreciative leader, this is the work and the call of leadership, serving as the driver of both purpose and role and one of the key foundations of personal, professional, and organizational health.


INSTRUCTIONS The emerging principles and practices of appreciative leadership



* Read the article. The test for this nursing continuing professional development (NCPD) activity is to be taken online at


* You'll need to create an account (it's free!) and log in to access My Planner before taking online tests. Your planner will keep track of all your Lippincott Professional Development online NCPD activities for you.


* There's only one correct answer for each question. A passing score for this test is 7 correct answers. If you pass, you can print your certificate of earned contact hours and access the answer key. If you fail, you have the option of taking the test again at no additional cost.


* For questions, contact Lippincott Professional Development: 1-800-787-8985.


* Registration deadline is September 6, 2024.



Lippincott Professional Development will award 1.5 contact hours for this nursing continuing professional development activity.


Lippincott Professional Development is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation.


This activity is also provider approved by the California Board of Registered Nursing, Provider Number CEP 11749 for 1.5 contact hours. Lippincott Professional Development is also an approved provider of continuing nursing education by the District of Columbia, Georgia, and Florida, CE Broker #50-1223. Your certificate is valid in all states.


Payment: The registration fee for this test is $17.95.




1. Malloch K, Porter-O'Grady T. Appreciative Leadership: Building Sustainable Partnerships for Health. Cambridge, MA: Jones & Bartlett; 2022. [Context Link]


2. Daft RL. Management. Farmington Hills, MI: Cengage Learning; 2013. [Context Link]


3. Finkelman AW. Leadership and Management for Nurses: Core Competencies for Quality Care. 2nd ed. Boston, MA: Pearson; 2012. [Context Link]


4. Gill R. Theory and Practice of Leadership. Thousand Oaks, CA: Sage Publications; 2011. [Context Link]


5. Northouse PG. Leadership: Theory and Practice. 9th ed. Thousand Oaks, CA: Sage Publications; 2021. [Context Link]


6. Barile S, Pellicano M, Polese F, eds. Social Dynamics in a Systems Perspective. New York, NY: Springer; 2018. [Context Link]


7. Davis H. Social complexity theory for sense seeking: unearthing leadership mindsets for unknowable and uncertain times. Emergence Complexity Organ. 2015;17(1):1-14.


8. Moerschell L, Banner D, Lao T. Complexity change theory: improvisational leadership for complex and chaotic environments. Leadersh Organ Manage J. 2013;13(1):24-47. [Context Link]


9. Albert N, Pappas S, Porter-O'Grady T, Malloch K. Quantum Leadership: Creating Sustainable Value in Health Care. 6th ed. Cambridge, MA: Jones & Bartlett; 2021. [Context Link]


10. Gros C. Complex Adaptive Dynamical Systems: A Primer. New York, NY: Springer; 2008.


11. Miller J. A Crude Look at the Whole: The Science of Complex Systems in Business, Life, and Society. New York, NY: Basic Books; 2015.


12. Nan N, Zmud R, Yetgin E. A complex adaptive systems perspective of innovation diffusion: an integrated theory and validated virtual laboratory. Comput Math Organ Theory. 2014;20(1):52-88.


13. Rutherford A. The Elements of Thinking in Systems: Use Systems Archetypes to Understand, Manage, and Fix Complex Problems and Make Smarter Decisions. Chicago, IL: Independent Publishers; 2019. [Context Link]


14. Bennet A, Bennet D, Lewis J. Leading with the Future in Mind: Knowledge and Emergent Leadership. Marlinton, WV: MQI Press; 2019. [Context Link]


15. Johannessen J-A, Stokvik H. Evidence-Based Innovation Leadership: Creating Entrepreneurship and Innovation in Organizations. Bingley, West Yorkshire, England: Emerald Publishing; 2019. [Context Link]


16. Mitterlechner M. Leading in Inter-Organizational Networks: Towards a Reflexive Practice. St. Gallen, Switzerland: Palgrave McMillan; 2019. [Context Link]


17. Goleman B. Emotional Intelligence: For a Better Life, Success at Work, and Happier Relationships. New York, NY: Brandon Goleman; 2019. [Context Link]


18. Murthy V. Loneliness and social connection with Brene Brown. 2021. [Context Link]


19. Barrieault K, Sisneros D, Rotering C. The language of appreciation: engagement and the clinical leader. In: Malloch K, Porter-O'Grady T, eds. Appreciative Leadership: Building Sustainable Partnerships for Health. Burlington, MA: Jones & Bartlett Learning; 2022. [Context Link]


20. Planetree International. Resources on person-centered care during COVID-19. 2021. [Context Link]