1. Criscitelli, Theresa MS, RN, CNOR

Article Content

Leadership skills are important not only for administrators and managers, but also for the nursing staff. Today's complex healthcare system is economically driven and must focus on safety and patient outcomes, making exemplary leadership skills essential for all nurses. Many nurses become formal leaders without formal leadership training, educational support, or necessary experience to succeed.1 So, where exactly does an RN obtain leadership skills?


A model for leadership development

Leadership skills can be developed in staff nurses using a holistic model. Quatro, Waldman, and Galvin described four basic domains of leadership development: being analytical, conceptual, emotional, and spiritual, to develop and practice.2 Leaders must acquire analytical skills based on personal cognitive abilities. This can be nurtured within the OR milieu by encouraging problem solving using problem-based learning techniques. Problem-based learning is a technique whereby a group works together and pulls from their current knowledge, searches for new information, and applies their combined skills to solve complex problems. This provides a deeper understanding and enables learners to connect relevant and contextual information to foster critical thinking.


Leaders must also possess conceptual abilities to understand and manage complex projects or situations. This can be encouraged by allowing staff members to brainstorm and creatively manage situations, for example, allowing an RN to design and manage a new initiative in the OR. This would enable the RN to utilize conceptual skills and navigate through the trials and challenges associated with a large project.


Emotionally, leaders must be able to persuasively communicate with an empathetic understanding of diverse situations. It's important to develop the ability to tune into emotional issues and handle multiple viewpoints that may emerge. Allowing an RN to persuasively communicate and empathetically understand the challenges related to managing a sensitive situation, such as a patient going into cardiac arrest in the OR, is a good example.


Spiritual purpose is relevant, yet often forgotten in the workplace. Through self-reflection and meditative thinking, a deeper understanding of personal values can be created and transcend into value-based leadership. Such leadership must provide outcomes that are aligned with the core values of the institution and reflective of the leader's style. It's important to develop all four facets of oneself to effectively lead, to possess a positive image, and to increase personal job performance.

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Leadership styles

Even though there are many leadership styles, transformational leadership is currently considered a nationally recognized standard for executive nursing practice.3 In this leadership style, the leader sets the tone for positive change through trusting relationships that are fostered within teams. Qualities of a transformative leader include self-confidence, positive emotional demeanor, charisma, motivation, and persuasiveness. This type of leader yields a high level of satisfaction and performance; however, it's very difficult to teach the transformational style of leadership. The OR is an ideal environment to transform and inspire change. Transformative leaders in the OR can change the culture of a unit, change policy, and institute evidence-based practice.


Other classic leadership styles include autocratic, bureaucratic, democratic, and laissez-faire, which all have a time and a place of relevance. An experienced leader will know when to utilize a particular leadership strategy to approach a specific situation. This takes experience and the ability to appreciate and evaluate the situation before being able to determine the correct style for each situation. Sometimes, combinations of styles are necessary to move a project forward depending on the context, the members of the group, and the time frame.


Autocratic leadership style is a classic approach in which the leader maintains as much decision-making authority and power as possible. Others are not consulted or allowed to give any input, and this style requires a structured set of rewards and punishments. Due to a large amount of criticism and job dissatisfaction related to this leadership style, it's usually only recommended when working with untrained staff, emergency situations, or when no other style is working.


Bureaucratic leadership style is an approach in which everything is performed according to policies and procedures. This style can be utilized when a group of nurses need to understand certain standards or procedures, when safety or security training is conducted, or when a repetitive task needs to be performed in a specific way. This can be ineffective when flexibility, creativity, or innovation are necessary to enhance a situation.


Democratic leadership style can also be called participative style, which is an approach whereby everyone is encouraged to be part of shared decision making and problem solving. The leader will act as a coach and make the final decision, which is first determined by all involved. This leadership style produces both high quality and high quantity of work while fostering collaboration and high morale. This style is quite successful when used with highly-experienced staff or during operational changes for an institution. Don't use this style when there's insufficient time to get proper input or when staff safety is threatened.


Laissez-faire leadership style is also known as "hands-off," whereby the leader provides little or no direction, and all decision-making power, goal setting, and resolutions are left up to the group. This style is only effective with very experienced and educated staff or when outside specialists are consulted and utilized. This should not be utilized when morale is low or when motivation is needed to get the job done.


Influential factors

Many factors affect leadership performance and the pursuit of leadership skills. Intrinsic factors that affect leadership performance include current knowledge base, personal vision, past experiences, the ability to apply learned skills, and the ability to communicate. Leaders possess self-esteem, internal motivation, optimism, courage, perseverance, and are goal-oriented with a high internal locus of control. Extrinsic factors include relationships built upon trust and respect, and the political, economic, and social climate of an institution that ultimately affects the nurse's ability to develop leadership skills and navigate as a leader within the system. Supportive environments are conducive to enhanced creativity and empowerment of the perioperative RN.


Personality, values, ethical beliefs, and experiences influence which leadership style RNs will choose to utilize once leadership skills are developed. It's important to be authentic when defining leadership styles and to not just emulate a particular style or person. It's always evident that authentic leaders are passionate, consistent, and lead with their hearts. Everyone can develop leadership skills, and some of these intrinsic and extrinsic characteristics can become learned behaviors if time is spent developing these skills.


Development of skills

Self-reflective practice is vital to develop personal leadership qualities and to enhance personal challenges that require additional development. Self-refection is an active process of understanding personal beliefs, strengths, limitations, and the impact it has upon others. Through journaling, personal observation, knowledge acquisition, and peer-to-peer dialogue, one can obtain an effective framework to build upon and develop a personal leadership style. Through self-reflection, authenticity develops and should be encouraged within the perioperative leadership role.


Utilizing self-assessment of oneself can help a nurse identify personal leadership strengths and challenges. This can be accomplished by better understanding personal perspectives and developing insight into other perspectives to objectively appraise accomplishments and constructive feedback. Self-assessment of personal leadership skill development can be informal yet effective in professional development. Leadership is a learned skill that takes practice to acquire the desired behaviors in a multitude of situations.


Tapping into resources provides limitless opportunities for perioperative nurses to obtain assistance with leadership resources. Some opportunities are within daily reach, such as hospital librarians, human resource department, and hospital administrators. Hospital librarians can provide a plethora of literature and resources free of charge. The human resource department can facilitate staff leadership through development of performance outcomes and creation of leadership skills within current job descriptions. It's possible to find hospital administrators or managers that possess the leadership skills RNs seek to acquire, and they can be called upon to disseminate their knowledge, triumphs, and challenges of leadership to staff at meetings or conferences.


Mentoring programs can provide the experiences of seasoned nurses to bolster and support the perioperative nurse through the transition of becoming a leader. Literature supports the need for mentorship programs and the benefits they can provide to create strong leaders and prevent job dissatisfaction. Mentoring relationships have been studied in various professional environments4,5 with positive results. The OR is a perfect venue to create a mentoring program to foster leadership skills and support professional development.


The positive effects of mentoring dyads can foster leadership skills. Mentoring relationships can develop in an unstructured environment or through a formal program. A mentor can be a valuable tool in the recruitment and retention of nurses, job satisfaction, and maximizing nurses' leadership abilities. The under the watchful eye of a mentor can bridge the gap between theory and practice. Through coaching, guidance, and encouragement, the mentoring dyad can be mutually beneficial.


Formal professional development

Supplemental and more structured support can be found through the International Council of Nurses, which established the Global Nursing Leadership Institute, an annual leadership development program for nurses (globally) to help increase the capacity of exemplary nurses and presence of strong nurse leaders.6 The World Health Report7 strongly expressed the need for new forms of leadership in health whereby nurses can emerge and become accountable for personal leadership. This report discusses rebuilding leadership in health by leadership reform that increases participatory, negotiation-based leadership and the need to reinvest in public leadership to protect and strengthen the health of not only our communities but the general public communities as well. The OR is the ideal milieu where intercollaborative teams are prevalent and can work effectively with strong RN leadership.


Clinical Nurse Leader (CNL) certifications are obtained after master's degree and are designed to create environments of improvement, to track and trend data, and to assess or intervene to improve and correct a gap in practice.8 The Clinical Nurse Leader Certification Program is an autonomous arm of the American Association of Colleges of Nursing and is governed by the Commission on Nurse Certification Board of Commissioners. These CNLs have advance practice knowledge and skills in order to focus on measurement of outcomes and evaluating evidence; they can improve current practices by establishing process changes that improve patient care, patient satisfaction, and patient outcomes. CNL programs do not endorse one specific leadership style but are centered upon high-level communication and accountability.


RNs must be cognizant of the changes in healthcare and seize the opportunity to become leaders within the perioperative setting. Through enhanced communication and empowerment, leaders can emerge among staff members. Transformational leaders can be staff members that possess the qualities needed to change current practice. Through support and educational opportunities, leaders can flourish and develop their skills to become intricate members of an ever-changing healthcare system. Nursing leaders affect all facets of healthcare from staff satisfaction, patient outcomes, to the fiscal status of an institution.9 RNs must become leaders within their own environments in order to transform practice and the future of healthcare locally, nationally, and globally.




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