1. Henrick, Suzanne MPH, MSN, RN
  2. Brennan, Betty EdD, MSN, RN, CEN, CNML
  3. Monturo, Cheryl PhD, MBE, ACNP-BC

Article Content

Modern challenges to our current healthcare environment, including policy reform, nursing shortages, and increased demands on an overly taxed system, require effective leadership. As you know, your individual leadership style impacts the work environment, affecting everything from the development of professional practice to staff engagement, and, ultimately, job satisfaction.1,2

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So, what makes an ideal leader in today's world of nursing? This qualitative study uncovers perceptions by midlevel managers and frontline nurses on what traits and actions define successful and unsuccessful leaders. The findings provide the basis for new strategies for optimization of leadership styles-including the transformational leadership style-and how these strategies can yield a positive impact on the work environment and staff engagement.


Transformational leadership

A main concern of nurse leaders is the creation and sustainability of healthy work environments that attract and retain nurses and enable them to provide quality care. Leadership style is directly linked with the ability to create this type of work environment. In particular, managers can positively or negatively affect work climate.3,4 As numerous research concludes, the relationship between the nurse and the nurse manager is critical to a healthy work environment and seen as a major predictor of job satisfaction and organizational commitment.5,6 Current studies show a trend toward a preference for transformational leadership, but additional research is needed to learn how this leadership style can elevate the professional status of nursing.


Past leadership style trends. Historically, healthcare organizations attempted to motivate employees using transactional leadership styles, which can be exemplified by the presence of conditional rewards and management by exception.2,7,8 This model emphasizes tasks and control by managers, and assumes that the staff response is driven by rewards, such as compensation and praise. Managers intervene with clinical nurses only when something goes wrong.8 This leadership style is based on the "transaction" of job performance for salary, benefits, and acceptable working conditions.

Table Participant pr... - Click to enlarge in new windowTable Participant profile

New way forward. Now, current studies support the concept that clinical nurses desire leaders who are increasingly visible and accessible, and who communicate effectively.5 These qualities are hallmarks of a transformational leader. The theory of transformational leadership proposes that meeting the needs of your direct reports is vital to achieving high work performance.9 By its very nature, transformational leadership lends itself to increased staff/job satisfaction.10 This type of leader invests in staff, inspiring nurses to higher levels of engagement, resulting in improved patient care and outcomes. Managers who use the principles of transformational leadership foster an environment wherein nurses have greater commitment to the organization and high levels of morale and job satisfaction.11


More data are needed. This leadership style is strongly associated with staff satisfaction in other industries.10 Although research exists broadly linking transformational leadership and nursing environment, only one qualitative study examines leadership style from the perspective of both frontline managers and clinical nurses.12,13 Further, clinical research is severely lacking. Additional studies, such as the one outlined here, are needed to more accurately measure the impact of transformational and other leadership styles on a multigenerational workforce and in the nursing environment.


This descriptive study aims to identify the perceptions of leadership style from two distinctly different populations in nursing. Anticipated benefits include insight into the perceptions of nursing staff and mid-level managers. The rationale for including two study groups is based on the relationship regarding the expectations of leaders and interaction between these groups. Results of this study may provide guidance in the development of more effective leadership styles to meet the expectations of those being managed, positively impact the environment, and potentially energize and transform both groups.



This Institutional Review Board-approved qualitative study conducted in a Mid-Atlantic community hospital used a total of 11 focus groups over a 3-week period to explore the research question: "What are the leadership expectations of midlevel managers and frontline nursing staff?" After consenting to take part in the study, volunteers from a list of eligible participants-licensed RNs with a minimum tenure of 2 years functioning as either a frontline patient care provider or clinical manager-completed a demographic survey and chose a scheduled 2-hour, paid focus group session to attend.


Seventy-five participants completed the focus groups. Most were female (97%), Caucasian (97%), and age 41 to 60 (65%). Frontline RNs (89%) made up the majority of the participants. Their practice in the current hospital spanned more than 10 years (57%), and they possessed at least a bachelor's degree in nursing (61%). (See Table 1.)

Table 1: Interview a... - Click to enlarge in new windowTable 1: Interview agenda

The focus groups met in a comfortable conference room selected to promote discussion without clinical interruptions. To allow for free expression of thoughts and protected participant anonymity, the groups were sorted by position: frontline RNs and midlevel managers. A neutral moderator and observer with no direct reporting responsibilities to the participants or their corresponding supervisor attended all focus group sessions. The moderator's responsibility included discussion facilitation via a semistructured guide. (See Table 2.) The moderator asked participants to identify terms that they associated with the concept of leadership. Questions moved from general to more specific, highlighting actual experiences with different types of leaders.


Data analysis. The moderator and observer used a variety of media to record the focus group sessions. Transcripts were then e-mailed to all participants for validation of the discussion content. Participants from each focus group responded to confirm accuracy of transcriptions. An external audit conducted by a qualitative nurse researcher and the creation of an audit trail ensured the dependability of the content.


Review of the transcripts from each focus group was initially performed by the two primary researchers using constant comparison analysis. These researchers then joined the remaining team members for additional analysis of the transcripts. The research team consisted of seven members: two nursing directors/primary researchers, one research director, one critical care educator, one director of nursing quality, one director of the physician liaison program, and one nursing faculty member. Key words or phrases were extracted from text recorded during each focus group.


Trustworthiness was established through several methods.14 Credibility was ensured through analyst triangulation, in which various team members in smaller groups tested for rival explanations and searched for negative cases before coming back to the large group. In addition, the faculty member, a qualitative researcher with experience in conducting and teaching qualitative methods, was added to the team to strengthen credibility.


Key themes

Perceptions from the frontline RNs and midlevel managers were sorted into two broad themes: Management 101 and The Right Stuff.


* Management 101. This category of feedback reflected the fundamental operational aspects of leadership, including the mechanics and logistics of running a unit, and the skills required to effectively negotiate the daily activities of patient care delivery. Feedback included phrases such as "never let them see you sweat," "puts out fires," "calm under pressure," "poised," and "organizes tasks, skill, and time to meet the goal." Conversely, the participants also identified negative perceptions within this category, including phrases such as "some without innate leader qualities" and the extremes of "can't make decisions" to "micro-manager." A larger group of feedback targeted skills necessary to navigate the leadership role, including "knows the best way to proceed," "critical thinker," "great at problem solving," "delegates," "knows the rules of the game," and "has connections." A final group examined the more challenging logistical aspects of a leadership role, including "completes disciplinary action," "ignites a fire when in a stalemate," and "if a staff member is toxic-willing to move." Other perceptions seemed to highlight the longstanding less-desirable traditions before implementation of shared governance, including "some get to the top and don't want to learn more," "lots of meetings," and "the longest seniority can be basis of becoming a leader."


* The Right Stuff. This category described the next level of hierarchy in personal leadership skills. The responses reflected advanced personal skills, building on the fundamental attributes described in Management 101. The feedback was further broken into the following subcategories: descriptors, coaching/mentoring, and moral compass. Descriptors included "articulate," "a beacon in unsteady times," "charismatic," "visionary," "innovative," "approachable," and "open-minded." Coaching and mentoring perceptions included phrases such as "moves nursing forward," "brings out the best in others," "instills confidence," "recognition of achievement, effort, and potential," and "encourages others to seek solutions." A third category of responses highlighted ethical issues related to the presence of a moral compass, including phrases such as "stands up for what's best for patient and staff," "supports a just culture," "principled," and "keeps old values but inspires new." Characteristics within this theme highlighted the positive perceptions of a strong leader. Some responses were paradoxical in nature, illustrating both positive and negative overtones. Examples of this type of response included "facilitator versus dictator," "eat their young" versus "indifferent," and "passive leaders who aren't effective" versus "my way or no way." Other comments included "doesn't realize their work or actions could either build up or tear down," "brings morale down, causes nurses to leave their areas of practice," "some are in it for themselves," and "use us as a stepping stone (just step over us)," all highlighting the effect of a negative change agent.



Data analysis

Adapting leadership styles to meet the expectations of your staff members has the potential to energize and transform both groups. Conversely, managers who focus predominantly on task-related activities are less engaged in relationships with staff.5


Nurses who took part in this study belonged to two distinct groups: frontline staff (nine focus groups) and midlevel managers (two focus groups). It was anticipated that differing perceptions based on this grouping would be found, and this expectation was realized to a large degree. However, the disparity of responses provided by the midlevel manager group wasn't expected. Although the number of midlevel managers resulted in the formation of only two focus groups, this group appeared to be more incongruent regarding leadership definitions and style than the frontline staff. Managers' perceptions included both the fundamental operational aspects of leadership and the advanced personal skills more consistent with transformational leadership, although the majority of responses were task-oriented in nature. Unlike the manager groups, the frontline staff responses were more consistent and displayed a broader vision of leadership and associated strategies more commonly linked with concepts of transformational leadership.


Similar research identified the importance of frontline staff and managers working together to create common ground for good care and professionalism.5 But in our work, it appeared that the groups weren't consistently working together.



The small number of midlevel manager focus groups and the disparity in responses allowed for limited interpretation of that particular role grouping. Additional groups may have provided more typical responses within that role. Smaller groups may have allowed for clearer interpretation of the responses. The study was designed to include audio taping, flip charts by the facilitator, and documentation of field notes by the observer. Although transcripts derived from flip charts and field notes provided key concepts, the poor quality of audio recordings resulted in the inability to use the verbatim responses and, therefore, a loss of some data.


Implications for nursing practice

One of the most powerful sources of evidence for the Magnet Recognition Program(R) is transformational leadership-expected outcome.15 To meet the expectation for this standard, Magnet organizations must demonstrate changes in the work environment and patient care based on input from nurses providing direct care. When implementing this type of cultural change, it's important to recognize the impact on the midlevel manager. With a focus sharply placed on empowering frontline staff, it's imperative that midlevel managers aren't inadvertently disenfranchised.


The span of control for midlevel managers requires evaluation to ensure ample opportunity for professional growth. Because the manager has the most direct interaction with frontline staff, responsibilities based on in-depth knowledge of staff behaviors automatically fall to them. These responsibilities include daily operational aspects of the unit in addition to annual evaluation and counseling. The inability to focus on strategic aspects of leadership can be an unintended consequence in the presence of such complex daily operational issues. To offset these demands and provide time for professional development, organizations must ensure that empowerment of frontline staff is accompanied by expectations of accountability. If these nurses are entrusted to play a strong role in determining patient care and the environment in which they practice, they should also be expected to manage their responsibilities as productive employees. Minimizing the time necessary for resolution of staffing and behavioral issues would significantly reduce the current workload of the midlevel manager, freeing up time to focus on the expansion and development of leadership skills.


Based on the results from this research study, it's imperative that educational efforts advance to include leadership skills and strategies, with the immediate goal of reengaging the midlevel manager and a long-term goal of advancing leadership and succession planning. In addition to investing in the midlevel manager's education, opportunities for broadening the role of the manager should also be evaluated, such as inserting these managers into roles historically held by directors (for example, committee chairs and project leaders).


A transformational future

As demonstrated, the alignment of leadership values between midlevel managers and frontline staff is vital to the development of a healthy work environment and staff engagement. Transformational leadership is essential to propel nursing practice toward this goal. Nurse administrators must balance two critical responsibilities: creating an environment in which the midlevel managers can cement the skills necessary to become transformational leaders, and continuing to encourage the voices of the frontline staff.


Results of this study provide insight into the perceptions of leadership style by RNs in both management and frontline positions. Many responses indicate a lack of distinction between the concepts of leadership and management, leading to interchangeability of these terms. In particular, midlevel managers appear less engaged in leadership and more focused on the task-oriented functions of their role. Although historical models of management such as "good bedside nurses make good managers" are fading with the implementation of shared governance, some of these perceptions still exist. Efforts to clarify terms and advance staff toward transformational leadership need to be well-rounded and inclusive of all roles. These findings may provide a road map for professional development focused on aligning both groups and increased development opportunities for the midlevel manager.




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