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Third Edition
From Expert Clinician to
Influential Leader
Marion E. Broome
Elaine Sorensen Marshall
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Marion E. Broome, PhD, RN, FAAN, is dean of the School of Nursing, vice
chancellor for nursing affairs, and Ruby Wilson Professor of Nursing at Duke
University, as well as associate vice president for academic affairs for nursing at Duke University Health System, Durham, North Carolina. Prior to joining Duke, Dr. Broome was dean of the Indiana University School of Nursing
and associate vice president for nursing at Indiana University Health, where
she was awarded the rank of distinguished professor. Widely regarded as
an expert, scholar, and leader in pediatric nursing research and practice, Dr.
Broome was funded externally by the American Cancer Society, the National
Institutes of Health, and various foundations for two decades. Dr. Broome’s
research is published in more than 121 papers in 58 nursing, medicine, and
interdisciplinary journals. She also has published seven books and 20 chapters.
Dr. Broome is editor in chief of Nursing Outlook, the official journal of the
American Academy of Nursing and the Council for the Advancement of
Nursing Science. She completed a variety of leadership training courses while
serving in the Army Nurse Corp, a Management and Leadership in Education
Certificate from Harvard University, and the Center for Creative Leadership’s
Leading for Organizational Leadership Course.
Elaine Sorensen Marshall, PhD, RN, FAAN, is former Castella Distinguished
Professor and chair of the Department of Health Restoration and Care Systems
Management at the University of Texas Health Science Center School of Nursing,
San Antonio, Texas; former professor and Bulloch Endowed Chair at the School
of Nursing at Georgia Southern University, Statesboro, Georgia; and professor
and dean emerita of the College of Nursing at Brigham Young University, Provo,
Utah. She has served in national elected and appointed leadership positions for
the American Association of Colleges of Nursing, the American Association for
the History of Nursing (AAHN), and the Western Institute of Nursing (WIN).
Dr. Marshall has published two books and more than 50 articles and book
chapters. She received the New Professional Book Award from the National
Council on Family Relations, the Lavinia Dock Award from the AAHN, and the
Jo Eleanor Elliott Leadership Award from the WIN.
From Expert Clinician to Influential Leader
Third Edition
Marion E. Broome, PhD, RN, FAAN
Elaine Sorensen Marshall, PhD, RN, FAAN
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Names: Marshall, Elaine S., author, editor. | Broome, Marion, author,
Title: Transformational leadership in nursing : from expert clinician to
influential leader / Marion E. Broome, Elaine Sorensen Marshall.
Description: Third edition. | New York, NY : Springer Publishing Company,
LLC, [2021] | Author’s names reversed on the previous edition. |
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Contributors vii
Foreword Patricia Reid Ponte, DNSc, RN, FAAN, NEA-BC ix
Preface xi
1. Frameworks for Becoming a Transformational Leader   3
Elaine Sorensen Marshall and Marion E. Broome
2. Transformational Leadership: Complexity, Change, and Strategic
Planning  35
Marion E. Broome and Elaine Sorensen Marshall
3. Current Challenges in Complex Healthcare Organizations
and the Quadruple Aim   67
Katherine C. Pereira and Margaret T. Bowers
4. Practice Models: Design, Implementation, and Evaluation   99
Mary Cathryn Sitterding, Christy Miller, and Elaine Sorensen Marshall
5. Collaborative Leadership Contexts: It Is All About Working
Together  155
Marion E. Broome and Elaine Sorensen Marshall
6. Shaping Your Own Leadership Journey   183
Marion E. Broome and Elaine Sorensen Marshall
7. Building Cohesive and Effective Teams   213
Marion E. Broome and Elaine Sorensen Marshall
8. Creating and Shaping the Organizational Environment and
Culture to Support Practice Excellence   237
Megan R. Winkler and Elaine Sorensen Marshall
vi • Contents
9. Economics and Finance of Healthcare   277
Brenda Talley
10. Leading Across Systems of Care and in the Larger Community   319
Marion E. Broome and Elaine Sorensen Marshall
Margaret (Midge) T. Bowers, DNP, RN, FNP-BC, AACC, FAANP
Associate Professor
Duke University School of Nursing
Durham, North Carolina
Marion E. Broome, PhD, RN, FAAN
Dean and Ruby Wilson Professor of Nursing
Duke University School of Nursing
Vice Chancellor for Nursing Affairs, Duke University
Associate Vice President for Academic Affairs for Nursing
Duke University Health System
Durham, North Carolina
Elaine Sorensen Marshall, PhD, RN, FAAN
Castella Distinguished Professor and Department Chair (retired)
University of Texas Health Science Center School of Nursing
San Antonio, Texas
Bulloch Endowed Chair (retired), School of Nursing, Georgia Southern
Statesboro, Georgia
Professor and Dean Emerita, College of Nursing, Brigham Young University
Provo, Utah
Christy Miller, MSN, RN, CPN
Clinical Program Manager
Cincinnati Children’s Hospital Medical Center
Cincinnati, Ohio
Katherine C. Pereira, DNP, RN, FNP-BC, ADM-BC, FAAN, FAANP
Director, Doctor of Nursing Practice Program
Duke University School of Nursing
Durham, North Carolina
viii • Contributors
Mary Cathryn Sitterding, PhD, RN, CNS, FAAN
Vice President, Patient Services
Center for Professional Excellence
Cincinnati Children’s Hospital Medical Center
Cincinnati, Ohio
Brenda Talley, PhD, RN, NEA-BC
Clinical Associate Professor
The University of Alabama in Huntsville
Huntsville, Alabama
Megan R. Winkler, PhD, RN, CPNP-PC
Researcher, Division of Epidemiology and Community Health
University of Minnesota School of Public Health
Minneapolis, Minnesota
I am so pleased to be writing the foreword for the third edition of Transformational
Leadership in Nursing: From Expert Clinician to Influential Leader. As a seasoned
health services nurse leader, I know much about the complexities and challenges of healthcare delivery, and I appreciate the importance of effective leadership in advancing excellence in this important domain.
This book provides readers with a vibrant and up-to-date view of these
complexities and challenges. It imparts a plethora of knowledge, both theoretical and empirical, that positions readers to develop their own effectiveness as
people and leaders so that they can ultimately positively influence healthcare
delivery in the future. This book is perfectly geared toward nurses who are
interested in becoming more effective and more influential people and leaders
as they carry out their professional roles in healthcare delivery.
When I first read the second edition of Transformational Leadership, I knew
immediately that this was the book I would use to teach nurses to be effective
leaders. I recently transitioned from my health services role to teaching DNP
students full time. I was designing the leadership course for a new DNP program and looking for just the right book. When I found the second edition, I was
immediately taken with the usefulness of the entire book. Every chapter was
filled with the content I knew I needed to prioritize for our new course.
When I reached out to Marion Broome and Elaine Marshall about my interest in knowing if a third edition would be coming out soon, I was so delighted
to hear that, in fact, the plan for that was well underway. Both Marion and
Elaine have incredible depth in their own expertise and experience in leading
in the academic setting. They could not be better suited to be editors for this
important text. That was evident to me as I read the second edition.
In this current edition, a comprehensive overview of leadership theory sets
the stage in the first chapter, but it does not stop there. The book encourages
readers to personalize the knowledge imparted in the book to their unique characters and roles in the healthcare setting. This book is written with application
in mind. It highlights key challenges that leaders face and provides ideas and
strategies based in evidence that can guide their planning, implementing, and
evaluating tactics and strategies to ensure excellence in all they do. There are
personal vignettes, cases, reflective questions, and a robust set of references for
even further exploration.
x • Foreword
What is most valuable about this particular nursing leadership book is that
it addresses the current healthcare system. It is rich with what is real today. In
this new third edition, several chapters were revised to add or update key priorities within healthcare delivery today. For instance, a chapter on the design,
implementation, and evaluation of innovative practice models is provided.
Additionally, the growth of population health initiatives and the importance
of recognizing, improving, and innovating care delivery across the continuum
are fully addressed. Information technology, use of machine learning, and the
possibilities of future technology for personalizing and guiding care are also
addressed. Nurse faculty, nursing students, practicing nurses, and APRNs alike
will find this third edition extremely helpful in their quest to improve care delivery while improving their own effectiveness as people, nurses, and leaders.
The authors use the term transformational as less about ascribing to a particular leadership theory and more about helping transform practice settings and
people who work in them through recognition of the benefits of diversity, by
encouragement of creativity, innovation, and professional development. They
also stress how important it is to recognize the importance of standards, policies, guidelines, recognition, governance, regulations, structures, and processes
that ensure that excellence is always present.
The authors also advance the idea that leadership is personal, it is a lifelong
journey, and it is about serving others and self with compassion, humility, and
kindness. That said, the book emphasizes execution and outcomes. In this way,
Transformational Leadership in Nursing: From Expert Clinician to Influential Leader
is very practical but also philosophical and clearly provides readers with a set
of values, principles, and evidence by which to start down the road of making a
tremendous difference in people’s lives.
Patricia Reid Ponte, DNSc, RN, FAAN, NEA-BC
Associate Clinical Professor
William F. Connell School of Nursing
Woods College of Advanced Studies
Master of Health Administration Program
Boston College, Chestnut Hill, Massachusetts
Professor of Practice—Adjunct
College of Natural, Behavioral, and Health Sciences
Simmons University, Boston, Massachusetts
This book is for nurse leaders of the future. It speaks to clinicians who are experts
in patient care and are now on a path toward leadership. Several clinician leaders offer their insights in their chapters, while other scenarios and examples
drawn from practice are placed throughout the book. This book is offered as
a resource as you embark on your own journey toward transformational leadership. You are needed to lead in the setting where you practice: from a solo
practice clinic in the community to the most complex healthcare system. From
an isolated rural community to an urban health sciences center, it is clear that
nurse leaders like yourself are needed to forge new and innovative models of
care that can meet the challenges of patients and families with whom we work.
If you are reading this book, you are likely already prepared for clinical practice.
You may be an expert in patient care, you may work as a manager in administration, or you may teach clinical nursing. Your challenge now is to enhance
your skills and stature to become an influential leader. If that “becoming” is
not a transforming experience, it will not be enough to prepare you to lead in
a future of enormous challenges. The future of healthcare in the United States
and throughout the world requires leaders who are transformational in the best
and broadest sense. It requires a thoughtful, robust sense of self as a leader. It
requires an intellectual, practical, and spiritual commitment to improve clinical
practice and lead others toward their own transformation in their professional
journey. It requires courage, knowledge, and a foundation in clinical practice. It
requires an interdisciplinary fluency and ability to listen, understand, and influence others across a variety of disciplines. Transformational leadership requires
vision and creativity!
Many who use this book are students in programs of study for a clinical
practice doctorate, for example, the DNP. A decade ago, the DNP emerged as
the credential for leaders in clinical practice. The DNP Essentials and the position statement on the DNP of the American Association of Colleges of Nursing
(AACN, 2004) called for a “transformational change in the education required
for professional nurses who will practice at the most advanced level of nursing” (AACN, 2006, p. 4) and “enhanced leadership skills to strengthen practice
and health care delivery” (AACN, 2006, p. 5). Such transformational leaders
focus not only on settings of direct patient care but also on healthcare for entire
xii • Preface
communities. The 2020 version of the DNP Essentials is being developed as we
send this book to press. But the core values of doctoral education—knowledge
translation, leadership, and practice excellence—serve as core concepts in this
This work is neither a comprehensive encyclopedia for healthcare leadership nor a traditional text in nursing management. Rather, its purpose is to
identify some key issues related to leadership development and contexts for
transformational leaders in healthcare. The book is meant to introduce you, as a
clinical expert, to important issues in your own aspirations toward becoming a
leader. It is offered as a text and supplement to your own study of the literature,
experts, and important experiences in the transition to leadership. It is meant to
accompany and guide you to more focused current literature and experts on a
variety of issues that healthcare leaders face. It is an aid to launch or guide you
on your own journey to become a leader.
You will read about transformational leadership, which needs some clarification. Although there are some formal theories and definitions of transformational leadership, this work refers to the concept in its best and broadest sense
without adhering only to a specific theoretical perspective. This book is heavily
referenced not only to provide citation but also to lead you to a vast range of
literature—both seminal and contemporary.
In this third edition, we have made some changes to update the messages
for present-day and future readers. We provide more opportunities for students
of leadership to access contemporary thinking of leaders from a variety of fields
through links to TED Talks, blogs, and other media. Because a global view of
healthcare is essential to today’s leader, global perspectives have been added
throughout the book. The focus on the context of complex healthcare organizations has been sharpened, with attention given to current legislation and concepts such as the Quadruple Aim to increase access, decrease costs, and improve
quality; seamless care delivery; and competencies of the American Organization
of Nurse Executives. There is also increased attention to national patient safety
benchmarks, issues in health disparities, workforce issues, and patient and
consumer satisfaction. We have invited experts to contribute on important
issues of interprofessional collaboration, creating and shaping diverse environments for care, healthcare economics, and other significant areas of leadership
The messages of this book are to be taken personally. Your journey toward
transformational leadership is a deeply personal one, and it requires courage
and creativity. Throughout the book, we provide cases of “Leadership Action”
for you to read about and see how nurses just like you played to their strengths,
sought out mentors, and solved complex problems. Finally, you will find discussion questions and occasional personal stories and opportunities to guide
your own personal reflection. We hope you enjoy reading this text and using
Preface  • xiii
what content and activities resonate with you as you continue your leadership
Marion E. Broome
Elaine Sorensen Marshall
American Association of Colleges of Nursing. (2004). AACN position statement on the
practice doctorate in nursing. Washington, DC: Author.
American Association of Colleges of Nursing. (2006). The essentials of doctoral education
for advanced nursing practice. Washington, DC: Author.
Qualified instructors may obtain access to supplementary PowerPoints
by emailing textbook@springerpub.com.
Frameworks for Becoming a
Transformational Leader
Elaine Sorensen Marshall and Marion E. Broome
A leader takes people where they want to go.
A great leader takes people where they don’t necessarily
want to go but ought to be.
—Rosalynn Carter
• To consider the challenges facing today’s leaders in healthcare systems and the need
for leaders who can transform these challenges into opportunities
• To review foundational historical and theoretical contexts for leadership
• To discuss the evolution and envisioned role of doctorally prepared nurses in healthcare systems and how they can exert positive influence as leaders within these systems
• To explore theoretical contexts in the discipline of leadership to guide transformational leadership
• To use activities within this book to develop leadership skills, assess current and
preferred future environments to make a difference, and shape the future of nursing
and healthcare
The world needs visionary, effective, and wise leaders. Never has this statement
been truer than it is in the world of healthcare today. Leadership matters. It matters
in every organization, not only for nurses to thrive in their careers but for them
to advance effective healthcare for society. The current state and pace of healthcare change continue to create unprecedented challenges for individuals, families,
and communities of the nation and the world. Healthcare continues to grow more
complex, corporate, costly, and expansive. In the United States, we face urgent
problems of system complexity, financial instability, and poor distribution of
resources; shortages of clinicians and provider expertise; issues of patient safety;
and controversy about who will pay for what, at what level of quality, and at what
cost for services (Institute of Medicine, 2010; Siwicki, 2017). Furthermore, leaders
face a host of health problems and disparities, such as greater incidence of chronic
illnesses, comorbidities, new epidemics of infectious diseases and opioid use, and
growing numbers of vulnerable, underserved, and aging populations. Important
issues of artificial intelligence, cybersecurity, disaster preparedness, drug prices,
and patient experiences add further challenges to today’s leaders (Siwicki, 2017).
Meanwhile, society impatiently waits with waning confidence in the current healthcare system. Dialogue becomes more strident, and positions become more polarized in legislatures, the federal government, among private insurers, and within
health systems themselves. Where are the transformational leaders who can take
us through these turbulent times?
The healthcare professions of past decades focused on clinical practice
and educational preparation for practice (Broome, 2019). Society demanded
clinical experts to master the burgeoning body of knowledge, research, clinical
information, and skill sets. Nurses, physicians, and other health professionals
across disciplines responded to that challenge, as they became highly specialized clinical experts. They devoted years of learning and practice to achieve
clinical excellence. Despite years of intermittent shortages, the nursing profession continued to provide registered nurses at the bedside, advanced clinical
specialists who worked in acute care settings providing and managing care for
patients, APRNs who practiced in primary care to provide health promotion
and management of chronic conditions, and administrators who led health systems through difficult demands of society. These professionals effectively met
healthcare needs for thousands of individuals and families. If you are reading
this book, you are among those nursing professionals who have made major
contributions to care delivery. The profession and society will continue to need
expert clinicians like you.
The context of health and healthcare has changed dramatically in the past
decade. We now recognize that patients spend most of their time living with
their illness outside clinics and inpatient units. Our care delivery models of the
past heavily focused on highly technical inpatient settings. Care is now, more
than ever, expanded into the community and the homes of patients. Our need
now is for leaders who can work within and across systems and settings. Your
clinical expertise, whether it is in direct patient care, clinical education, research,
or administration, is needed as a foundation for your emerging leadership in
changing healthcare environments. We need nurse leaders who can draw from
their roots in clinical practice to collaborate with leaders in other disciplines,
with policy makers, and with members of the community to create new solutions to the problems facing all of us, to improve quality of life, to transform
healthcare systems, and to inspire the next generation of leaders.
1. Think about your current practice environment. Is it organized in such
a way that patients and staff feel safe, cared for, and able to express
2. Are you ready to think of your practice in a different way?
3. What are the areas in your practice where you notice a need for a new
kind of leadership?
4. What new challenges do you face in your practice?
Preparation at the highest level of practice must include preparation for
leadership. The world needs expert clinicians to become transformational leaders. The world needs you to become a leader to transform healthcare for the
next generation.
The story of modern Western nursing began with little noted but great leaders,
and it traditionally starts with Florence Nightingale. Although her contributions
are not usually described from a purely leadership perspective, the inspiration
and effectiveness of her leadership have been celebrated for over 150 years. Her
work in Scutari, Turkey, designing safer healthcare environments and hospital
structures, training nurses, and using epidemiological data to improve health,
can only be described as “transformational.” The list of other transformational
leaders in the history of nursing practice is daunting, including some who are
unrecognized today. Well-known charismatic leaders in nursing of the 19th
century include Clara Barton, who founded the American Red Cross; Dorothea
Dix, who championed advocacy for patients and prisoners and who ruled her
staff nurses with an iron fist; and, perhaps, even Walt Whitman, the celebrated
poet who was a volunteer nurse during the American Civil War.
Best-known and revered models in our heritage of leadership in nursing
include the handful of women in North America at the dawn of the 20th century who are credited with the vision of professional nursing: Isabel Hampton,
Mary Adelaide Nutting, Lavinia Lloyd Dock, and Lillian Wald (see Keeling,
Hehman, & Kirchgessner, 2018 for a comprehensive history of nursing).
• Hampton led nurse training at Johns Hopkins in Baltimore and was the first
president of what became the American Nurses Association. “Her vision
of nursing . . . required a transformation of . . . accepted norms. [Her work]
demonstrated her ability to effectively lead change and inspire others toward
her cause” (Keeling et al., 2018).
• Nutting was Hampton’s student at Johns Hopkins and was among the first
visionaries to foresee academic nursing education, rather than apprentice
nurse training solely in hospitals. She led efforts to develop the first university nursing programs at the Teachers College of Columbia University and to
secure funding for such programs (Gosline, 2004).
• Dock was a strong woman who was involved in many “firsts” that influenced
the profession for years. She firmly believed in self-governance for nurses and
called for them to unite and stand together to achieve professional status. She
was among the founders of the Society for Superintendents of Training Schools
for Nurses, which later became the National League for Nursing (2019), and
an author of one of the first textbooks for nurses and history of nursing. She
encouraged nurses and all women to become educated, to engage in social
issues, and to expand their views internationally (Lewenson, 1996). She was
known as a “militant suffragist” and champion for a broad range of social
reforms, always fighting valiantly for nurses’ right to self-governance and for
women’s right to vote.
• Wald, who modeled the notion of independent practice a century before it
became a regulatory issue, founded the first independent public health nursing practice at Henry Street in New York. She not only devoted her life to caring for the poor people of the Henry Street tenements but also was the first to
offer clinical experience in public health to nursing students. She worked for
the rights of immigrants, for women’s right to vote, for ethnic minorities, and
for the establishment of the federal Children’s Bureau (Brown, 2014).
Many other leaders of the 20th century valiantly promoted the development of the profession of nursing. Among them was Mary Elizabeth Carnegie,
who established one of the first baccalaureate programs in nursing in 1943
at Virginia’s Hampton University (American Association for the History of
Nursing, 2018). She became the first African American nurse to be elected
to a board of directors of a state nurses association (Florida). She was on the
editorial staff of the American Journal of Nursing, was senior editor of Nursing
Outlook, and the first editor of Nursing Research. Carnegie was a president of the
American Academy of Nursing and was awarded eight honorary doctorates
over the course of her career. Her legacy of leadership included making the
contributions of African American nurses visible in the professional literature
(see Carnegie, 2000).
Ildaura Murillo-Rohde was a Panamanian American nurse, academic, and
organizational administrator. She came to the United States in 1945 and studied
at Columbia University. She was the first Hispanic nurse awarded a PhD from
New York University. Her specialty was psychiatric–mental health nursing, and
she was an outstanding advocate for mental health needs of Hispanics. MurilloRohde was an associate dean at the University of Washington and the first
Hispanic dean at New York University. She founded the National Association
of Spanish-Speaking Spanish-Surnamed Nurses in 1975 and served as its first
president. She was named a living legend in the American Academy of Nursing
(National Association of Hispanic Nurses, 2019).
Modern leadership for advanced practice in the mid-20th century ultimately
led to the development of the DNP degree. The vision, courage, and leadership
qualities of Loretta Ford and Henry Silver at the University of Colorado are evident in their pioneer work in establishing the first nurse practitioner program in
the United States in 1965. By the 1990s, preparation for advanced nursing practice had moved to the master’s degree. Now, in the face of increasing complexity of healthcare, trends among other healthcare disciplines toward doctoral
preparation, and the urgent need for knowledge workers and wise leaders, the
practice doctorate is becoming the required preparation for advanced practice
Today’s healthcare leaders inherit courage, vision, and grit that must not be
disregarded. We stand on the shoulders of valiant nursing leaders of the past
who left a foundation that cries for study of its meaning and legacy for leadership today. They were visionary champions for causes that were only dreams
in their time but today are essential. They dared to think beyond the habits and
traditions of the time. These leaders were truly transformational. You are among
the pioneer leaders to move healthcare forward to better serve society.
Lurking in the archives of your own institution, community, or state are the
stories of other exemplary leaders in nursing and healthcare.
1. Who were/are they?
2. How have they changed healthcare?
3. What can you/we learn from them?
Although the theme of this book is transformational leadership, it is important
to understand that the purpose, content, and principles of this book are not confined to the tenets of a specific theory of transformational leadership. To become
a full citizen of the discipline, it is important that the transformational leader
in healthcare understands the history, culture, and theoretical language of the
science and practice of the discipline of leadership. Here we explore several
leadership frameworks of the past and present with the expectation that some
might resonate with you in your own career.
The popularity of any particular theory for leadership may wax or wane, but
some leadership principles are timeless. Any truly transformational leader will
have a solid foundation of understanding of the value of a theoretical approach
to leadership in practice.
The first principle for leadership is that leaders be grounded in a set of
ethics or core values that guide human behaviors and actions. No matter how
brilliant the strategy or how productive the actions, if leaders do not hold the
trust and act in the best interests of those they serve, they are not competent.
Leaders in today’s healthcare and academic settings deal with a variety of ethical issues and must ground themselves in values that enable them to lead
with grace and effectiveness. Nurse leaders have a responsibility to shape ethical cultures (Broome, 2015) using the knowledge of ethical standards in the
discipline (American Nurses Association, 2015) and expert guidelines (Johns
Hopkins Berman Institute of Bioethics, 2014). More than a decade ago, YoderWise and Kowalski (2006, p. 62) outlined the following principles for ethical
leadership: respect for others, beneficence (promoting good), veracity (telling
the truth), fidelity (keeping promises), nonmaleficence (doing no harm), justice (treating others fairly), and autonomy (having and promoting personal
freedom and the right to choose). Such principles continue to be reflected in
leadership today.
Historical Overview of Leadership Theories
It is beyond the scope of this text to provide a comprehensive history of
leadership theories. A brief review is offered to give a sense of how traditional theories continue to influence leaders. Early management theories
were developed during the industrial revolution and, thus, reflect the factory environment of worker productivity. Such theories included classic
and scientific management theory that emphasized formal processes of the
organization rather than the characteristics or behaviors of the individual.
Primary concepts included hierarchical lines of authority, chain-of-command
decision-making, division of labor, and rules and regulations. Such theories
were originated by early 20th-century industrial thinkers such as Max Weber,
Frederick W. Taylor, F. W. Mooney, and Henri Fayol. Approaches focused on
organization and processes. They included time-and-motion studies, mechanisms, and bureaucracy. Advantages of such theories were clear organizational boundaries and efficiency. Disadvantages included rigid rules, slow
decision-making, authoritarianism, and bureaucracy (Garrison, Morgan, &
Johnson, 2004).
Behavioral and Trait Theories
In the mid-20th century, management focus turned away from the organization and moved toward people within the organization. Theories that emerged
may be referred to as behavioral or trait theories. Even with a new focus on
people rather than organizations, early behavioral theories promoted linear
thinking, compartmentalization, functional work, process orientation, clear
and fixed job requirements, and predictable effects (Capra, 1997; Cook, 2001;
Wheatley, 1994).
Other early behavioral theories moved the focus from people, or even leaders
themselves, to an emphasis on the concept of leadership. Thus, the ideas of leadership styles emerged. Styles were considered people based, task based, or a combination of both. Such styles include authoritarian, democratic, and laissez-faire
(Lewin, Lippitt, & White, 1939). Leaders were expected to determine objectives,
initiate action, and coordinate the efforts of workers. These early theories set
the stage for modern theories of management by objectives (Williams, 2017).
Problems with behavior or style theories are related to the issue of context.
For example, in the heat of a crisis, such as pandemic influenza, which style is
most effective? Theory X or Theory Y? Do the styles describe all aspects of the
personality, character, motivation, or behavior of the leader? Do the behavioral
styles account for all situations? Which, if any, style is uniquely applicable to leaders in healthcare? Another important question is, “Do all individuals respond to
certain styles or do followers require some tailoring or combination of styles?”
Current trait theories seem, in some respects, to return to an old “great person” approach as they target the intellectual, emotional, physical, and personal
characteristics of the leader. Trait theories propose that desirable characteristics
of successful leaders may be learned or developed. Trait theories continue to
be popular. Just pass by a bookstore in any airport to find shelves full of business or leadership self-help books based on some list of qualities, behaviors, or
habits marketed for success. The notion of successful leadership traits cannot
be denied, but the science of predicting optimal traits under differing circumstances has still not matured.
Emotional intelligence is increasingly recognized as an important characteristic of effective and successful leaders. It may be considered here among trait
theories. It includes self-awareness, self-management of emotions, empathy,
and effective communication and relationship management. These characteristics allow leaders to deal with the daily challenges in healthcare organizations
by understanding how they respond to stress, how to regulate emotions such
as anger and resentment, and how to make decisions and communicate their
rationale to others. Since Goleman’s original work on emotional intelligence in
1995, his work continues to influence leaders in many areas, with growing use
in nursing and medicine (see Carragher & Gormley, 2017; Goleman, Boyatzis,
& McKee, 2002; Heckemann, Schols, & Halfens, 2015; Johnson, 2015; Lewis,
Neville, & Ashkanasy, 2017).
See Table 1.1 for examples of behavioral and trait theories over time.
TABLE 1.1 Examples of Behavioral and Trait Theories for Leadership
Theory X
Theory X is a directive style, wherein the
leader makes decisions, gives directions, and
expects compliance.
The leader is a
motivator and role
model for follower
Follower productivity is related to incentives
and punishments.
Theory Y
(McGregor, 2006)
Theory Y is a participative style, wherein the
leader seeks consensus.
Followers focus on quality and productivity
and are rewarded for problem-solving.
Theory Z (Ouchi,
The theory Z leader promotes employee–
follower well-being on and off the job
to promote high morale, satisfaction,
stable personnel employment, and high
(Gardner, 1989)
Leadership attributes include physical vitality
and stamina, intelligence and action-oriented
judgment, eagerness to accept responsibility,
task competence, understanding of followers
and their needs, skill in dealing with
people, need for achievement, capacity to
motivate people, courage and resolution,
trustworthiness, decisiveness, selfconfidence, assertiveness, and adaptability.
This promotes
less “theory,” with
associated concepts
and propositions,
and more “lists”
of preferred
characteristics or
Eight habits
(Covey, 1989,
Eight habits of successful leaders:
• Be proactive and take goal-directed action
rather than reacting to circumstances
• Begin with the end in mind—goal oriented
• Put first things first—distinguish important
versus urgent
• Think win–win—negotiate to mutually
• Seek first to understand, then to be
• Synergize—engage in activities that
amplify most effective aspects of all
leadership habits
The first seven
habits codified
principles in a
national bestseller
of the popular
business literature.
Later Covey added
the eighth habit of
“finding your voice.”
TABLE 1.1 Examples of Behavioral and Trait Theories for Leadership (continued)
• Sharpen the saw—attend to personal
maintenance and renewal
• Find and express your voice in vision,
discipline, passion, conscience
attributes (Shirey,
2006, 2009, 2017)
Leadership attributes: genuineness,
trustworthiness, reliability, compassion,
Provides another list
of commonsense
Organization of
Nurse Executives,
Leadership competencies:
• Communication and relationship-building
• Knowledge of the healthcare environment
• Leadership
• Professionalism
• Business skills
Provides a list
of specific skills
related to nursing
Situation/Contingency and Constituent Relationship Theories
Situational theories grew largely as a reaction to trait theories, proposing the
opposite premise that the characteristics of the situation, rather than personal
traits of the person, produced the leader (see Table 1.2). Theorists called for a
repertoire of leadership traits or styles and defined the appropriate style for specific types of situations. Building on the work of Lewin et al. (1939), situational
theory would propose that authoritarian leadership may be required in a time
of crisis, a democratic style in situations for team or consensus building, and
laissez-faire style in traditional single-purpose, well-established organizations.
1. What do you think are ideal conditions under which one learns successful
leadership traits?
2. What leadership traits might be needed in a leader of a state public
health department? Are these similar to those needed by the chief
nursing officer of a large hospital system? If different, which ones are
needed and why?
3. What leadership traits do you think would be most predictive of
effectiveness in a particular role?
4. Which theory best “fits” your perception of effective leadership?
TABLE 1.2 Examples of Situational and Constituent Interaction Theories for
Path–goal theory
(House, 1971)
Leader responds to follower motives in
working relationships.
Leader influences
followers’ perceptions
of work and goals
and creates paths to
attain these goals and
expectancies for goal
Leader identifies and removes barriers,
gives support and direction, secures
resources, and facilitates goal or task
achievement of followers.
Leader focuses on followers’ needs for
affiliation and control by promoting
clarity of expectations and supportive
Describes transactional leader behaviors
as achievement oriented, directive,
participative, or suppressive. These
are connected to environmental and
follower factors or situations.
theory (Hersey &
Blanchard, 1977;
Hersey, Blanchard,
& Johnson, 2008)
Four leadership styles and associated
• Telling, or giving direction
• Selling, or participatory coaching
• Participating, or sharing
• Delegating, or assigning responsibility
for task or goal achievement
Expands scenario in
which leadership occurs
to include follower and
situational needs.
Leader in context
of quanta and
chaos theory
(Porter-O’Grady &
Malloch, 2011)
Recognition of phenomena of
disequilibrium, disorganization, or chaos
to lead a natural course to new orders.
Constant change is a way of being.
Leadership and organizations can thrive
on the paradox that order can emerge
from disorder.
Application of “New
Age” theories from
physics to leadership.
Allowance for
phenomena beyond the
control of the leader to
evolve and emerge.
• Partnership
• Accountability
• Equity
• Ownership
TABLE 1.2 Examples of Situational and Constituent Interaction Theories for
Leadership (continued)
(Goleman et al.,
Monitoring of emotional perceptions of
self and others.
Expands concepts of
social–emotional aspects
of human relationships
to complement
traditional business
• Self-awareness
• Self-management
• Social awareness
• Relationship management
Five steps to advance as leader:
• Identify “ideal self”
• Identify “real self”
• Create a plan to build on strengths
• Practice the plan
• Develop trust and encourage others
Servant leadership
(Van Dierendonck,
Leader’s motivation is to serve and
meet the needs of others. Rather than
directing followers, the leader inspires,
motivates, influences, and empowers.
Servant leaders combine
their motivation to lead
with a need to serve
Ten characteristics:
• Humility
• Empathy through framing questions
• Authenticity
• Awareness
• User of persuasion
• Interpersonal stewardship
• Foresight
• Provide distraction
• Commitment to the growth of people
• Co-builder of learning/working
Thus, the leader would adjust behaviors according to circumstances of worker
experience, maturity, and motivation. Less-motivated workers would require
a directive task focus, and highly motivated workers would require a focus on
support and relationships. See Table 1.2 for examples of situational and constituent theories.
Situational/contingency theories represented attempts to consider both the
leader and the situation. However, studies over the past few decades were most
often done in typical American, middle-class, male organizations with little
regard for situations or styles that considered gender, culture, political climate,
or specific types of organizations such as those of healthcare. Relationshipbased theories, which evolved more recently, paved the way for more transformational theories in the 21st century that are believed to be critical to the success
of any organization and leader. They also expanded thinking to incorporate the
notion that engaged followers are an essential part of any leader’s effectiveness.
As you thought about your answers to the earlier reflection questions, did you
think of certain individuals who were more effective than others as leaders in
your own experience? Or did you ask yourself some basic questions such as,
“What is leadership?” or “Who are the leaders we need?” Leadership is one
of those difficult concepts that is sometimes readily identified but never easily
defined. Simply put, leadership is the discipline and art of guiding, directing,
motivating, and inspiring a group or organization toward the achievement of
common goals. It includes the engaging and management of people, information, and resources. It requires energy, commitment, communication, creativity,
and credibility. It demands the wise use of power. Leadership has been defined
by many people over the years.
Leadership is the ability to guide others, whether they are colleagues, peers,
clients, or patients, toward desired outcomes. A leader uses good judgment, wise
decision-making, knowledge, intuitive wisdom, and compassionate sensitivity
to the human condition—to suffering, pain, illness, anxiety, and grief. A nursing
leader is engaged and professional and acts as an advocate for health and dignity.
You might also ask at this point, “But what does a leader do?” Leaders “are
people who have a clear idea of what they want to achieve and why” (Doyle
& Smith, 2009, p. 1). They are usually identified by a title or position and are
often associated with a particular organization—but not always. Leaders are the
resource for confidence, assurance, and guidance. Renowned leadership guru
Peter Drucker (2011) listed the following things leaders must do to be effective:
• Ask what needs to be done.
• Ask what is right for the enterprise.
• Develop action plans.
• Take responsibility for decisions.
• Take responsibility for communicating.
• Focus on opportunities, not problems.
• Run productive meetings.
• Think and say “we” not “I.”
These are pragmatic but highly effective strategies to motivate others,
improve the organization, and empower followers to achieve excellence. Not
a single item on the list is easy or straightforward, but each provokes thinking
and action. All can be learned behaviors if one is open to that learning.
Leaders are seldom born, made, or found by luck, but rather they emerge
when preparation, character, experience, and circumstance come together at
a time of need. Those leaders build on strong leadership characteristics they
always had. Leaders are most often ordinary people demonstrating extraordinary courage, skill, and “spirit to make a significant difference” (Kouzes &
Posner, 2007, p. xiv).
So, you can prepare yourself and learn to be a leader. That is one reason you
seek additional education. Others in your environment can and will support,
coach, and mentor you as you learn to know yourself and your strengths, try on
new behaviors, and own your future. The purpose of this book is to help you as
an advanced clinician to prepare to become a transformational leader.
Transformational Leadership
Simply defined, transformational leadership is a process through which leaders
influence others by changing the understanding of others of what is important
(Broome, 2013). An operative word here is process. It is not just a list of attributes
or characteristics but a dynamic and ever-evolving style that is focused on self,
others, the situation, and the larger context. Transformational leaders inspire
others to achieve what might be considered extraordinary results. Leaders
and followers engage with each other, raise each other, and inspire each other.
Transformational leadership includes value systems, emotional intelligence,
and attention to each individual’s spiritual side. It connects with the very soul
of the organization and honors its humanity. It raises “human conduct and ethical aspirations of both the leader and the led and, thus has a transforming effect
on both” (Burns, 1978, pp. 4, 20). Transformational leaders are energetic, committed, visionary, and inspiring. They are role models for trust. Their leadership is based on commitment to shared values. For over a decade, nurses have
discussed the need for transformational leaders. Where and how leadership is
truly “transformational” in nursing and healthcare may still not be clear, but
there is no question that such leadership is much needed.
The original concept and foundational theory for transformational leadership are attributed to James MacGregor Burns, who proposed the idea in
1978. Other leadership scholars continue to build on the principle. Bass (1985)
developed the concept of a continuum between transactional and transformational leadership. As noted earlier, Goleman further advanced the perspective to include aspects of emotional intelligence, such as self-awareness,
self-­management, social awareness, and relationship management (Goleman
et al., 2002; Heckemann et al., 2015). Bass, Avolio, and Jung (2010) created an
instrument to measure transformational leadership, and many studies have
been conducted in diverse settings and disciplines to examine leadership among
various groups. Since this book does not embrace a sole theoretical perspective,
transformational leadership is considered here in its best and broadest sense, as
a context and backdrop for leadership development.
Components of Transformational Leadership
Though we refer to transformational leadership in its broadest sense, without
strict adherence to a specific theoretical framework, it is important to recognize
and review the foundational seminal work on the concept. Some of the core
concepts of transformational leadership, as developed by theorists Burns and
Bass (Bass, 1985, 1990; Bass, Avolio, Jung, & Berson, 2003; Bass et al., 2010; Bass
& Riggio, 2006; Burns, 1978), are outlined in the following paragraphs.
A transformational leader is a role model of values and aspirations for followers. He or she inspires trust and commitment to a cause. Charisma refers to the
ability to inspire a vision. Unlike the individual with narcissistic charisma, who
focuses on self, the person with charisma of idealized influence finds effectiveness stemming from a strong belief in others. Charisma is the ability to influence others, to inspire not only a willingness to follow, but also an expectation
of success, an anticipation of becoming part of something greater than self.
Charismatic leaders know who they are and where the organizational unit they
are leading has the potential to go. They have themes and personal mantras
in their lives. One leader keeps a file called “Dream” that holds ideas about
future opportunities, or another keeps a hand-drawn diagram of her “Tree of
Life” showing the roots, trunk, and branches of her life and future. Charismatic
leaders, grounded in a commitment to values, influence others to make a positive difference in the world. Healthcare needs such leaders. Indeed, one study
demonstrated higher satisfaction and greater happiness among workers who
follow a charismatic leader (Erez, Misangyi, Johnson, LePine, & Halverson,
2008). On the other hand, other researchers found that leaders too high in charisma may be less effective because they are not able to engage in operational
demands. Their conclusion was that too little charisma brings less strategic
thinking and behavior, while too much may not get the job done (Vergauwe,
Wille, Hofmans, Kaiser, & DeFruyt, 2018).
Charismatic leaders often emerge in times of crisis. They exhibit personal
qualities that draw people to believe and follow them. If they are wise, they
inspire followers in a synergistic manner that provides safety, direction, beliefs,
and actions that exceed the expectations of either follower or leader.
To be charismatic does not mean to be flamboyant. Indeed, the most successful leaders “blend extreme personal humility with intense professional
will” they are often “self-effacing individuals who display the fierce resolve
to do whatever needs to be done to make the [organization] great” (Collins,
2001, p. 21). In their early seminal study of 28 elite companies (i.e., those who
moved from “good to great”), Collins and colleagues found that level 5 (transformational) leaders channeled their ego away from themselves to the larger
goal of building a great company. They were ambitious—but more for their
organization than for themselves. One charismatic leader shared, “I want to
look out from my porch at one of the greatest companies in the world someday and be able to say, ‘I used to work here’” (Collins, 2001, p. 26). Collins also
later confirmed that the steady commitment to move forward, such as “turning a flywheel,” creates momentum toward success for the entire enterprise
(Collins, 2019).
Charisma may refer to a quality of authenticity, transparency, and trust that
draws others to you to share the vision and the will to work toward the goal.
Kouzes and Posner (2012) noted that such leaders may be ordinary people who
accomplish extraordinary results by being role models, being examples, and
leading by behavior that authentically reflects the behaviors expected of and
admired by others.
Transformational leaders also create a compelling vision of a desired future.
Kouzes and Posner (2007, p. 17) explained, “Every organization, every social
movement, begins with a dream. The dream or vision is the force that invents
the future.” Thompson (2019) outlined how successful leaders create a shared
vision: Be clear about the desired destination, dream big, communicate a strong
purpose, and set strategic goals. Transformational leaders influence others by
high expectations with a sight toward the desired future. They set standards
and instill others with optimism, a sense of meaning, and commitment to a
dream, goal, or cause. They extend a sense of purpose and purposeful meaning
that provides the energy to achieve goals. They inspire from a foundation of
The transformational leader is a broadly educated, well-informed individual
who looks at old problems in new ways. He or she challenges boundaries,
promotes creativity, and applies a range of disciplines, ideas, and approaches
to find solutions. This involves fearlessness and risk-taking. The transformational leader in healthcare reads broadly, takes lessons from many disciplines
beyond clinical practice, and engages as an interested citizen in public discourse
on a full range of topics. Such a leader may find strategies from the arts and
literature, humanities, business, or other sciences. He or she consults experts
from a variety of fields and settings to weigh in on complex problems faced
by the organization. Such leaders ask questions. Asking questions about problems, large and small, allows leaders to understand the landscape in which the
problem “lives,” and they can pull together teams to work on the problem and
encourage, expect, and nurture independent and critical thinking. The transformational leader assumes that people are willing and eager to learn and test
new ideas.
The transformational leader has a kind of humility that looks beyond self to the
mission of the organization and the value of the work of others as individuals.
He or she uses many professional skills including listening, coaching, empathy,
support, and recognition of the contributions of followers. The transformational
leader enables others to act toward a shared vision. The effective leader recognizes and promotes the contributions of others and creates a culture of sharing,
celebration, and unity within the entire team. Who gets the credit is less important than how team members affirm each other’s work.
Transformational leaders effectively build on these characteristics and integrate principles from a variety of leadership theories and pragmatic approaches
to advance, enhance, and expand clinical expertise from a focus on direct individual patient care to a focus on the care of groups, aggregates, and entire populations in a variety of environments. They consider the individual and the
aggregate at once.
Recently, in addition to a plethora of reviews about transformational
leadership and leadership in general, there have been some studies on how
leaders in nursing demonstrate transformative leadership and influence followers. Fischer (2016) found transformational leadership in nursing to include
“high-performing teams and improved patient care,” but it is not considered to
be a set of skills or competencies that can be taught. Masood and Afsar (2017)
found a relationship between transformational leadership and innovative work
behavior when combined with knowledge sharing of best practices and mistakes. Lin, Maclennan, Hunt, and Cox (2015) identified a relationship between
transformational leadership and nurse job satisfaction and organizational commitment. Yet, we know little beyond the description of actions of such leaders
(Broome, 2013; Disch, 2017a; Disch, Edwardson, & Adwan, 2004; Giddens, 2018).
Hutchinson and Jackson (2013) confirmed that there is little applicable research
or critical review of transformational leadership in nursing literature. We still
know little about how transformational leadership works, or what it ultimately
means to followers and patients. Such research and role models must emerge
from the next generation of leaders. It is your job to envision and articulate
the prototypes for transformational leadership in healthcare for the future or
to test their effectiveness. The transformational leader must make a conscious
decision to lead. Often, competent nurses are given opportunities to supervise
or manage, but successful leaders choose to lead. And some individuals find
they learn a great deal very quickly and go on to build on that experience and
become transformational leaders, while others find the emotional costs and
Elaine Sorensen Marshall, PhD, RN, FAAN
I remember the first “official” day I was required to be a leader. I had been out
of nursing school for less than a year, working at a job I loved as a staff nurse
on a medical–surgical unit in a large flagship hospital. The nurse manager, then
referred to as the team leader, called in sick. One by one, calls to all the other
usual suspects to take her place were in vain. The house supervisor came to me
and said, “You are it today. You are in charge. I will be available if you need
anything.” I was left in charge of a unit staff of one other registered nurse, two
practical nurses with more bedside experience than I had in years of life, two
nursing assistants, and 22 very sick patients. My heart raced simultaneously with
the surge of excitement and panic. I will not violate privacy regulations here to
tell you all the near-death adventures that day, but I can say that it was probably
not the ideal first step on a path toward transformational leadership. I did learn,
almost immediately, what worked and what did not work to inspire or influence
others. Eventually, over a lifetime, I gained knowledge, insight, and experience as
a transformational leader, but I always return to that summer day when I learned
the “sink or swim” theory of leadership. I learned that my heart was in the right
place, that I wanted to care for others, that I had some innate abilities to influence
others for good, that I was a natural goal setter, that I had fairly good judgment in
making decisions, and that others trusted me. But I had no specific knowledge of
how to lead, no preparation for leadership, no coach or mentor, little confidence,
and not much insight on organization of resources to meet what came next. I
knew only that I was in a situation that needed a leader, and on that day, I was
recruited and stepped up to it.
Since that day, I have had the benefit of advanced education, professional
leadership training, and years of experience in academic leadership. I have led
teams in private and public settings as well as a large academic health center. My
joy has been to help others to grow and watch them flourish.
Marion E. Broome, PhD, RN, FAAN
I spent my early career learning how to be a competent nurse, then nursing
educator, and then nurse researcher—always focused on improving the care of
children and their families. Twelve years after I graduated with my BSN, and 2 years
after completing my PhD, I assumed my first administrative role, as an associate
dean for research. For the first time in my nursing career I found myself on the
LEADERSHIP (continued )
“side” of hearing the complaints, issues, and needs of nurses in the organization,
in this case related to support for faculty research development. I must admit I was
not entirely prepared for the responsibility of “fixing the problems” the faculty
brought to me. However, once I began to reframe the issues—as problems to
be solved, systems to be put in place so faculty could be successful—and honed
my listening skills to focus intently on what a person was really asking for, my
enthusiasm for the job increased. I began to see myself as a problem solver and
someone who needed to have a vision for how things could be. To my amazement,
I enjoyed solving problems, and I enjoyed thinking about how to make the systems
we had in place work better. I also learned quickly that while you could tell others
their issue was solved, it was not until they actually worked with the office (to
submit a grant, to develop an institutional review board [IRB] proposal, or to hire
personnel), and things went smoothly, that they became true believers. It seemed
so easy (and fun). For me, the real satisfaction of leadership was seeing others be
able to achieve their goals with the least amount of hassle and the most amount of
perceived support. Then they could dream bigger and better and move the whole
organization ahead!
time investment of leadership not to be congruent with where they see themselves making a contribution. In Boxes 1.1 and 1.2 we share our personal leadership stories.
In their zeal to promote charismatic transformational leadership, some writers make unfortunate distinctions between managers and leaders, as though
managers are undesirable, and leaders are more effective across all situations.
Jennings, Scalzi, Rodgers, and Keane (2007) reviewed the literature to find a
growing lack of discrimination between nursing leadership and management
Traditionally, managers are thought to control and maintain processes with
a focus on the short term, relying on authority rather than influence, while leaders are visionary, insightful, and influential. Managers minimize risk, and leaders maximize opportunity. In reality, most leaders will tell you it is important to
know enough about processes in one’s organization to be able to decide what
new directions to take and how to assess the efficiencies of a unit to preserve or
redirect resources. It is likely a matter of balance between the two sets of competencies of manager or leader that is crucial to master.
Transformational leadership theorists refer to the manager style as transactional leadership (Bass et al., 2010). Transactional leaders primarily motivate
others by systems of rewards and punishments. Their power lies largely in the
authority of their position. A manager may be referred to as the “laissez-faire”
supervisor who provides little direction or motivation for change, leaving most
decision-making to the followers. Transformational leaders, on the other hand,
develop, innovate, focus on developing others, inspire and create trust, and
hold a long-term, big-picture, futuristic view.
The reality is that anyone in charge of a group of people working toward
effective goal achievement needs the wisdom to develop and use the qualities of
both manager and leader in different situations. Williamson (2017, p. 4) asserted
that “nurses are called to leadership” regardless of the position title of leader
or manager. Thus, the terms manager and leader may be used interchangeably,
as appropriate, in this book, not for lack of precision, but with the view that the
characteristics of each are needed in effective leadership. Effective leaders (and
managers) rely on a broad repertoire of style, rather than specialization of techniques. And neither should rely on their position to motivate or reward others.
You must be able to distinguish when incentive/punishment motivation is
needed versus when charismatic inspiration will achieve the desired results, or
even when “well enough” is left alone. The next generation of leaders will be
required to blend techniques of artistic management and wise leadership, all “on
the run,” in a rapidly changing healthcare environment (Bolman & Deal, 2013).
Indeed, early studies of military platoons in combat (the ultimate fast-paced
and stressful environment) showed both transformational and transactional
leadership to be positively related to group cohesion and performance (Bass
et al., 2003). Researchers have compared the effects of transformational leadership with other leadership styles and have found high correlations among all
styles with organizational outcomes, employee satisfaction, and change management (Fischer, 2016; Lin et al., 2015; Molero, Cuadrado, Navas, & Morales,
2007), confirming the idea that a variety of leadership styles and approaches
can be effective in differing roles and circumstances (Burke, 2017).
You have taken a step toward assuming leadership for the profession by pursuing the DNP degree. From the beginning of the development of the degree,
leadership development has been a high priority (Lenz, 2005). Indeed, the need
for leaders prepared in advanced clinical practice was a precipitating factor in
the earliest discussions of the DNP. Since the inception of the DNP, leadership
roles have been studied and promoted as essential to healthcare practice and
education (see Gosselin, Dalton, & Penne, 2015; Malloch, 2017; Morgan & Tarbi,
2016; Smith, Hallowell, & Lloyd-Fitzgerald, 2018; Tyczkowski & Reilly, 2017;
Walker & Polancich, 2015; ). Broome (2012) proposed that doctorally prepared
nurses will bring unique expertise to several areas, including innovative educational approaches, patient management knowledge and expertise, theoretical
expertise, research methods expertise (both qualitative and quantitative), statistical and analytical expertise, and political awareness. They will also open doors
to new roles and positions to gain entry to care for specific patient populations
at the highest levels.
When leaders in nursing education developed DNP programs in the early
part of the 21st century, we joined other practice disciplines, such as medicine,
optometry, pharmacy, physical therapy, and audiology, which had elevated
their practices and leadership by preparing practitioners with the highest professional academic degree. The American Association of Colleges of Nursing
(2004, 2015) affirmed the fundamental need for DNP-prepared leaders, noting
that “the knowledge required to provide leadership in the discipline of nursing
is so complex and rapidly changing that additional or doctoral level education
was needed.”
One of the competencies listed in the Essentials of Doctoral Education for
Advanced Nursing Practice (DNP Essentials) (American Association of Colleges
of Nursing, 2006, p. 10) is “Organizational and systems leadership for quality
improvement and systems thinking.” Specifically, DNP graduates should be
prepared to:
• Develop and evaluate care delivery approaches that meet the current and
future needs of patient populations based on scientific findings in nursing
and other clinical sciences, as well as organizational, political, and economic
• Ensure accountability for the quality of healthcare and patient safety for populations with whom they work.
• Use advanced communication skills/processes to lead quality improvement
and patient safety initiatives in healthcare systems.
• Employ principles of business, finance, economics, and health policy to
develop and implement effective plans for practice-level and/or system-wide
practice initiatives that will improve the quality of care delivery.
• Develop and/or monitor budgets for practice initiatives.
• Analyze the cost-effectiveness of practice initiatives accounting for risk and
improvement of healthcare outcomes.
• Demonstrate sensitivity to diverse organizational cultures and populations,
including patients and providers.
• Develop and/or evaluate effective strategies for managing the ethical dilemmas inherent in patient care, the healthcare organization, and research.
(American Association of Colleges of Nursing [AACN], 2006, pp. 10–11)
Although early in its development, the DNP was met with controversy
within the discipline of nursing (see Chase & Pruitt, 2006; Dracup, Cronenwett,
Meleis, & Benner, 2005; Joachim, 2008; Otterness, 2006; Webber, 2008). Some
leaders proclaimed that “the question facing the nursing community is no longer whether the practice doctorate is ‘future or fringe’” (Marion et al., 2003),
but rather how do we move forward together (O’Sullivan, Carter, Marion, Pohl,
& Werner, 2005). As of 2017, there were 135 PhD programs in nursing with
enrollment of 4,698 (AACN, 2017). As of 2018, there were 348 DNP programs
with enrollment of 32,678 (AACN, 2018). Clearly, the DNP degree has been
embraced by many nurses in practice who want to take their careers as practitioners to a new level and provide leadership and expertise to shape care delivery. Clearly, new models of care are needed, designed by nurses prepared at the
highest levels of practice and education (see Mason, Martsolf, Sloan, Villarruel,
& Sullivan, 2019). Graduates of DNP programs are fulfilling the hope for a new,
more effective advanced practitioner and healthcare leader.
Taken together, the complexity of healthcare systems, emphasis on
­evidence-based practice and information management to improve patient outcomes, information explosions in science, advances in technology, and a new
world of ethical issues only amplify the need for new leadership grounded in
expert clinical practice. It is the hope of the profession that the DNP-prepared
leader will offer the highest level of practice expertise and have the skills to
translate knowledge into evidence, as well as practice-based evidence into
better outcomes for patients and families (Zaccagnini & White, 2017). As a
DNP-prepared leader, you will be expected to guide and inspire organizational systems, quality improvement, systems and analytical evaluations, and
policy development and translation, and to forge intra- and interdisciplinary
collaborations to improve patient health outcomes (Broome, 2012). Much of
this important work is done in context and collaboration with interprofessional
teams. We elaborate more on this later, but at the outset of considering yourself
a leader, it is critical to understand the style, dynamics, and climate of interpro­
fessional collaboration (Agreli, Peduzzi, & Bailey, 2017; Disch, 2017b) and teambased care.
Prepared at the highest level of practice, you will understand the broad perspective of resource management in a sociopolitical environment to influence
policy decisions and use your influence to lead teams to develop and test new
care models. There is every reason to hope that you will be able to invent systems of care yet unknown that will strengthen, correct, and transform healthcare systems as we know them today. You will work with teams from various
disciplines and various levels of preparation and backgrounds even in nursing.
The success of teamwork is the goal and responsibility of the transformational
leader. Transformational leaders in nursing include those with preparation at a
variety of levels.
Many hospitals throughout the United States, especially those in academic health
centers, employ nurses prepared with the Doctor of Philosophy (PhD) degree to
lead various sectors of the enterprise, including education, professional development, and research. PhD-prepared nurses are also most commonly employed
in academic institutions. You might ask, “What is the difference between the
two degrees and their preparation? How will we work together?” The PhD
is not a professional degree but rather the highest research-focused academic
degree given across a variety of disciplines. The PhD program and degree
require the student to understand the philosophy of science and the nature of
knowledge, and to master, extend, and generate knowledge for the discipline
through research.
PhD programs provide graduates with an understanding of the environment within which nurses practice and prepare graduates to advance the
science of the discipline (Broome & Fairman, 2018). The core of the PhD program is an understanding of nursing and the development of competencies to
expand science that supports the discipline and practice of nursing (AACN,
2010). Since the mid-1990s, hospitals and health systems have employed
nurse scientists to engage in the development and testing of interventions
designed to improve patient outcomes. In addition, these nurses collaborate
with researchers in other practice disciplines to develop and evaluate evidence-based initiatives to improve care delivery. DNP- and PhD-prepared
nurses will find themselves as collaborative team members or leaders of teams
to develop, test, and translate knowledge that has the potential to improve
patient outcomes (Broome, 2012; Gilbert, Von Ah, & Broome, 2017). The complementary in-depth skill base of both fields of study can maximize effectiveness and efficiency of any initiative.
The professional background of the advanced clinician provides the unique
opportunity for new eyes to examine the leadership tradition, including the
vision of new roles for the leader and others. We cannot tell you what new roles
you will envision or be expected to fill. We can only help you prepare to invent
and lead in those roles. You must be fearless and creative to envision the role.
If you reach deep into your own knowledge and find the courage to step out of
old habits, you will design and fulfill models that will work.
To become a transformational leader requires both theoretical and conceptual understanding of the real-world practice of leadership. It is beyond the
scope of this book to explore the range of theories for nursing. Rather, we have
focused on a broader scope of theories for leadership. Leadership is a discipline
in itself, with a body of knowledge, theories, culture, and practice expertise. By
learning from theories and principles of leadership, then applying vision and
courage, you will become a citizen of the community of leaders who will solve
the problems of the future.
One of your major challenges as an advanced clinician and leader at the
organizational level will be to shift the perspective of care from the individual
patient to that of entire populations of patients, professionals, peers, and other
stakeholders. Your world will broaden. This means you must learn new skills—
especially the ability to “zoom in and zoom out” (Kanter, 2011) in the face of
challenges. The ability to zoom out cannot be overestimated.
Evidence is mounting that links the influence of transformational leaders to
both improved nursing practice at the bedside and positive patient outcomes
in the aggregate (see Lin et al., 2015; Masood & Afsar, 2017). There continues
to be a need for more research and practice results in this area, particularly
those aimed at examining how effective leaders influence both patient and staff
The expertise of the advanced clinician in the position of organizational
leader offers a treasure trove of perspective, professional and personal knowledge, and in-the-trenches experience that is frequently missing in healthcare
today. For example, in settings where the chief executive officer is not a clinician, it is often the chief nursing officer who provides the insight, experience,
and model for clinical leadership. Clinical expertise brings context, credibility,
and a dose of reality to a leadership position. So, many areas of healthcare will
benefit from the clinical leadership roles yet to be invented.
Such roles are currently needed to achieve the quadruple aim of increased
access to care, improved quality, decreased cost, and work meaning (Sikka,
Morath, & Leape, 2015). New leaders are needed in such clinical areas as child
1. What are your goals and dreams as a DNP-prepared leader?
2. What are your greatest concerns about assuming the “mantle” of
leader? What resources can you take advantage of now and in the near
future to address those concerns?
3. Identify your own goals and strengths. Consult any of the numerous free
strength aptitude tests online. Then respond to the following:
a. What are your greatest strengths?
b. How can you use these strengths in the practice setting?
c. How will they be useful to you while in this graduate program?
4. Interview a nurse executive in your setting who hires nurses into
advanced practice roles. What does he or she think is a good fit in the
organization for the skill set of a DNP graduate?
health and risk reduction for chronic conditions, transitions of aging, symptom management, and palliative and end-of-life care. They are needed in settings of primary and acute care, as well as community and home care. We
need leaders for new kinds of comprehensive preventive screening centers,
immigrant health, Internet and telehealthcare, and other settings and practice areas yet to be imagined. In the environment of fast-paced complex systems, the bold and creative expert clinician will invent the new roles needed
to lead care teams, patient groups, public interest groups, and organizations
that may better manage challenges, solve problems, and take advantages of
As noted, transformational leadership is increasingly the focus of empirical
study among healthcare organizations. For instance, one study examined the
relationships among transformational leadership, knowledge management, and
quality improvement initiatives among various departments in 370 hospitals in
all 50 states. Results demonstrated that transformational leadership and quality management improve knowledge management. Researchers concluded that
transformational leadership skills among healthcare executives promote effective knowledge of management initiatives that enhance quality improvement
programs. Furthermore, the integration of transformational leadership, knowledge management, and quality improvement was closely associated with organizational and patient outcomes, including patient safety (Gowen, Henagan, &
McFadden, 2009). The idea of transformational theories sometimes refers to a
group of several different approaches that focus on “positive constructs such
as hope, resiliency, efficacy, optimism, happiness, and well-being as they apply
to organizations” (Avolio, Walumbwa, & Weber, 2009, p. 423), rather than on
traditional models, some of which focus on deficit reduction, or working on
what is wrong with a leader. Currently, transformative leaders are the best hope
for mobilizing intellectual and social capital within their organizations to not
only improve outcomes for patients but to enhance working environments for
professional nurses (Gilbert et al., 2017).
From an empirical and theoretical perspective, evidence for the effectiveness of transformational theories remains to be demonstrated. Such theories
continue to secure a major place in contemporary literature on leadership. There
seems to be a hunger in society for the positive hope and promise of the transformational leader. The discipline of nursing offers a welcome laboratory to test
the promise of transformational leadership. Nursing practice is grounded in
concepts of caring and altruism; it already attracts people motivated toward
self-actualization, achievement, and helping; and it embraces tenets of holism
(Jackson, Clements, Averill, & Zimbro, 2009). Such principles are highly consistent with those of transformational leadership.
We have moved from the industrial era to an age of information, with the
explosion of knowledge of facts and complexity of systems. You were likely
trained as a clinician to meet the challenges of simply keeping up with growing
information. Futurists predict with hope that the next generation will be the age
of wisdom. What will be needed next are vision and wisdom regarding how to
best employ information, resources, and people to meet healthcare needs within
complex systems. Leadership can be learned and practiced, and you are in the
right time and place to do it. Critical clinical skills and judgment, amplified
and enriched by thoughtful, wise decision-making and leadership, are what are
most needed now.
The challenge of the next decade for nurse leaders is to create an empirical
foundation of evidence for best practices in leadership in complex healthcare
organizations. Malloch and Melnyk (2013) described competencies and challenges for executive leaders. Their competencies include:
• Evidence-driven consciousness
• Cross-generation communication competence
• Innovation leadership expertise
• Work–life balance
• Commitment to lifelong learning
• Transdisciplinary teamwork and inspiring teams
• Management of dynamic time pressures
• Shaping policy
Leaders with such competencies promote nursing practice but must also
invite interprofessional engagement in the bigger picture of healthcare. Perhaps
the initiative of the advanced clinician in the organizational leadership role will
launch that discovery. It is especially important to note that a working theory,
empirically tested and specific to clinical leadership in complex healthcare systems, is yet to be developed, discovered, or invented.
Many impressive theories explain or guide leadership of people and organizations, but few have included the environment or setting as much more
than an artifact or a backdrop, implying that context may not be relevant. As a
healthcare provider, you know that the context of healthcare is uniquely challenging and complex. The innovative leader can think in terms of multiprofessional caregivers, patients, community, and context from a systems perspective.
He or she understands not only leadership theory but also theories of complexity and complex adaptive systems. The new transformational leader will
design new environments and systems for care—some we have not dared to
imagine. Perhaps, theories of the past will be revised or proven altogether irrelevant. The world is waiting for your creativity to care for those in need, and to
inspire other leaders to come together in new ways of thinking and practice.
Transformational leaders of the future will see the world with a new vision,
break old rules, discover or create new rules, and thrive in the paradoxes of
complexity. Innovation requires the space for creativity and the courage to be
wrong. Mistakes teach as much as success. The truth is, there is often no right or
wrong but, rather, change, diversity, and helping people come together to solve
problems and help others.
Innovation is a paradox that requires a willingness to learn all you can,
bring your clinical experience to bear, and then eagerly suspend previous learning and experience to welcome new ideas, recognize a different point of view,
embrace chaos, winnow what must remain and what must change, and set a
new course. These are not easy things to do, but leaders must encourage those
in their environment to ask questions and seek out new and different solutions
to challenges that present themselves over and over in healthcare.
The chapters that follow expose you to information and learning activities,
media (see Box 1.3), cases, and sharing of expertise from key leaders in the field.
You will learn about healthcare as a context in which the transformative leader
must not just adapt but must lead others to shape a preferred future. We discuss
current theoretical perspectives about change management, chaos, and complex organizations. We consider contemporary challenges related to technology,
quality and safety, healthcare workforce issues, and consumer and provider satisfaction. And we note other issues related to success in achieving the quadruple aim of increasing access, decreasing cost, increasing quality, and finding
meaning in the work of healthcare, with the goal of improving the health status
of all. We share our knowledge and experiences about our own leadership journeys and how important it is to understand oneself as a leader.
You will learn how finance models influence care models, the importance of
economics to healthcare (Platt, Kwasky, MacDonald, & Spetz, 2019), and understand how financial complexities and solutions are part of the work of the successful leader. We also discuss the importance of intra- and interprofessional
team growth and management to help achieve an organization’s goals, as well
as how leaders can influence teamwork. Creating and shaping environments
in which diversity is not just valued but embraced and used to maximize all
individuals’ contributions is the focus of one chapter and truly the primary job
of any transformative leader. We close with the view forward for your career
and provide some guidance for you to consider as you work with others outside of professional provider contexts, including boards of trustees, community
boards, and policy makers. In sum, we hope this book serves you as you begin
your next leadership journey. The authors and editors of this book have provided you with their best knowledge and wisdom about leadership, an overview of the evidence to support leadership development, and opportunities to
reflect on where you have been, where you are now, and where you hope to be
in the future.
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