Nurs Admin Q

Vol. 32, No. 2, pp. 117125

c 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright 

Illuminating the Inner

Leadership Journey by
Engaging Intention and
Mindfulness as Guided by
Caring Theory
Teresa Britt Pipe, PhD, RN
Sustained, high-performance nursing leadership can be effectively guided by caring theory. While
much of leadership performance is manifested by external behaviors, highly effective leaders are
also grounded by internal work of self-reflection and growth. This article focuses primarily on the
inward journey of leadership as guided by Jean Watsons Theory of Human Caring. Key elements of
the theory are interpreted within the context of the emerging, urgent, high-stakes challenges of the
current healthcare environment. The links between self-nurturance and caring-healing leadership
of others are explored. Key words: leadership, self-nurture, Theory of Human Caring

URSING LEADERS find themselves on

a quest for creative and effective approaches to address the perfect storm of
nursing shortages of staff and faculty, growing demand and complexity of care needed
by an older and sicker population, fiscal
pressures, and socio-political-environmental
issues that require rapid and ready responsiveness. Among others, Harrison,1 Neil,2 and
Watson3,4 have outlined other pressing challenges to the ethic of caring in nursing, including the issue of a dispirited nursing workforce.
They have suggested possible ways of meeting
the emerging issues and pointed out that theory can help guide, direct, and inspire nursing
leadership in organized and systematic ways
that are congruent with the disciplinary theory and science of nursing. Jean Watsons Theory of Human Caring5,6 can be used to inform
and organize leadership approaches that are

intentional, effective, and uphold human dignity among those served.

Leadership, for the purposes of this article, is broadly defined as behavior and ways
of being that have a positive, enduring influence on those whose lives are impacted by
ones presence. Part of the work of nursing
leadership is to bring health and healing to
individual colleagues, clinical nurses, groups,
and organizations by virtue of exerting a positive and lasting influence. Self-reflection, nurture, and renewal are key strategies toward
this goal. A primary focus of this article is the
inward journey of leadership as guided by the
Theory of Human Caring.57 While much of
leadership performance is manifested externally in actions and behaviors, effective highperforming leadership is rooted in the inner
work of self-reflection and growth.
WHY USE A THEORETICAL APPROACH?

From the Mayo Clinic Hospital, Phoenix, Ariz.

Corresponding author: Teresa Britt Pipe, PhD, RN, Mayo
Clinic Hospital, 5777 E Mayo Blvd, Phoenix, AZ 85054
(e-mail: pipe.teri@mayo.edu).

Nurse leaders are typically faced with multiple and changing priorities and operate
within short time frames. The question naturally arises about why nursing theory would
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be relevant or useful when addressing the

rapid-fire and often-chaotic challenges currently emerging in healthcare. The following
simple illustration may be useful in answering
this question. Imagine a car at night, departing from a well-lit parking lot such as a super
shopping center or mall. The driver leaves the
parking lot and enters a busy street with multiple streetlights. Soon the driver notices that
several cars in the oncoming lane are flashing their headlights as they pass. Suddenly, the
realization hits that the driver has forgotten
to turn on the headlights and so immediately
remedies the situation by doing so. Now, the
dashboard is illuminated making the instrumentation panel easily readable, so that the
driver can have instant feedback about the
cars speed, direction, and other navigational
capacities. Likewise, the road in front of the
car is now much more easily seen. Communication with other vehicles is enhanced because oncoming traffic can readily see the
cars approach. While driving without headlights on is physically possible, driving with
them on is a safer, more efficient, and easier way to travel and ultimately reach the
destination.
Nursing theory can similarly illuminate
nursing leadership practice. Using this illustration, engaging nursing theory is like turning on the headlights. Nursing leadership, like
driving, is possible without the use of theory.
However, using theory can help illuminate the
internal workings of the mind and spirit, assisting leaders to see the dashboard consisting of personal thoughts, insights, and professional values. This dynamic feedback can
be used to guide outward activities and adjust the course, momentum, and energy exerted on leadership initiatives. Similarly, using theory can help communicate with others
by providing a common language structure,
shared vision, and relationships between concepts. Others can see where you are coming
from when theory is used to direct activities
and make them more effective, systematic, orderly, and predictable. Theory can also, like
headlights, help reach the destination or outcome safely and efficiently.

ENGAGING THEORY FOR REFLECTIVE

LEADERSHIP PRACTICE: AN
INTERPRETATION OF JEAN WATSONS
THEORY OF HUMAN CARING
Many individual nurse leaders as well as
healthcare systems are turning to theoretical
models as a way to meet the current tensions with optimism, encouragement, and a
unifying vision for how healthcare can be
shaped in a way that is scientific and caring.
Watson3,4 highlights Nybergs8 application of
the science of human caring in nursing administration and suggests the following updated
and expanded responsibilities of nurse leaders and administrators3,4 :
understanding and communicating caring as a philosophy and ethic for organizational processes, structures, and
relationships;
developing skills of caring behaviors, caring presence in formal-informal relationships with individuals and groups;
being alert and responsive to situations
for modeling, creating, and articulating
theoretical-philosophical ethics of caring
with staff and colleagues;
providing leadership in implementing and evaluating experimentaldemonstration models of caring-healing
theoryguided practices;
promoting and supporting research on
caring and healing/health outcomes;
exploring relationships between and
among data which document connections between caring theoryguided
practice models, nurse retention, patientnurse satisfaction, healing outcomes,
and costs; and
serving as stewards of caring-economicscosts by incorporating caring as a valuable economic resource and as the foundational ethical variable in cost-benefit
ratios.
In addition to these external leadership initiatives, it may also be beneficial to revisit the
foundational ideas presented in the Theory of
Human Caring5,6 with the lens of internal leadership practice. An aspect of this theory that

Illuminating the Inner Leadership Journey

makes it particularly appealing to the current
workforce challenges is that it encompasses
a focus on nurses and nursing as well as on
the care of patients. Likewise, the tenets of
the theory also support self-nurturing for the
leader as well as the one being cared for.
The major elements are the caritas processes, transpersonal caring, and the caring
moment.5,6 Each of the elements will be
presented along with interpretive statements
regarding possible application to leadership
practice, with a concentrated emphasis on the
inner work of the leader. The following are 10
caritas processesfrom the Theory of Human
Caring as interpreted for use in nursing administration and leadership. The one being
cared forin these instances may include other
colleagues, individuals, or groups being led,
the one being mentored, or the student. The
caritas processes can be applied to the selfcare practices of the leader as he or she turns
loving-kindness and healing efforts inward in
preparation for leadership.
Caritas originated from the Greek word
meaning to cherish, to appreciate, to give
special attention, if not loving, attention to;
it connotes something that is very fine, that
indeed is precious.5,6 Caritas characterizes
the approach that leaders can choose to take,
extending an intentional, positive regard for
self and other as an essential part of cultivating a mindful, intentional leadership practice.
Self-acceptance and cherishing are also important attitudes to cultivate within the spirit of
caritas.
CARITAS PROCESSES
Practice
of
loving-kindness
and
equanimity within context of a caring
consciousness.5,6 The word practice is a
reminder that the attitude of loving-kindness
and equanimity is not something that can be
accomplished quickly or permanently. This
attitude is practiced not with the striving goal
of achievement, but rather with the objective
of continually becoming more conscious of
how we approach ourselves and those we
lead. The leadership role affords many oppor-

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tunities each day to practice loving-kindness.

Ideally, the attitude of loving-kindness and
compassion is extended to the self as well as
to others. Taking a moment to engage this
attitude before answering the phone, opening the office door, making the presentation,
or replying to an e-mail will help build the
strength and discipline of meeting individuals
with consciousness of caring.
Equanimity is the quality of being calm and
even-tempered. It refers to an evenness of
mind characterized by calm temper or firmness of mind: patience, composure, and a
steadiness of the mind under stress. Cultivating equanimity during times of relative calm
will help strengthen its application during
times of increased stress and tension. The
leader sets the emotional tone for the group or
organization, and thus can consciously make
the choice to transmit calm confidence.
Being authentically present and enabling
and sustaining the deep belief system and
subjective life worldview of self and onebeing-cared-for.5,6 Authenticity is a key attribute that is valued and expected of organizational leaders. Research suggests that
honesty and authenticity are essential characteristics that followers identify as important for leaders to possess, regardless of the
age/generation category of the follower.8 To
convey a genuine and sincere sense of self,
leaders must take the time to conduct ongoing self-assessments and exploration. Selfknowledge is not only a vital leadership competency but also an important strategy toward
gaining a true sense of authenticity.
At times, reflective activities can seem selfish, unless the links among reflection, authenticity, and effective performance as a leader
are well understood. Successful leaders develop strategies to cultivate greater understanding of ones self in the context of others, with the recognition that taking the time
and effort to understand ones own perspective, values, strengths, and weaknesses will
contribute greatly to achieving meaningful
goals and fostering a heightened sense of interconnectedness with those who look to
them for guidance and support. Reflective

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leadership practices that support authenticity

may include keeping a journal of personal insights and growth opportunities, talking with
trusted colleagues or mentors to glean information on performance, and cultivating opportunities for solitude and self-reflection.
Authenticity requires that the leader know
who he or she is and how he or she contributes to the one being cared for. While authenticity sounds very simple, it can be counterintuitive within the context of modern
standardized healthcare practice to remember that each nurse or colleague brings something unique to the organization and unless
the individual talents and gifts of the leader are
known, they cannot be shared. Discovering
ones unique sense of authenticity involves
taking the time to reflect on how experiences, clinical learning, personal knowledge,
culture, belief system, aspects of personality,
and a vast array of other factors unique to each
individual can be cultivated to help in the current leadership situation.
Cultivation of ones own spiritual practices and transpersonal self, going beyond
ego self.5,6 This element of caring requires a
delicate balance. Caring leadership involves
tapping into the leaders own source of
strength according to a personal belief system, while taking care not to assume the other
person shares in these values. The leader who
is able to recognize and benefit from his or her
personal source(s) of strength can use this as
an internal navigational guide for help monitoring and motivating outward leadership
activities.
Using the transpersonal self requires that
the leader be able to sustain healthy personal boundaries and acknowledge yet be able
to put aside private concerns, worries, and
needs to care for the other. This part of the
approach involves supporting the other person in their spiritual beliefs and source(s) of
strength and meaning, although they may differ from the leaders own beliefs. Going beyond the ego self means acknowledging the
uniqueness of each individual, and being able
to rise above self-interest to consider the various perspectives of others.

To temper the sacrifice of leadership

and to promote resilience and high performance, the effective leader cultivates practices that actively renew and replenish, preferably throughout the day and integrated with
the flow of activities that typify a life of leadership. Resonant leadership has been described
as living in a state of full conscious awareness
of ones whole self, other people, and the context in which we live and work.9 Resonant
leadership is supported by ongoing, frequent,
and feasible practice of renewing behaviors,
such as mindfulness, deep breathing, listening
to music, whatever the individual leader finds
most effective and reasonable to incorporate
into the moment-to-moment life.
Developing and sustaining a helpingtrusting authentic relationship.5,6 The leader
has the choice of framing the leadership interaction as a professional healing-caring relationship. Within this framework, the leader
cultivates a caring consciousness as integral
to the healing-leading process. Developing
the professional relationship takes time, intention, and patience. Proper boundaries are
established according to the organizational
culture. The leader who is authentically, professionally present with followers sets an example for how staff members are expected
to interact with patients and others. When
followers have a high level of trust with the
leader, they are more likely to share meaningful information and feedback that can be
critical to the performance of the organization. For example, if a nurse has an idea for
a clinical process innovation, he or she is
much more likely to share the idea with the
leader if there is a high level of trust that the
nurses thoughts will be treated with respect
and compassion rather than discounted.
Being present to, and supportive of the expression of positive and negative feelings as
a connection with deeper spirit of self and
the one-being-cared-for.5,6 Being present to
and supportive of ones own positive and negative feelings as a leader is an important first
step in being able to live this caritas process
within a leadership role. Acknowledging and
honoring the range of human emotions that

Illuminating the Inner Leadership Journey

occur within can help strengthen the leaders
performance by providing insights and empathy for others while also helping develop
healthy personal boundaries. By nurturing a
healthy regard for the emotions of the self and
others, the leader is better prepared to meet
challenges with a balanced presence.
The leader recognizes that within a trusting relationship, the colleague or group will
feel more comfortable with sharing negative
as well as positive expressions and may voice
disagreements and deeper feelings than might
not otherwise be exchanged. It is the leaders
role to listen to what is said as well as to develop an understanding of what is left unstated, or reading between the lines. It is a
good idea to confirm or validate verbally what
the leader understands from the others expression. Possible questions to ask include,
How do you feel cared for and nurtured as
a professional? What are the triggers that you
are not feeling cared for? How do you replenish yourself? What are your rituals for letting
go of work/obligations?
Sometimes being present to a colleague
only requires that the leader observes and
describes the behavior as it is seen. For instance, a nurse on a critical care unit described it as particularly meaningful when
the manager of the unit simply described the
caring behaviors that were observed. Simply noticing and acknowledging caring behaviors can be a powerful nursing leadership intervention, especially if they are also
linked explicitly and intentionally with patient
outcomes.
Creative use of self and all ways of knowing as part of the caring process; to engage
in artistry of caring-healing practices.5,6 By
taking the time to dwell within, experiencing ones own thoughts, feelings, dreams, and
visions places the leader in a position of
strength with a strong grounding in personal
and professional values. From here, strategies
and actions can be directed and executed
more effectively. To do this, high-performing
leaders learn to make optimal use of time,
space, and rituals needed to cultivate selfknowledge and focused energy.9

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It takes time to bring intentional, creative

focus to leadership practice. Questions to
consider include, When are you at your creative best? When do your inner critics come to
haunt? What is the link you draw among selfcare, creativity and leadership?Sometimes, it
is necessary to create rituals as part of focusing on being creative. For example, when confronted by an issue or problem that requires
an innovative solution, a leader might play
certain music, take a walk, seek solitude, or
talk with an energetic colleague. Having the
self-knowledge to put together the resources
and environment that support creative thinking are part of the challenge.
Leaders often use creativity in ways that
help them connect with staff. For example,
leaders may use stories about themselves
or their creative pursuits to illustrate major points during discussions or presentations with staff. Creative use of self can help
build trusting and healing relationships because it may help colleagues and clinical staff
relate more closely with the leaders human
experience.
Engaging in genuine teaching-learning
experience that attends to unity of being and
meaning attempting to stay within others
frame of reference.5,6 Teaching and learning
can be inward activities, as the leader seeks
to grow personally through self-evaluation,
reflection, and deciding how to respond to
feedback from trusted others. Self-learning
involves choosing new competencies to explore, selecting new opportunities for expanding skills, and garnering the resources to
take the next steps. In this sense, the leader
becomes the teacher and learner within ones
self to become a more effective teacher, role
model, and mentor for others.
Leaders are also constantly teaching others, both formally and informally. Formal presentations and communication strategies can
be well thought out and structured intentionally. On the other hand, informal teaching is
often impromptu and occurs by role modeling and sometimes unexpectedly. Therefore,
it is beneficial for leaders to carefully consider their ways of being present in situations

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NURSING ADMINISTRATION QUARTERLY/APRILJUNE 2008

that wouldnt be traditionally thought of as

educational.
Leaders assess the learning needs and styles
of their colleagues and clinical staff and tailor their educational approaches accordingly.
By individualizing communication, the leader
conveys a sense of respect and responsibility.
Staying within the others frame of reference
requires tuning into the audiences verbal and
non-verbal behaviors. As leaders teach, they
are open to new learning within themselves.
Teaching provides a vehicle for information to
flow both ways and not only from leader to
learner.
Listening is a vital, yet underrecognized
part of teaching and leadership. Listening is an
essential competency that involves more than
the ears and hearing. It allows exploration of
deeper meanings and pathways for the most
successful approaches. Listening can provide
a way for innovative practices to be advanced
and it may prevent irrelevant work. Listening
conveys caring.
Creating healing environment at all levels, physical as well as non-physical, subtle
environment of energy and consciousness
whereby wholeness, beauty and comfort,
dignity and peace are potentiated.5,6 Leaders
can focus on creating a personal workspace
that is supportive of the ability to think, create, converse in private, seek peaceful energy,
and support self-nurturing strategies. The purpose is to find a way to manipulate the environment in an arrangement that supports focused intentional energy and creativity. The
space should be welcoming and energizing,
and the ways to accomplish this are very individualized depending on the style of the
leader. Even the interpersonal space of the
leader becomes a tool for effective caring behaviors if the leader conveys a sense of confident equanimity and compassion with his or
her physical presence.
The leader works with others in the organization to create the best environment, physical and nonphysical, for healing to occur.
Leaders may encourage staff to identify ways
by which the environment can be improved
to support healing for patients and staff. Ma-

nipulation of the environment can range from

basic to more complex. To the greatest extent
possible, the physical environment should be
well-lit, ventilated, clean, and ergonomically
supportive. Beyond that, the leader can work
to incorporate elements of beauty including
sources of color, movement, texture, and form
to enhance the healing environment. When
possible, a view of the outdoors, a change
in surroundings, paintings, flowers, plants,
and music can also be incorporated. It is important to eliminate or reduce unnecessary
noise, clutter, and other distractions from the
environment.
The nonphysical environment is also important. Creating and sustaining a culture of
respect and healthy communication, conflict
management, and innovation is part of directing the nonphysical environment. In the
fast pace of healthcare environments, there
is an emphasis on acting, doing, and reacting. This focus can be positive if the strategies and decisions are anchored on what the
leader knows to be what is true and right
according to the needs of the organization.
However, sometimes leaders find themselves
reacting too quickly, and in retrospect, the
actions taken may have been misdirected or
misappropriated. When this dissonance occurs, symptoms can include miscommunication, a need for backtracking, errors and
leaders may find themselves off course and
needing to readjust. Most importantly, in
haste, relationships may have been harmed
and there may be fear or frustration in the very
people we were hoping to inspire.9 Doing the
work of leadership and being an inspirational
force require that leaders cultivate a focused,
clear mind and engage others in creating an
environment conducive to intentional, wellreasoned action. Helping self and others to
identify dissonant and supportive behaviors is
a key leadership function.
Assisting with basic needs, with an intentional caring consciousness, administering
human care essentials which potentiate
alignment of mindbodyspirit wholeness and
unity of being in all aspects of care tending to both embodied spirit and evolving

Illuminating the Inner Leadership Journey

spiritual emergence.5,6 Self-nurturing for
leaders focuses on making sure that the mind,
body, and spirit are well cared for and in the
most optimal condition in preparation for
the challenges of high-performance leadership. Hungry, tired, mentally and physically
exhausted leaders are not typically in the best
condition to make important decisions and
exert positive, confident influence. It is well
recognized that leadership roles are inherently stressful, so preparing the body with
rest, exercise, food, and recreation is vital
to performance, just like it would be with
a highly competitive athlete. Leaders find
tailored methods of creating and renewing a
relaxed but focused energy, perhaps through
exercise, meditation, enjoyment of the arts,
or social gatherings. The basics are simple,
but sometimes not easily accomplished. It
may take ongoing experimentation to find the
right combination of scheduling, organization
and prioritization to make true self-nurturing
a reality. In addition, patterns of need change
over time and so the self-nurturing practices
of the leader can be a dynamic process that is
adjusted and refreshed periodically.
Basic needs of employees include fundamental resources such as healthy food choices
in the cafeteria, clean and ergonomically supportive workspaces, and a safe environment
in which to work. The leader, working within
the context of the caring-healing perspective,
can align needs and resources to meet these
requirements with an explicit focus on caring. In addition, more attention is currently
being focused on the leaders role in bringing
together resources that support a healing environment for healthcare professionals. This
may mean arranging for classes on stress management, employee fitness centers, childcare
facilities, or the availability of quiet places for
meditation or contemplation.
Opening and attending to spiritualmysterious, and existential dimensions of
ones own life-death; soul care for self and
the one being cared for.5,6 Leaders may be
rewarded by exploring the existential dimensions of life and work as part of rediscovering
the personal sources of meaning that come

123

from work and leadership. Pausing periodically to examine what things about work
and life inspire and motivate the spirit can be
energizing and can reinvigorate leadership
practice. Nyberg described this as, we do
believe our work has a meaning beyond the
concrete here and now.10(p357) Regularly
identifying and reflecting on how to best
bring about the legacy, one hopes to leave
can be a very informative and restorative
exercise for leaders.
In healthcare, the essence of the work is
often high-stakes, time-sensitive, and centers
on the preservation of life, health, and human dignity. During times of conflict, confrontation, or critical clinical situations, employees sometimes have serious questions or
concerns, perhaps even about their own personal or professional future and what the
event means for them individually. This is an
environment in which patients and families
often confront issues of loss and mortality,
even if the injury or illness is not considered
life threatening. Leaders can help staff members with difficult situations by providing access to resources such as counseling or employee assistance and by supporting programs
that help professionals deal with the suffering
and pain they see on a daily basis. Acknowledging the emotional work of nursing roles is
particularly important.

TRANSPERSONAL CARING-HEALING
RELATIONSHIPS
Traditionally, transpersonal caring relationship connotes the sharing of authentic self
among individuals and within groups in a
reflective frame.5,6 This focus can be extended to developing and enriching the relationship with the self. The leader can nurture a sense of self-discovery, and build on
it by sustaining a trusting relationship with
the self. Aspects of this relationship with
self include being honest internally, honoring the commitments one makes to ones self,
and finding new ways to grow, improve, enjoy, and give back. By nurturing a healthy

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NURSING ADMINISTRATION QUARTERLY/APRILJUNE 2008

relationship with the self, the leader can

subsequently turn the focus outward more
effectively and with sustained stamina over
time.
Caring leadership is founded on transpersonal caring relationship and built on moral
commitment, intentionality, and caritas consciousness. All parties are changed within the
relationship. It is a vehicle for healing through
the auspices of the relationship. The leader
recognizes and connects with the inner aspect of the other through presence, being
centered in the caring moment, and through
actions, words, intuition, body language, cognition, thoughts, senses, and other ways of interacting and connecting with others.5,6
Leaders can help followers understand
the connections between theory-illuminated
practices and specific nursing outcomes. For
example, the leader is in the translational role
of helping explicate the important connections among caring behaviors, transpersonal
caring relationships, and patient safety metrics such as fall prevention, pain management,
and safe medication administration. Knowing
the individual patient and identifying patterns
of health, healing and disease can help nurses
prevent problems from growing and can encourage patient advocacy behaviors that are
linked with safe and effective care.
THE CARING MOMENT
The caring moment happens when the
leader and the one being cared for come together with their unique life stories and enter into the human-to-human relationship in
a given point in space and time.5,6 The caring moment can also be the moment of internal awakening and insight the leader ex-

periences through reflective practice. There

is awareness that the moment in time is transient; there are choices and actions one makes
about how to spend the time, occasion, or
opportunities that transcend the moment itself. On a more global plane: We learn from
one another how to be human by identifying ourselves with others, finding their dilemmas in ourselves. What we all learn from it is
self-knowledge. The self we learn about . . .
is every self. It is universal- the human self.
We learn to recognize ourselves in others, (it)
keeps alive our common humanity and avoids
reducing self or other to the moral status of
object.6
CONCLUSION
Leadership practice can be illuminated by
caring theory.11 Leaders can act as translational forces, enacting caring theories by
living the self-nurturing practices that support intentional, mindful leadership attitudes
and behaviors. Internalizing the approaches
and energies of caring and compassion toward the self can help build and guide the
leaders outward influence. Exhibiting the attitudes and behaviors of caring toward the
self and then toward others becomes a natural expression of caring-healing, transformational leadership.11 Recognizing and acknowledging caring behaviors in others also help
build an environment and culture of caring. As
Watson points out, From this leading from
the inner voice, nurse leaders emerge as spiritual warriors, leaders who are grounded in
their own sense of being and becoming; their
own power with others; connected with and
guided by that which is greater than self or
system.11(p4)

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Illuminating the Inner Leadership Journey

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