Nursing Leadership

Literature Review

March 2007
 ARNNL Nursing Leadership Literature Review

Table of Contents

Introduction ......................................................................................................... 1
Leadership ........................................................................................................... 1
Theories...................................................................................................... 2
Nursing Leadership Skills/Attributes ......................................................... 3
Leadership Competencies........................................................................... 3
Leadership Issues in Health Care ........................................................................ 4
Leadership Barriers & Facilitators ............................................................. 6
Implications for Leadership........................................................................ 6
Leadership Development..................................................................................... 7
Models & Theories..................................................................................... 7
Programs..................................................................................................... 8
Leadership Strategies ................................................................................. 9
Conceptual Framework for Leadership Development
in Newfoundland & Labrador............................................................................ 12
Summary............................................................................................................ 13
References ......................................................................................................... 15

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 ARNNL Nursing Leadership Literature Review
Introduction
The health care system has undergone
dramatic reforms in recent years as
organizations attempt to reduce or
maintain costs while increasing qual-
ity and outcomes. There is a renewed
interest in leadership development in
acknowledging the central role it
plays in relation to complex health
care issues.
In this review, the meaning of leader-
ship will be explored. An overview of
selected theories and research related
to leadership will be presented as a
background to understanding the con-
tinuing development of the concept. A
discussion of leadership in health care
will include an analysis of issues,
highlighting facilitators of and barri-
ers to leadership in practice, and im-
plications for nursing leadership. Dis-
cussion of leadership development
will include selected models and pro-
grams and suggested strategies as
identified in the literature. A concep-
tual framework for leadership devel-
opment in Newfoundland and Labra-
dor will be presented.
Nursing leadership exists at all levels
(Ferguson-Pare, Mitchell, Perkin, &
Stevenson, 2002). While nurses in
direct care roles have content exper-
tise, nurses in leadership and manage-
ment roles have context expertise,
attending to the environment and re-
sources required for the provision of
direct care. “Both context and con-
tent knowledge is critical to ensure
quality patient/client care is
achieved” (Ferguson-Pare ,et َ al., p. 6)
This review will address leadership at
all levels, including nurses in direct
care positions.
Leadership
The terms leader and leadership have
been conceptualized in various ways
in the literature. There is general
agreement that a leader is one who
has a vision, moves forward, takes
risks, influences and guides.
Tourangeau (2003) stated that “ exem-
plar leaders are those who challenge
the process, inspire a shared vision,
enable others to act, model the way,
and encourage the heart” (p. 625). A
leader is sometimes addressed through
identification of roles/attributes, in-
cluding advocate for quality care, col-
laborator, role model, articulate com-
municator, mentor, risk taker, and vi-
sionary (RNABC, 2001). “One of the
primary roles of leadership is to en-
courage and inspire others in a way
that keeps them committed to the di-
rection and values of the organiza-
tion” (Porter O’Grady, 2003a, p. 109).
The discussion of leadership and man-
agement is often interrelated in the
literature, and there is not always
clear distinction between a leader and
a manager (Hibberd, Smith & Wylie,
2006). Management involves an obli-
gation to achieve organizational goals; Nursing leadership exists
leadership emphasizes interpersonal at all levels (Ferguson-
relationships. Leadership is essential Pare, Mitchell, Perkin, &
for management effectiveness. Effec- Stevenson, 2002). While
tive managers apply leadership strate- nurses in direct care roles
gies, and leaders consider manage- have content expertise,
nurses in leadership and
ment implications. Leaders may be
management roles have
formal or informal and do not always context expertise, attending
have delegated authority. to the environment and
resources required for the
provision of direct care.
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 ARNNL Nursing Leadership Literature Review
Theories
Theories of leadership date back to
the beginning of the 20th century as
psychologists, political scientists and
experts in various fields attempted to
understand what makes successful
leaders (Leatt & Porter, 2003).
Early theories focused on traits, and
proposed that people who have spe-
cific qualities or traits are better suited
to leadership (Marquis & Huston,
2006). Traits of prominent leaders in
history were considered important,
including intelligence, charisma, self-
confidence, emotional control, domi-
nance, assertiveness, dependability
and independence (Hibberd et al.,
2006). Trait theories focused on the
leader, rather than leadership, and
there was no understanding of how
leadership could be developed.
Behavioral theories focused on the
action of leaders; i.e., how they organ-
ize their work in order to achieve
goals. Based on the work of Lewin
(1951) and White & Lippitt (1960),
three leadership styles were com-
pared: autocratic, democratic, and
laissez-faire (cited in Marquis &
Huston, 2006). Autocratic leaders ex-
ercise a great deal of control, make all
of the decisions, and give detailed
directions about work to be done. De-
mocratic leaders maintain less control,
are more flexible, and involve others
in decision making. Laissez-faire
leaders have limited control, and are
very flexible, with decisions being
made by the group. According to
these theories, people can learn to be
leaders.
2
In an attempt to further understand
successful leadership, contingency
theory focused on variables that might
determine the leadership style that is
best suited for a specific situation
(Hibberd, et al., 2006). According to
this theory, leadership styles need to
vary according to the circumstances.
Effective leadership is influenced by
the leader-member relations, the de-
gree of structure of the task to be ac-
complished, and the position or per-
ceived authority of the leader.
Other theories considered leadership
to be a process of influencing and in-
teracting with others. These include
transactional and transformational
theories that emphasize the relation-
ship between the leader and the fol-
lower (Hibberd, et al., 2006). The
transactional leader is focused on the
task and achievement of a standard
performance, and is concerned with
the day to day operations. In contrast,
the transformational leader is vision-
ary, inspires others, and aims to
achieve a higher level of performance
(Leatt & Porter, 2003).
During the 1990’s, the concept of
emotional intelligence addressed the
relationship of the leader with his/her
followers (Hibberd, et al., 2006). It
includes self-awareness, impulse con-
trol, persistence, self-motivation, and
social awareness. In applying this the-
ory, the behaviors of the leader have
an impact on the behaviors of the
team (Porter-O’Grady, 2003a). The
emotions of each member also influ-
ence the other members of the team.
Four skill sets are considered as es-
sential for leaders: self awareness
(emotional awareness, self-
 ARNNL Nursing Leadership Literature Review
assessment, self-confidence), self
management (self-control, openness,
adaptability), social awareness
(empathy, political awareness), and
relational management (influence,
developing others, team work,
change, conflict management)
(Goleman, Boyatzis, & McKee, 2003,
cited in Hibberd, et al., 2006).
Nursing Leadership Skills/
Attributes
While leadership theories have
evolved from the work of various dis-
ciplines and have been applied to
nursing, a number of research studies
have been conducted to explore nurs-
ing leadership, and to determine the
skills/attributes of successful leaders
in nursing.
In a phenomenological study of 6 hos-
pital-based managers, King (1999)
found their ability to scan and reflect
contributed to their effectiveness as
leaders. Scanning and reflecting
helped them to understand the behav-
ior, needs, uniqueness, and perspec-
tives of others; the needs, values and
abilities of self; and the needs of the
situation. Reflection helped shape
their leadership and contributed to
accomplishment of goals.
Cook and Leathard (2004) studied
nursing leaders who were involved in
providing direct clinical care and in-
fluenced others in providing quality
care. These leaders worked in various
roles in hospital and community-
based settings. Five key attributes of
effective clinical leaders were identi-
fied: creativity (generating new ways
of working), highlighting (looking for
new ways of working), influencing
(providing meaningful information to
others), respecting (alert to and re-
spectful of others), and supporting
(supporting others through change).
Antrobus & Kitson (1999) researched
socio-political factors that impact on
nursing leadership. According to
study findings, nursing leadership can
shape and influence both nursing
practice and health policy. It was pro-
posed that future nurse leaders would
be: influential operators (work with
and empower others), strategic think-
ers (create meaning and facilitate
learning), developers of nursing
knowledge, reflexive thinkers
(understand self and recognize values,
purpose and personal meaning), and
process consultants (work with and
through others).
In exploring the work of leaders, re-
search findings indicate that caring for
self is important. Effective nurse
leaders are knowledgeable, reflective,
and creative, have consideration and Effective nurse leaders are
respect for others, and influence oth- knowledgeable, reflective,
and creative, have consid-
ers through working with them.
eration and respect for
others, and influence oth-
Leadership Competencies ers through working with
them.
Leadership competencies are iden-
tified as occurring in four domains
of practice: education, research,
administration/ management, and
clinical practice (CNA, 2003). A po-
tential future domain will include pol-
icy development and health reform. In
each domain, competencies are organ-
ized into categories of knowledge and
skills related to leadership: visioning,
change, caring, leading self, leading
others, policies/politics, managing,
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 ARNNL Nursing Leadership Literature Review
teambuilding, project management,
and communicating. The competen-
cies in each category include abilities
and skills that can be performed and
measured, forming a basis for devel-
oping standards of performance.
Leadership Issues in
Health Care
From the traditional bureaucratic or-
ganizational structures of the past, to
the dramatically reformed system of
health care of today, the resulting
changes present many challenges to
nursing leadership. Following a brief
review of the impact of these changes
on nursing, barriers and facilitators to
leadership will be identified, and the
implications for leadership will be
highlighted.
Health care reforms during the early
1990’s have resulted in restructuring,
closure of acute care beds, downsizing
of personnel, and reduced funding. In
addition, technological advances have
had a major impact on the health care
system.
During restructuring, employers
eliminated many chief nurse, head
nurse, and unit manager positions
(CNAC, 2002). Decision-making was
decentralized, leaving managers with
a greater span of control. The de-
mands of management increased, tak-
ing the manager away from the unit
(Porter O’Grady, 2003a). As a result,
the mentoring and guidance tradition-
ally provided for nurses were no
longer available. (CNA, 2006). Sup-
ports such as mentoring and unit-
based education are needed by less
experienced nurses to improve prac-
4
tice and increase patient safety
(McGillis Hall, Doran, & Pink, 2004).
In a study by Daiski (2004), staff
nurses expressed concern about the
lack of support they received from
managers. Nurses, who feel they do
not have management support, have
less commitment to the organization
and are less satisfied with their careers
(CNA).
The closure of hospital beds and the
early discharge of patients have re-
sulted in a rapid turnover of patients
in hospitals, with nurses providing
care for patients with an increased
level of acuity. Nurses in the commu-
nity are challenged to provide services
for patients who experience an early
discharge home, and for families
who require additional support.
Nurses require increasingly com-
plex decision-making skills at a
time when mentoring and support
from managers have been with-
drawn.
The role of the manager is seen as
increasingly demanding, with time
being spent on paper and budgets,
rather than working with patients
(CNAC, 2002). Recruitment of man-
agers is difficult, and younger nurses
have little interest in assuming these
roles. In a study by Sherman (2005b),
nurses reported that current leaders
consistently gave a negative percep-
tion of leadership positions, with
stress associated with the role being a
key factor. The areas of most concern
in relation to taking a leadership posi-
tion was compensation, lack of con-
trol over decision making, and level
of responsibility.
 ARNNL Nursing Leadership Literature Review
Downsizing of personnel resulted in
staff shortages at all levels, which fur-
ther contributed to the stress of pro-
viding services (Porter O’Grady,
2003a). In order to cope with the nurs-
ing shortage, senior managers require
nurses to work overtime, sometimes
involuntarily (CHSRF, 2006). This
may increase the risk of errors, when
nurses who work long hours become
fatigued (Rogers, Hwang, Scott,
Aiken, & Dinges, 2004). The amount
of overtime worked may also be one
contributing factor to the high rate of
absenteeism in the workforce, since
nurses who work overtime are more
likely to report absent from work.
When compared with other workers in
Canada, nurses have had the highest
or second highest rate of absenteeism
for the past 15 years (CNA, 2006).
Reasons for absenteeism include ill-
ness, injury, burnout or disability, and
may be related to the work nurses do
or their place of work.
There was a reduction in the number
of full-time positions in nursing and
an increase in part-time and casual
positions. In 2004, almost half of the
nurses in Canada (42.2%) worked in
part-time and casual positions (CIHI,
2004). This may result in inefficient
use of existing personnel, and have an
impact on the ability of the team to
function effectively. It may also im-
pact patients by influencing continuity
of care.
Work demands have increased and
heavy workloads are reported by
nurses, resulting in work overload and
job strain (CNAC, 2002; CHSRF,
2006). Nurses who work in hospitals
with lower levels of staffing are more
likely to rate the quality of care as fair
or poor (Aiken, Clarke & Sloan,
2002). Reports indicate that they are
frustrated, trying to provide quality
care in a more complex environment.
In addition to an increased nursing
workload, nurses are expected to do
the work of other staff. This decreases
self-esteem and creates the perception
that the work of nursing is not valued.
While nurses often perform non-
nursing duties, they are sometimes
restricted from doing what they are
qualified to do. Nurses need the free-
dom to work to their full scope of
practice and feel that their skills are
recognized and valued (CNAC).
Due to limited funding, resources for
education have been cut (CNAC, When compared with other
2002; CHSRF, 2006). Nurses report workers in Canada, nurses
have had the highest or
there is little support for continuing
second highest rate of ab-
education in the workplace. They of- senteeism for the past 15
ten find it difficult to attend scheduled years (CNA, 2006). Rea-
inservices, since there is no one to sons for absenteeism in-
replace them and they are unable to clude illness, injury, burn-
leave the patient units. There are few out or disability, and may
opportunities for professional devel- be related to the work
opment or for promotion. While nurses do or their place of
nurses have traditionally considered work.
their profession to be a long-term ca-
reer, the nurses of today are less toler-
ant of the physical and emotional
challenges of work (CNAC). Known
as Generation X, they are loyal to
friends and family and “have a differ-
ent perspective on working long hours
and making career sacri-
fices” (Sherman, 2005b, p. 126).
Advances in technology also impact
nursing and health care. While tech-
nology has contributed to advances in
health care and the resulting changes
in the work setting, it provides access
5

The challenges to leader-
ship in nursing evolve from
reforms in health care and
impact on the practice and
work life of nurses. While
many different aspects are
relevant, the issues are
interrelated and influence
leadership development.
“Nursing requires strong,
consistent, and knowledge-
able leaders who are visi-
ble, inspire others and
support professional nurs-
ing practice (CNA, 2002)”.
ARNNL Nursing Leadership Literature Review
to a vast amount of information
(Porter-O’Grady, 1999). Nurses now
work with a more educated consumer,
who expects higher quality services,
more information about treatment op-
tions, and more accountability for per-
formance.
The challenges to leadership in nurs-
ing evolve from reforms in health care
and impact on the practice and work
life of nurses. While many different
aspects are relevant, the issues are
interrelated and influence leadership
development.
Leadership Barriers and Facili-
tators
Barriers to leadership and facilitators
are identified through discussion and
analysis of issues that impact on nurs-
ing and health in a changing system of
health care.
Barriers to leadership include exces-
sive workloads, inadequate staffing,
overtime work, part-time and casual
employment, wide span of control,
lack of managerial and employer sup-
port, lack of support workers, unclear
roles, inadequate funding, and lack of
opportunities for education or profes-
sional development.
Leadership facilitators include mana-
gerial, employer and organizational
support, narrow span of control, men-
torship, reasonable workload, positive
work environment, flexible work
schedules, opportunities to perform to
full scope of practice, role clarity, ac-
cess to information, opportunities to
learn, and strong alliance with co-
workers.
6
Implications for Leadership
Issues related to nursing have been
addressed in major reports globally,
nationally, and provincially. A consis-
tent theme is the need for strong nurs-
ing leadership in order to address the
challenges in health care and achieve-
ment of quality outcomes. “Nursing
requires strong, consistent, and
knowledgeable leaders who are visi-
ble, inspire others and support profes-
sional nursing practice”(CNA , 2002).
These leaders are needed in every
level of the health care system hierar-
chy, including policy making and de-
cision making positions.
In many organizations, nurses who
have been promoted to positions of
authority have been the best managers
of patient care (Laurent, 2000). They
then use these same skills in a man-
agement role. In order to be effective,
nurses in positions of authority must
be both competent managers and
skilled leaders (ARNNL, 2005). Man-
agers are now expected to act as lead-
ers, coaches, and facilitators. They
must respond to and meet the expecta-
tions of both the organization and the
staff, and many have not been pre-
pared to take on this changed role
(Kramer, Schmalenberg, & Maguire,
2004). The first step in becoming a
leader is to release control (Laurent).
Porter-O’Grady (2003a) addressed the
characteristics of leadership in a
changing fast-paced system of health
care. In today’s environment, skills in
collective problem solving, communi-
cations, and team work are considered
to be more relevant. In creating a new
 ARNNL Nursing Leadership Literature Review
context for practice, leaders must con-
front change in their own work and be
able to help others to confront change
(Porter-O’Grady, 2003b).
Work life issues in nursing practice
also have implications for leaders. It
has been documented in the literature
on magnet hospitals that addressing
work environments encourages and
rewards professional nurses (Morgan,
Lahman, & Hagstrom, 2006). Health
care agencies that achieve Magnet
designation are recognized for nursing
excellence, a contributing factor to
quality patient outcomes. According
to Laschinger, Almost, & Tuer-Hodes
(2003), professional practice in mag-
net hospitals is supported by work
environments that provide access to
information, support, resources, op-
portunities to learn, flexible job activi-
ties, and strong alliance with cowork-
ers. In addition, professional working
environments for nurses contribute to
patient safety. Laschinger and Leiter
(2006) found both staffing adequacy
and a nursing model of care to di-
rectly affect patient safety outcomes.
In a study of surgical patients, Aiken
et al., (2002) found there was a higher
mortality rate within 30 days of ad-
mission for patients in hospitals with
high patient-to-nurse ratios.
At a time of change and uncertainty in
health care, leaders must create an
environment that supports quality out-
comes for patients and professional
practice for nurses.
Leadership Development
Leadership development programs are
guided by two different approaches: a
model/theory or a framework of pro-
gram delivery (CNA, 2003). As a
background for developing a model
for leadership in nursing, selected ap-
proaches to development of a model
will be presented. Program delivery
methods and leadership strategies will
be identified through discussion of
literature findings.
Models and Theories
Leadership development is conceptu-
alized in different ways, depending on
various factors, including the target
group. These include professionals in
public health (Wright, Rowitz &
Merkle, 2001), developing health care
leaders (Leatt & Porter, 2003), and
health care leaders in general
(Thompson, 2004). Leadership in
nursing may be guided by a frame-
work (Tourangeau, 2003) or a theory
(Laurent, 2000).
Wright, Rowitz & Merkle (2001) ad-
dressed aspects to be considered when
developing a leadership program; ca-
pacity development need, recruitment
target, geographic area, program con-
tent, learning level, learning approach,
and implementation methods. These
stages were applied in a model to ad-
dress leadership development for pro-
fessionals in public health.
Leatt and Porter (2003) applied the
concept of life-long learning to a lead-
ership development model. It should
include formal education, manage-
ment training (field experiences, fel-
lowships, etc.), assessment and feed-
back, formal mentoring, and intense
leadership development experience.
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 ARNNL Nursing Leadership Literature Review
The model is competency-based and
assessment oriented, within a frame-
work of quality improvement.
According to Thompson (2004), a
framework addresses the values, be-
liefs, and behaviors for each leader.
The dimensions are not dependent on
the organizational characteristics and
include: integrity, honesty, continual
learning, comfort with uncertainty,
holding multiple perspectives without
judgement, discovery of potential,
nurturing the emotional and intellec-
tual self, caring for one self, career
development, and embracing diver-
sity.
The D. M. Wylie Leadership Institute
addresses competencies for nursing
leadership in each of 4 domains: nurs-
ing practice, the business of health
care, leadership practices, and use of
self (Tourangeau, 2003). Theoretical
and experiential opportunities are of-
fered to develop leadership competen-
cies. Tourangeau used Leadership
Practices Inventory by Kouzes & Pos-
ner to measure the practices of partici-
pants at that institute. Practices in-
cluded: challenge the process, inspire
a shared vision, enable others to act,
model the way, and encourage the
heart.
Laurent (2000) discussed the applica-
tion of leadership theories to nursing,
and proposed using Oralando’s model
for nursing and a dynamic leader–
follower relationship model. Using
this leadership model, the leader pro-
vides direction and guidance for the
employees to choose their own plan.
An example of the application of this
model would be to give employees the
8
opportunity to fill a management posi-
tion, using the parameters established
by the leader. Accountability would
be shared, and employees would as-
sume responsibility for their deci-
sions, actively participating in the
planning of the organization. In addi-
tion, employees would learn leader-
ship skills.
Models for leadership vary according
to the focus and the definition of the
concepts. In general, they include de-
velopment of leadership competencies
and support the principles of lifelong
learning.
Programs
A variety of approaches to delivery of
leadership development programs are
described in the literature. These pro-
grams vary in length from a one-day
session, to achievement of learning
goals over a period of time; e.g., 6-12
months. The target group varies ac-
cording to the identified need and may
focus on a specific group, e.g., clinical
leaders, or a whole leadership team.
Basic B.N. educational programs also
address leadership development.
The content of leadership programs
varies according to the goals. A one-
day program, described by Sherman
(2005a), included 4 critical skills:
communication, supervision and dele-
gation, conflict management, and
team building. In other programs,
content was determined based on
learning needs identified by partici-
pants through an initial assessment
(Hill, 2003; McNally & Lukens,
2006; Sullivan et al., 2003; Mills,
2005). In formal educational pro-
 ARNNL Nursing Leadership Literature Review
grams in schools of nursing, core con-
cepts are identified based on literature
findings (Heller et al., 2004). Other
recommendations are made through
discussion of research findings. An-
trobus and Kitson (1999) recom-
mended that leadership programs in-
clude the development of clinical
leadership skills, and the knowledge
and skills to work within academic,
management, and political domains.
Learning activities include: small
group activities with peers for analy-
sis and reflection of issues (Leatt &
Porter, 2003), professional coaching;
i.e., internal and external coach part-
nering in developing and implement-
ing program (McNally & Lukens,
2006), interactive learning activities
(Collins, 2000; Mills, 2005), experi-
ential learning (Cook & Leathard,
2004; Heller et al., 2004; Collins), and
mentoring (Sullivan et al., 2003;
Heller et al.).
Feedback mechanisms are important
to include in the process of leadership
development. Suggestions include:
self-assessment (Heller, et al., 2004);
feedback from peers, instructors/
supervisors (Collins, 2000; Mills,
2005); personal log for systematically
collecting and organizing learning
experiences; observation of behavior
and leadership styles (Heller et al.;
Hill, 2003).
Leadership Strategies
Literature sources support strategies
that reflect transformational values
and competencies to address leader-
ship issues in nursing practice
(CHSRF, 2004; Thyer, 2003; Trofino,
2000). A variety of strategies are dis-
cussed as contributing to leadership
development:
1. Activities that support profes-
sional nursing practice contribute
to leadership development and
quality patient outcomes
(Ferguson-Pare َet al., 2002).
They include:
a. nursing newsletter and pro-
fessional publications that
include input from all
nurses, including managers
(Trofino, 2000)
b. attendance at professional
meetings (Trofino)
2. Academic and continuing edu-
cation initiatives support lead-
ership development (Heller et
al., 2004; Sullivan, Bretschnei-
der, & McCausland, 2003).
They include:
a. leadership education for
experiences and new man-
agers (Sullivan, et al., 2003)
and nurses in practice
(Heller et al., 2004)
b. adequate funding (Trofino,
2000); e.g., tuition reim-
bursement, scholarships,
bursaries, merit awards
c. replacement staff for
nurses to attend formal and
informal educational ses-
sions
d. networking opportunities
for nurses; e.g., professional
meetings, workshops
(Tofino; Tracy & Nicholl,
2006)
e. evidence informed practice
9
 ARNNL Nursing Leadership Literature Review
(CNA, 2006)
f. opportunities to learn
(Laschinger, 2003)
g. life-long learning (CNA,
2006; Donner & Wheeler,
2004)
h. participation in nursing re-
search (Trofino)
i. self-assessment (Heller et
al.)
j. career development
(Donner & Wheeler)
3. Employers must implement
processes to facilitate decision
making for nurses in practice
(Trofino, 2000; Daiski, 2004).
They include:
a. nursing committees chaired
by managers and expert
clinical nurses (Trofino)
b. participative communica-
tions; meetings for problem
solving, networking on all
shifts (Trofino)
c. participation of all staff in
setting division/unit goals
(Trofino)
d. interprofessional approach
to address quality issues
(Trofino, Daiski)
e. feedback at clinical level;
e.g., peer review, merit re-
view (Trofino)
4. Recognition of work quality
promotes nursing leadership
(Trofino, 2000; Daiski. 2004).
Examples include:
a. encouragement and positive
reinforcement (Daiski)
b. empowerment; a supportive
environment for creativity
and decision-making, com-
10
munication of respect
(Daiski)
c. staff recognition; e.g. lunch-
eons, plaques, awards, pub-
lic recognition, etc.
(Kerfoot, 2005)
d. communication of nursing
goal achievement to divi-
sion, agency and commu-
nity (Trofino)
e. focus on learning, rather
than errors (Kerfoot)
5. Role models effectively
demonstrate leadership com-
petencies (Trofino, 2000).
They include:
a. self-confidence in goal set-
ting (Trofino)
b. problem solving, decision
making (Trofino)
c. self management; e.g., time,
caring for self (Leatt & Por-
ter, 2003)
6. Organizational infrastructure
supports leadership in prac-
tice (Kerfoot, 2005). Exam-
ples include:
a. a narrow span of control
(CHSRF, 2004)
b. care delivery models spe-
cific to the setting; e.g.,
based on acuity, length of
stay and staff experience
(Deutschendorf, 2000)
c. positive organizational cul-
ture (Morgan et al., 2006)
d. a nursing model of care
(Laschinger & Leiter, 2006
e. visible managers
f. open, truthful communica-
tions with staff, even in un-
certain times
g. a d e q u a t e s t a f f i n g
 ARNNL Nursing Leadership Literature Review

(Laschinger & Leiter)

h. supportive work environ-
ment (Laschinger et al.,
2003)

7. Coaching and mentorship

(informal & formal) supports
leadership development
(Tracey & Nicholl, 2006;
Heller et al., 2004). Examples
include:
a. participation in interpro-
fessional team (Leatt &
Porter, 2003; Laschinger
& Leiter, 2006)
b. building and fostering
strategic relationships
c. articulation of a vision
(Donner & Wheeler,
2004)

11
 ARNNL Nursing Leadership Literature Review

Conceptual Framework for Leadership Development

In Newfoundland and Labrador
Based on literature findings, a conceptual framework for leadership development in
Newfoundland and Labrador is presented.

Concepts of Model

Education: Basic and continuing education (formal & informal)

Competencies: theory and practice

Support: Provided by: manager, employer, government, ARNNL,

NLNU
Includes: nursing standards, Code of Ethics, position
statements, funding, mentorship, work environment,
technology

Self-development: Professional development, ethical practice, career devel-

opment, reflection, continuing competence, networking,
political awareness, empowerment, lifelong learning

Leadership: Interrelationship between education, support and self-

development

12
 ARNNL Nursing Leadership Literature Review

Summary

This review of the literature explores

the meaning of leadership, including
the discussion of selected theories and
application to nursing. Nursing leader-
ship skills and competencies are iden-
tified. A discussion of issues in a sys-
tem of health care reforms highlights
complex challenges for leadership,
including barriers and facilitators to
leadership development. Implications
for leadership are discussed. As a
background to developing a model for
leadership development, selected mod-
els, programs, and strategies are dis-
cussed. A conceptual model for leader-
ship development in Newfoundland
and Labrador is presented.

13
ARNNL Nursing Leadership Literature Review

14
ARNNL Nursing Leadership Literature Review

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ARNNL is the professional organization representing all 6300 Registered Nurses and 89 Nurse Practitioners in
the province. In pursuit of its vision, “Healthy People in Newfoundland and Labrador,” ARNNL exists so there
will be excellence in nursing, public protection, quality health care, and healthy public policy.

Association of Registered Nurses of Newfoundland and Labrador

55 Military Road, St. John’s, NL. A1C 2C5
Web Site: www.arnnl.nf.ca, Email: info@arnnl.nf.ca
Telephone: 709-753-6040, Toll Free: 800-563-3200
Facsimile: 709 753 4940