leadership in nursing assignment

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Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Management and Professional Concepts [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2022.

Nursing Management and Professional Concepts [Internet].

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Chapter 4 - Leadership and Management

4.1. leadership & management introduction, learning objectives.

• Compare and contrast the role of a leader and a manager

• Examine the roles of team members

• Identify the activities managers perform

• Describe the role of the RN as a leader and change agent

• Evaluate the effects of power, empowerment, and motivation in leading and managing a nursing team

• Recognize limitations of self and others and utilize resources

As a nursing student preparing to graduate, you have spent countless hours on developing clinical skills, analyzing disease processes, creating care plans, and cultivating clinical judgment. In comparison, you have likely spent much less time on developing management and leadership skills. Yet, soon after beginning your first job as a registered nurse, you will become involved in numerous situations requiring nursing leadership and management skills. Some of these situations include the following:

• Prioritizing care for a group of assigned clients
• Collaborating with interprofessional team members regarding client care
• Participating in an interdisciplinary team conference
• Acting as a liaison when establishing community resources for a patient being discharged home
• Serving on a unit committee
• Investigating and implementing a new evidence-based best practice
• Mentoring nursing students

Delivering safe, quality client care often requires registered nurses (RN) to manage care provided by the nursing team. Making assignments, delegating tasks, and supervising nursing team members are essential managerial components of an entry-level staff RN role. As previously discussed, nursing team members include RNs, licensed practical/vocational nurses (LPN/VN), and assistive personnel (AP).[ 1 ]

Read more about assigning, delegating, and supervising in the “ Delegation and Supervision ” chapter.

An RN is expected to demonstrate leadership and management skills in many facets of the role. Nurses manage care for high-acuity patients as they are admitted, transferred, and discharged; coordinate care among a variety of diverse health professionals; advocate for clients’ needs; and manage limited resources with shrinking budgets.[ 2 ]

Read more about collaborating and communicating with the interprofessional team; advocating for clients; and admitting, transferring, and discharging clients in the “ Collaboration Within the Interprofessional Team ” chapter.

An article published in the  Online Journal of Issues in Nursing  states, “With the growing complexity of healthcare practice environments and pending nurse leader retirements, the development of future nurse leaders is increasingly important.”[ 3 ] This chapter will explore leadership and management responsibilities of an RN. Leadership styles are introduced, and change theories are discussed as a means for implementing change in the health care system.

4.2. BASIC CONCEPTS

Organizational culture.

The formal leaders of an organization provide a sense of direction and overall guidance for their employees by establishing organizational vision, mission, and values statements. An organization’s  vision statement  defines why the organization exists, describes how the organization is unique from similar organizations, and specifies what the organization is striving to be. The  mission statement  describes how the organization will fulfill its vision and establishes a common course of action for future endeavors. See Figure 4.1 [ 1 ] for an illustration of a mission statement. A  values statement  establishes the values of an organization that assist with the achievement of its vision and mission. A values statement also provides strategic guidelines for decision-making, both internally and externally, by members of the organization. The vision, mission, and values statements are expressed in a concise and clear manner that is easily understood by members of the organization and the public.[ 2 ]

Mission Statement

Organizational culture  refers to the implicit values and beliefs that reflect the norms and traditions of an organization. An organization’s vision, mission, and values statements are the foundation of organizational culture. Because individual organizations have their own vision, mission, and values statements, each organization has a different culture.[ 3 ]

As health care continues to evolve and new models of care are introduced, nursing managers must develop innovative approaches that address change while aligning with that organization’s vision, mission, and values. Leaders embrace the organization’s mission, identify how individuals’ work contributes to it, and ensure that outcomes advance the organization’s mission and purpose. Leaders use vision, mission, and values statements for guidance when determining appropriate responses to critical events and unforeseen challenges that are common in a complex health care system. Successful organizations require employees to be committed to following these strategic guidelines during the course of their work activities. Employees who understand the relationship between their own work and the mission and purpose of the organization will contribute to a stronger health care system that excels in providing first-class patient care. The vision, mission, and values provide a common organization-wide frame of reference for decision-making for both leaders and staff.[ 4 ]

Learning Activity

Investigate the mission, vision, and values of a potential employer, as you would do prior to an interview for a job position.

Reflective Questions

1. How well do the organization’s vision and values align with your personal values regarding health care?

2. How well does the organization’s mission align with your professional objective in your resume?

Followership

Followership  is described as the upward influence of individuals on their leaders and their teams. The actions of followers have an important influence on staff performance and patient outcomes. Being an effective follower requires individuals to contribute to the team not only by doing as they are told, but also by being aware and raising relevant concerns. Effective followers realize that they can initiate change and disagree or challenge their leaders if they feel their organization or unit is failing to promote wellness and deliver safe, value-driven, and compassionate care. Leaders who gain the trust and dedication of followers are more effective in their leadership role. Everybody has a voice and a responsibility to take ownership of the workplace culture, and good followership contributes to the establishment of high-functioning and safety-conscious teams.[ 5 ]

Team members impact patient safety by following teamwork guidelines for good followership. For example, strategies such as closed-loop communication are important tools to promote patient safety.

Read more about communication and teamwork strategies in the “ Collaboration Within the Interprofessional Team ” chapter.

Leadership and Management Characteristics

Leadership and management are terms often used interchangeably, but they are two different concepts with many overlapping characteristics.  Leadership  is the art of establishing direction and influencing and motivating others to achieve their maximum potential to accomplish tasks, objectives, or projects.[ 6 ],[ 7 ] See Figure 4.2 [ 8 ] for an illustration of team leadership. There is no universally accepted definition or theory of nursing leadership, but there is increasing clarity about how it differs from management.[ 9 ]  Management  refers to roles that focus on tasks such as planning, organizing, prioritizing, budgeting, staffing, coordinating, and reporting.[ 10 ] The overriding function of management has been described as providing order and consistency to organizations, whereas the primary function of leadership is to produce change and movement.[ 11 ] View a comparison of the characteristics of management and leadership in Table 4.2a .

Management and Leadership Characteristics[ 12 ]

View in own window

Not all nurses are managers, but all nurses are leaders because they encourage individuals to achieve their goals. The American Nurses Association (ANA) established  Leadership  as a Standard of Professional Performance for all registered nurses. Standards of Professional Performance are “authoritative statements of action and behaviors that all registered nurses, regardless of role, population, specialty, and setting, are expected to perform competently.”[ 13 ] See the competencies of the ANA  Leadership  standard in the following box and additional content in other chapters of this book.

Competencies of ANA’s Leadership Standard of Professional Performance

• Promotes effective relationships to achieve quality outcomes and a culture of safety

• Leads decision-making groups

• Engages in creating an interprofessional environment that promotes respect, trust, and integrity

• Embraces practice innovations and role performance to achieve lifelong personal and professional goals

• Communicates to lead change, influence others, and resolve conflict

• Implements evidence-based practices for safe, quality health care and health care consumer satisfaction

• Demonstrates authority, ownership, accountability, and responsibility for appropriate delegation of nursing care

• Mentors colleagues and others to embrace their knowledge, skills, and abilities

• Participates in professional activities and organizations for professional growth and influence

• Advocates for all aspects of human and environmental health in practice and policy

Read additional content related to leadership and management activities in corresponding chapters of this book:

• Read about the culture of safety in the “ Legal Implications ” chapter.

• Read about effective interprofessional teamwork and resolving conflict in the “ Collaboration Within the Interprofessional Team ” chapter.

• Read about quality improvement and implementing evidence-based practices in the “ Quality and Evidence-Based Practice ” chapter.

• Read more about delegation, supervision, and accountability in the “ Delegation and Supervision ” chapter.

• Read about professional organizations and advocating for patients, communities, and their environments in the “ Advocacy ” chapter.

• Read about budgets and staffing in the “ Health Care Economics ” chapter.

• Read about prioritization in the “ Prioritization ” chapter.

Leadership Theories and Styles

In the 1930s Kurt Lewin, the father of social psychology, originally identified three leadership styles: authoritarian, democratic, and laissez-faire.[ 14 ],[ 15 ]

Authoritarian leadership  means the leader has full power. Authoritarian leaders tell team members what to do and expect team members to execute their plans. When fast decisions must be made in emergency situations, such as when a patient “codes,” the authoritarian leader makes quick decisions and provides the group with direct instructions. However, there are disadvantages to authoritarian leadership. Authoritarian leaders are more likely to disregard creative ideas of other team members, causing resentment and stress.[ 16 ]

Democratic leadership  balances decision-making responsibility between team members and the leader. Democratic leaders actively participate in discussions, but also make sure to listen to the views of others. For example, a nurse supervisor may hold a meeting regarding an increased incidence of patient falls on the unit and ask team members to share their observations regarding causes and potential solutions. The democratic leadership style often leads to positive, inclusive, and collaborative work environments that encourage team members’ creativity. Under this style, the leader still retains responsibility for the final decision.[ 17 ]

Laissez-faire  is a French word that translates to English as, “leave alone.” Laissez-faire leadership gives team members total freedom to perform as they please. Laissez-faire leaders do not participate in decision-making processes and rarely offer opinions. The laissez-faire leadership style can work well if team members are highly skilled and highly motivated to perform quality work. However, without the leader’s input, conflict and a culture of blame may occur as team members disagree on roles, responsibilities, and policies. By not contributing to the decision-making process, the leader forfeits control of team performance.[ 18 ]

Over the decades, Lewin’s original leadership styles have evolved into many styles of leadership in health care, such as passive-avoidant, transactional, transformational, servant, resonant, and authentic.[ 19 ],[ 20 ] Many of these leadership styles have overlapping characteristics. See Figure 4.3 [ 21 ] for a comparison of various leadership styles in terms of engagement.

Leadership Styles

Passive-avoidant leadership  is similar to laissez-faire leadership and is characterized by a leader who avoids taking responsibility and confronting others. Employees perceive the lack of control over the environment resulting from the absence of clear directives. Organizations with this type of leader have high staff turnover and low retention of employees. These types of leaders tend to react and take corrective action only after problems have become serious and often avoid making any decisions at all.[ 22 ]

Transactional leadership  involves both the leader and the follower receiving something for their efforts; the leader gets the job done and the follower receives pay, recognition, rewards, or punishment based on how well they perform the tasks assigned to them.[ 23 ] Staff generally work independently with no focus on cooperation among employees or commitment to the organization.[ 24 ]

Transformational leadership  involves leaders motivating followers to perform beyond expectations by creating a sense of ownership in reaching a shared vision.[ 25 ] It is characterized by a leader’s charismatic influence over team members and includes effective communication, valued relationships, and consideration of team member input. Transformational leaders know how to convey a sense of loyalty through shared goals, resulting in increased productivity, improved morale, and increased employees’ job satisfaction.[ 26 ] They often motivate others to do more than originally intended by inspiring them to look past individual self-interest and perform to promote team and organizational interests.[ 27 ]

Servant leadership  focuses on the professional growth of employees while simultaneously promoting improved quality care through a combination of interprofessional teamwork and shared decision-making. Servant leaders assist team members to achieve their personal goals by listening with empathy and committing to individual growth and community-building. They share power, put the needs of others first, and help individuals optimize performance while forsaking their own personal advancement and rewards.[ 28 ]

Visit the Greenleaf Center site to learn more about  What is Servant Leadership ?

Resonant leaders  are in tune with the emotions of those around them, use empathy, and manage their own emotions effectively. Resonant leaders build strong, trusting relationships and create a climate of optimism that inspires commitment even in the face of adversity. They create an environment where employees are highly engaged, making them willing and able to contribute with their full potential.[ 29 ]

Authentic leaders  have an honest and direct approach with employees, demonstrating self-awareness, internalized moral perspective, and relationship transparency. They strive for trusting, symmetrical, and close leader–follower relationships; promote the open sharing of information; and consider others’ viewpoints.[ 30 ]

Characteristics of Leadership Styles

Outcomes of Various Leadership Styles

Leadership styles affect team members, patient outcomes, and the organization. A systematic review of the literature published in 2021 showed significant correlations between leadership styles and nurses’ job satisfaction. Transformational leadership style had the greatest positive correlation with nurses’ job satisfaction, followed by authentic, resonant, and servant leadership styles. Passive-avoidant and laissez-faire leadership styles showed a negative correlation with nurses’ job satisfaction.[ 31 ] In this challenging health care environment, managers and nurse leaders must promote technical and professional competencies of their staff, but they must also act to improve staff satisfaction and morale by using appropriate leadership styles with their team.[ 32 ]

Systems Theory

Systems theory  is based on the concept that systems do not function in isolation but rather there is an interdependence that exists between their parts. Systems theory assumes that most individuals strive to do good work, but are affected by diverse influences within the system. Efficient and functional systems account for these diverse influences and improve outcomes by studying patterns and behaviors across the system.[ 33 ]

Many health care agencies have adopted a culture of safety based on systems theory. A  culture of safety  is an organizational culture that embraces error reporting by employees with the goal of identifying systemic causes of problems that can be addressed to improve patient safety. According to The Joint Commission, a culture of safety includes the following components[ 34 ]:

• Just Culture:  A culture where people feel safe raising questions and concerns and report safety events in an environment that emphasizes a nonpunitive response to errors and near misses. Clear lines are drawn by managers between human error, at-risk, and reckless employee behaviors. See Figure 4.4 [ 35 ] for an illustration of Just Culture.
• Reporting Culture:  People realize errors are inevitable and are encouraged to speak up for patient safety by reporting errors and near misses. For example, nurses complete an “incident report” according to agency policy when a medication error occurs or a client falls. Error reporting helps the agency manage risk and reduce potential liability.
• Learning Culture:  People regularly collect information and learn from errors and successes while openly sharing data and information and applying best evidence to improve work processes and patient outcomes.

“Just Culture Infographic.png” by Valeria Palarski 2020. Used with permission.

The Just Culture model categorizes human behavior into three categories of errors. Consequences of errors are based on whether the error is a simple human error or caused by at-risk or reckless behavior[ 36 ]:

• Simple human error:  A simple human error occurs when an individual inadvertently does something other than what should have been done. Most medical errors are the result of human error due to poor processes, programs, education, environmental issues, or situations. These errors are managed by correcting the cause, looking at the process, and fixing the deviation. For example, a nurse appropriately checks the rights of medication administration three times, but due to the similar appearance and names of two different medications stored next to each other in the medication dispensing system, administers the incorrect medication to a patient. In this example, a root cause analysis reveals a system issue that must be modified to prevent future patient errors (e.g., change the labelling and storage of look alike-sound alike medications).[ 37 ]
• At-risk behavior:  An error due to at-risk behavior occurs when a behavioral choice is made that increases risk where the risk is not recognized or is mistakenly believed to be justified. For example, a nurse scans a patient’s medication with a barcode scanner prior to administration, but an error message appears on the scanner. The nurse mistakenly interprets the error to be a technology problem and proceeds to administer the medication instead of stopping the process and further investigating the error message, resulting in the wrong dosage of a medication being administered to the patient. In this case, ignoring the error message on the scanner can be considered “at-risk behavior” because the behavioral choice was considered justified by the nurse at the time.[ 38 ]
• Reckless behavior:  Reckless behavior is an error that occurs when an action is taken with conscious disregard for a substantial and unjustifiable risk. For example, a nurse arrives at work intoxicated and administers the wrong medication to the wrong patient. This error is considered due to reckless behavior because the decision to arrive intoxicated was made with conscious disregard for substantial risk.[ 39 ]

These categories of errors result in different consequences to the employee based on the Just Culture model:

• If an individual commits a simple human error, managers console the individual and consider changes in training, procedures, and processes.[ 40 ] In the “simple human error” example above, system-wide changes would be made to change the label and location of the medications to prevent future errors from occurring with the same medications.
• Individuals committing at-risk behavior are held accountable for their behavioral choices and often require coaching with incentives for less risky behaviors and situational awareness.[ 41 ]In the “at-risk behavior” example above, when the nurse chose to ignore an error message on the barcode scanner, mandatory training on using barcode scanners and responding to errors would likely be implemented, and the manager would track the employee’s correct usage of the barcode scanner for several months following training.
• If an individual demonstrates reckless behavior, remedial action and/or punitive action is taken.[ 42 ] In the “reckless behavior” example above, the manager would report the nurse’s behavior to the State Board of Nursing for disciplinary action. The SBON would likely mandate substance abuse counseling for the nurse to maintain their nursing license. However, employment may be terminated and/or the nursing license revoked if continued patterns of reckless behavior occur.

See Table 4.2c describing classifications of errors using the Just Culture model.

Classification of Errors Using the Just Culture Model

Systems leadership  refers to a set of skills used to catalyze, enable, and support the process of systems-level change that is encouraged by the Just Culture Model. Systems leadership is comprised of three interconnected elements:[ 43 ]

• The Individual:  The skills of collaborative leadership to enable learning, trust-building, and empowered action among stakeholders who share a common goal
• The Community:  The tactics of coalition building and advocacy to develop alignment and mobilize action among stakeholders in the system, both within and between organizations
• The System:  An understanding of the complex systems shaping the challenge to be addressed

4.3. IMPLEMENTING CHANGE

Change is constant in the health care environment.  Change  is defined as the process of altering or replacing existing knowledge, skills, attitudes, systems, policies, or procedures.[ 1 ] The outcomes of change must be consistent with an organization’s mission, vision, and values. Although change is a dynamic process that requires alterations in behavior and can cause conflict and resistance, change can also stimulate positive behaviors and attitudes and improve organizational outcomes and employee performance. Change can result from identified problems or from the incorporation of new knowledge, technology, management, or leadership. Problems may be identified from many sources, such as quality improvement initiatives, employee performance evaluations, or accreditation survey results.[ 2 ]

Nurse managers must deal with the fears and concerns triggered by change. They should recognize that change may not be easy and may be met with enthusiasm by some and resistance by others. Leaders should identify individuals who will be enthusiastic about the change (referred to as “early adopters”), as well as those who will be resisters (referred to as “laggers”). Early adopters should be involved to build momentum, and the concerns of resisters should be considered to identify barriers. Data should be collected, analyzed, and communicated so the need for change (and its projected consequences) can be clearly articulated. Managers should articulate the reasons for change, the way(s) the change will affect employees, the way(s) the change will benefit the organization, and the desired outcomes of the change process.[ 3 ] See Figure 4.5 [ 4 ] for an illustration of communicating upcoming change.

Identifying Upcoming Change

Change Theories

There are several change theories that nurse leaders may adopt when implementing change. Two traditional change theories are known as Lewin’s Unfreeze-Change-Refreeze Model and Lippitt’s Seven-Step Change Theory.[ 5 ]

Lewin’s Change Model

Kurt Lewin, the father of social psychology, introduced the classic three-step model of change known as Unfreeze-Change-Refreeze Model that requires prior learning to be rejected and replaced. Lewin’s model has three major concepts: driving forces, restraining forces, and equilibrium. Driving forces are those that push in a direction and cause change to occur. They facilitate change because they push the person in a desired direction. They cause a shift in the equilibrium towards change. Restraining forces are those forces that counter the driving forces. They hinder change because they push the person in the opposite direction. They cause a shift in the equilibrium that opposes change. Equilibrium is a state of being where driving forces equal restraining forces, and no change occurs. It can be raised or lowered by changes that occur between the driving and restraining forces.[ 6 ],[ 7 ]

• Step 1: Unfreeze the status quo.  Unfreezing is the process of altering behavior to agitate the equilibrium of the current state. This step is necessary if resistance is to be overcome and conformity achieved. Unfreezing can be achieved by increasing the driving forces that direct behavior away from the existing situation or status quo while decreasing the restraining forces that negatively affect the movement from the existing equilibrium. Nurse leaders can initiate activities that can assist in the unfreezing step, such as motivating participants by preparing them for change, building trust and recognition for the need to change, and encouraging active participation in recognizing problems and brainstorming solutions within a group.[ 8 ]
• Step 2: Change.  Change is the process of moving to a new equilibrium. Nurse leaders can implement actions that assist in movement to a new equilibrium by persuading employees to agree that the status quo is not beneficial to them; encouraging them to view the problem from a fresh perspective; working together to search for new, relevant information; and connecting the views of the group to well-respected, powerful leaders who also support the change.[ 9 ]
• Step 3: Refreeze.  Refreezing refers to attaining equilibrium with the newly desired behaviors. This step must take place after the change has been implemented for it to be sustained over time. If this step does not occur, it is very likely the change will be short-lived and employees will revert to the old equilibrium. Refreezing integrates new values into community values and traditions. Nursing leaders can reinforce new patterns of behavior and institutionalize them by adopting new policies and procedures.[ 10 ]

Example Using Lewin’s Change Theory

A new nurse working in a rural medical-surgical unit identifies that bedside handoff reports are not currently being used during shift reports.

Step 1: Unfreeze:  The new nurse recognizes a change is needed for improved patient safety and discusses the concern with the nurse manager. Current evidence-based practice is shared regarding bedside handoff reports between shifts for patient safety.[ 11 ] The nurse manager initiates activities such as scheduling unit meetings to discuss evidence-based practice and the need to incorporate bedside handoff reports.

Step 2: Change:  The nurse manager gains support from the Director of Nursing to implement organizational change and plans staff education about bedside report checklists and the manner in which they are performed.

Step 3: Refreeze:  The nurse manager adopts bedside handoff reports in a new unit policy and monitors staff for effectiveness.

Lippitt’s Seven-Step Change Theory

Lippitt’s Seven-Step Change Theory expands on Lewin’s change theory by focusing on the role of the change agent. A  change agent  is anyone who has the skill and power to stimulate, facilitate, and coordinate the change effort. Change agents can be internal, such as nurse managers or employees appointed to oversee the change process, or external, such as an outside consulting firm. External change agents are not bound by organizational culture, politics, or traditions, so they bring a different perspective to the situation and challenge the status quo. However, this can also be a disadvantage because external change agents lack an understanding of the agency’s history, operating procedures, and personnel.[ 12 ] The seven-step model includes the following steps[ 13 ]:

• Step 1: Diagnose the problem.  Examine possible consequences, determine who will be affected by the change, identify essential management personnel who will be responsible for fixing the problem, collect data from those who will be affected by the change, and ensure those affected by the change will be committed to its success.
• Step 2: Evaluate motivation and capability for change.  Identify financial and human resources capacity and organizational structure.
• Step 3: Assess the change agent’s motivation and resources, experience, stamina, and dedication.
• Step 4: Select progressive change objectives.  Define the change process and develop action plans and accompanying strategies.
• Step 5: Explain the role of the change agent to all employees and ensure the expectations are clear.
• Step 6: Maintain change.  Facilitate feedback, enhance communication, and coordinate the effects of change.
• Step 7: Gradually terminate the helping relationship of the change agent.

Example Using Lippitt’s Seven-Step Change Theory

Refer to the previous example of using Lewin’s change theory on a medical-surgical unit to implement bedside handoff reporting. The nurse manager expands on the Unfreeze-Change-Refreeze Model by implementing additional steps based on Lippitt’s Seven-Step Change Theory:

• The nurse manager collects data from team members affected by the changes and ensures their commitment to success.
• Early adopters are identified as change agents on the unit who are committed to improving patient safety by implementing evidence-based practices such as bedside handoff reporting.
• Action plans (including staff education and mentoring), timelines, and expectations are clearly communicated to team members as progressive change objectives. Early adopters are trained as “super-users” to provide staff education and mentor other nurses in using bedside handoff checklists across all shifts.
• The nurse manager facilitates feedback and encourages two-way communication about challenges as change is implemented on the unit. Positive reinforcement is provided as team members effectively incorporate change.
• Bedside handoff reporting is implemented as a unit policy, and all team members are held accountable for performing accurate bedside handoff reporting.

Read more about additional change theories in the  Current Theories of Change Management pdf .

Change Management

Change management  is the process of making changes in a deliberate, planned, and systematic manner.[ 14 ] It is important for nurse leaders and nurse managers to remember a few key points about change management[ 15 ]:

• Employees will react differently to change, no matter how important or advantageous the change is purported to be.
• Basic needs will influence reaction to change, such as the need to be part of the change process, the need to be able to express oneself openly and honestly, and the need to feel that one has some control over the impact of change.
• Change often results in a feeling of loss due to changes in established routines. Employees may react with shock, anger, and resistance, but ideally will eventually accept and adopt change.
• Change must be managed realistically, without false hopes and expectations, yet with enthusiasm for the future. Employees should be provided information honestly and allowed to ask questions and express concerns.

4.4. SPOTLIGHT APPLICATION

Jamie has recently completed his orientation to the emergency department at a busy Level 1 trauma center. The environment is fast-paced and there are typically a multitude of patients who require care. Jamie appreciates his colleagues and the collaboration that is reflected among members of the health care team, especially in times of stress. Jamie is providing care for an 8-year-old patient who has broken her arm when there is a call that there are three Level 1 trauma patients approximately 5 minutes from the ER. The trauma surgeon reports to the ER, and multiple members of the trauma team report to the ER intake bays. If you were Jamie, what leadership style would you hope the trauma surgeon uses with the team?

In a stressful clinical care situation, where rapid action and direction are needed, an autocratic leadership style is most effective. There is no time for debating different approaches to care in a situation where immediate intervention may be required. Concise commands, direction, and responsive action from the team are needed to ensure that patient care interventions are delivered quickly to enhance chance of survival and recovery.

4.5. LEARNING ACTIVITIES

Learning activities.

(Answers to “Learning Activities” can be found in the “Answer Key” at the end of the book. Answers to interactive activities are provided as immediate feedback.)

Sample Scenario

An 89-year-old female resident with Alzheimer’s disease has been living at the nursing home for many years. The family decides they no longer want aggressive measures taken and request to the RN on duty that the resident’s code status be changed to Do Not Resuscitate (DNR). The evening shift RN documents a progress note that the family (and designated health care agent) requested that the resident’s status be made DNR. Due to numerous other responsibilities and needs during the evening shift, the RN does not notify the attending physician or relay the information during shift change or on the 24-hour report. The day shift RN does not read the night shift’s notes because of several immediate urgent situations. The family, who had been keeping vigil at the resident’s bedside throughout the night, leaves to go home to shower and eat. Upon return the next morning, they find the room full of staff and discover the staff performed CPR after their loved one coded. The resident was successfully resuscitated but now lies in a vegetative state. The family is unhappy and is considering legal action. They approach you, the current nurse assigned to the resident’s care, and state, “We followed your procedures to make sure this would not happen! Why was this not managed as we discussed?”[ 1 ]

1. As the current nurse providing patient care, explain how you would therapeutically address this family’s concerns and use one or more leadership styles.

2. As the charge nurse, explain how you would address the staff involved using one or more leadership styles.

3. Explain how change theory can be implemented to ensure this type of situation does not recur.

IV. GLOSSARY

The process of altering or replacing existing knowledge, skills, attitudes, systems, policies, or procedures.[ 1 ]

Anyone who has the skill and power to stimulate, facilitate, and coordinate the change effort.

Organizational culture that embraces error reporting by employees with the goal of identifying systemic causes of problems that can be addressed to improve patient safety. Just Culture is a component of a culture of safety.

The upward influence of individuals on their leaders and their teams.

A culture where people feel safe raising questions and concerns and report safety events in an environment that emphasizes a nonpunitive response to errors and near misses. Clear lines are drawn between human error, at-risk, and reckless employee behaviors.

The art of establishing direction and influencing and motivating others to achieve their maximum potential to accomplish tasks, objectives, or projects.[ 2 ],[ 3 ]

Roles that focus on tasks such as planning, organizing, prioritizing, budgeting, staffing, coordinating, and reporting.[ 4 ]

An organization’s statement that describes how the organization will fulfill its vision and establishes a common course of action for future endeavors.

The implicit values and beliefs that reflect the norms and traditions of an organization. An organization’s vision, mission, and values statements are the foundation of organizational culture.

A set of skills used to catalyze, enable, and support the process of systems-level change that focuses on the individual, the community, and the system.

The concept that systems do not function in isolation but rather there is an interdependence that exists between their parts. Systems theory assumes that most individuals strive to do good work, but are affected by diverse influences within the system.

The organization’s established values that support its vision and mission and provide strategic guidelines for decision-making, both internally and externally, by members of the organization.

An organization’s statement that defines why the organization exists, describes how the organization is unique and different from similar organizations, and specifies what the organization is striving to be.

Licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/ .

• Cite this Page Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Management and Professional Concepts [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2022. Chapter 4 - Leadership and Management.
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In this Page

• LEADERSHIP & MANAGEMENT INTRODUCTION
• BASIC CONCEPTS
• IMPLEMENTING CHANGE
• SPOTLIGHT APPLICATION
• LEARNING ACTIVITIES

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Introduction Leadership is a process which involves individual activity to state desire objective and vision in a situation, providing support and motivating other people to attend set goals (Swearingen, 2009). Danae et al. (2017) believe that leadership is broadly recognised as a key aspect of overall effective healthcare. Therefore, nurses require strong leadership skills to accomplish various tasks to improve care quality. In this assignment, I will cross reference six experts (see appendices) from my professional development portfolio related to the four domains of standards of competence for preregistration nursing (NMC, 2010). Additionally, I will address each domain using Rolfe, Freshwater and Jasper (2001) reflection model, which is composed of three stages ‘what’, ‘so what’, and ‘now what’. This model is suitable to link practical experiences with theory, it helps to improve clinical practice and identify further learning opportunities; which will be addressed by formulating a S.M.A.R.T action plan (Doran, 1981). Domaine 1: Professional values What? Appendix 1 shows aspects of the professional values that I need to address. It contains mentor’s comment about patient advocacy skill. During my Nursing Practice 5 (NP5), I looked after a 56-year-old disabled woman with Spina Bifida who was alert and orientated, unable to move on her own, but, had clearly expressed her need to be moved every two hours to avoid another pressure ulcer as she had one before. This was not respected by health care assistant taking for excuses “the ward is very busy, she is not the only patient”. I regret I didn’t advocate for her. Furthermore, appendix 2, which is the leadership framework self-assessment tool demonstrates aspects of personal quality that I need to review. These are related to the (NMC, 2010) instructing nurses to take all reasonable steps to protect people who are vulnerable or at risk from harm, neglect or abuse. So what? Professionalism means practice through the application of the Code (NMC, 2017). In the UK, nurses must act as advocates for their patients, challenge poor practice and discriminatory attitudes and behaviour relating to the care of vulnerable people, (NMC, 2015). This is supported by the Royal College of Nursing (RCN) stating that speaking on behalf of another is an integral part of the nurse’s role (RCN, 2008). Moreover, The International Council of Nurses emphasises the need for nurses to respect the rights, values, customs and beliefs of individuals and families, and to advocate for equity and social justice in resource allocation and in access to health (ICN, 2012). Such endeavours are central, as illness nearly always increase levels of patient vulnerability and dependence (Marquis and Huston 2012). Emphasizing the fact that nurses should influence the way care is given in a manner that is open and responds to individual needs (RCN, 2015). Unfortunately, there have been cases where nurses have failed to provide fundamental care to patients. The report into the failing at the Mid Staffordshire Hospital identified poor leadership coupled with clinical staff accepting standards of care that should not have been tolerated (Ellis and Bach, 2015). More recently, Care Quality Commission (CQC) has issued a Warning Notice requiring some trusts to improve safety, patient consent and overall leadership (CQC, 2017). This accentuates the role of leadership in prioritising patient safety and in listening to and learning from patients (storey and Holti, 2013 ). Stressing the need for nurse leaders to be self-aware and recognise how their own values and principles may affect their practice (NMC, 2010). Leaders encourage teamwork by appreciating individuals’ contributions and ideas; this creates needed behaviour, such as shared respect, compassionate care, attention to detail, between team members (NHS Leadership Academy, 2013), and create a motivating work environment (Adair, 2002). Therefore, the quality of leadership has a direct impact on the quality of service provided at all levels. The leader’s obligation is to create an environment in which good people can provide good care (Engard, 2017). Pointing out personal attributes of nurses that help to enable advocacy like flexibility, empathy, self-motivation, professional commitment, sense of responsibility, and the ability to cope with stress (Choi, 2015). Reflecting on the above scenario, transformational and transactional leadership can both play a role in the negotiation of a win-win situation. Transformational leadership is defined as a leadership approach that causes changes in individuals and social systems. It is about having a vision of how things should or could be and being able to communicate this idea effectively to others (Ellis and Bach, 2015). Whereas transactional leadership is based on contingent rewards and can have a positive effect on followers’ satisfaction and performance (Tomlinson, 2012). Transformational leadership plays a more critical role in the present scenario. it can motivate and inspire healthcare assistant and have a more significant impact to change both their thinking and behaviour Jie-HuiXu (2017), thus, allowing them to reach their potential and deliver sustainable changes to care. Now what? Now I should strive on developing and sustaining my engagement in patient advocacy by the end of NP7. In my Ongoing Achievement Record document, I will work with my mentor to complete competency 1.2. called: Understand and apply current legislation to all service users, paying special attention to the protection of vulnerable people, including those with complex needs. I will actively seek mentor, patients, family and others health professionals’ feedback and reflect on when I have been involved in patient advocacy during placement and review this with my mentor at mid- and end-point review. Domain 2: Communication and Interpersonal Skill What? Communication and interpersonal skill are vital parts of collaborative working (NMC, 2010). I reflect on communication using Situation, Background, Assessment and Recommendation (SBAR) mentioned in appendix 3, which is a reflective writing during placement 5. In a surgical ward, during routine observation of a patient who had undergone a cystectomy, I noticed that the patient was spiking in temperature (38.5) although NEWS score was 1, I immediately informed my mentor who directed me to blip the doctor in charge of his care. While communicating with him I was unable to give a clear response to questions about the patient’s condition. Even though he reassessed my patient immediately, I regret I didn’t use SBAR tool, because it could have helped to communicate clearly and prevent any potential delays. Appendix 1 in the section ‘working with others’ further shows that I need to improve my interpersonal skills. These relate to part of the NMC (2010) stating: nurses must use a range of communication skills and technologies to support person-centred care and enhance quality and safety. So what? Bach and Grant (2010) state that good communication and interpersonal skills are essential characteristics of high-quality nursing practice. The NMC (2010) also said that all nurses must use the full range of communication methods, including verbal, nonverbal and written, to acquire, interpret and record their knowledge and understanding of people’s needs. Emphasizing the use of communication tools like SBAR. SBAR is a tangible approach to framing conversations, especially critical ones that require a nurse’s instant attention and action. It promotes the provision of safe, efficient, timely, and patient-centred communication (Chaboyer et al., 2010; Day, 2010). Moreover, SBAR can be used for multiple forms of communication. It can be a change-of-shift report (Pope et al., 2008; Thomas et al., 2009), or can be applied to written communication (Perry, 2014). In addition, SBAR helps nursing students and recent graduate nurses organize their thoughts prior to calling physicians, to save time, reduce frustration, and improve overall communication (Pope et al., 2008). Furthermore, the use of SBAR communication tool temporarily flattens the hierarchy perceived in most healthcare settings, resulting in more effective channels of communication between healthcare providers (De Meester, Verspuy, Monsieurs, & Van Bogaert, 2013). According to Hackman and Johnson (2013), leadership is first, and foremost, a communication-based activity. Depending on the circumstances, a leader should try to be more authoritarian, democratic or laissez-faire (Mitchell, 2012); or should focus the communication on the tasks or use a more interpersonal style (Hackman and Johnson 2013). Reflecting on the scenario related to this domain, an assertive, clear and focus communication using SBAR format would have provided a brief, organized, predictable flow of information improving critical thinking communication skills and patient safety (Olin, 2012). It can be argued that it is hard to serve as an effective leader without effective communication (Hackman and Johnson 2013). This is agreed by Perry et al (2014) stating that effective commutation is a central attribute of clinical leadership. Clinical leaders can influence their colleagues with effective communication skill such as good listening skill and extremely good at explaining things at the right level that can be understood by followers. However, it is important to note that each clinical leader has a preferred style of communication that would not necessary works every time. Hackman and Johnson (2013) recommend choosing a leadership communication style that will work best according to the situation and the level of knowledge of followers. Now what? During next placement (NP7), I will strive to change communicating SBAR in a more professional, concise, clear, in a timely manner when communicating with the multidisciplinary team to improve patient outcome. I will actively seek feedback from my mentor and other professionals at mid- and end-point reviews. I will also change my preferred communication style from passive aggressive to an assertive communication style. For that, I will use the communication style questionnaire at the beginning then altered my behaviour during the first part of the placement, then repeat the questionnaire at mid-point and ask for feedback to my mentor base on the comparison on two questionnaire results and base on her observation. And repeat this again by end-point. Domain 3: Nursing Practice and Decision Making What? Here I reflect on nursing practice and decision making, see appendix 4, which is an end-point mentor comment during NP3 showing that improvement is needed in this domain. This is underpinned by appendix 5: a reflection done at the beginning of NP6 when I looked after a patient with hypoxic brain damaged who had a seizure. On my entry into his room, I found the patient unconscious, I took the decision to clear his airway before pressing the emergency bell which could have jeopardised patient safety. This is related to the NMC (2010) stating that nurses must be able to recognise and interpret signs of normal and deteriorating mental and physical health and respond promptly to maintain or improve the health and comfort of the service user. My behaviour pointed out the need to enhance my skill and knowledge in this domain. So what? Judgement and decision-making are important facets of healthcare for nurses (Traynor et al., 2010). Judgement is defined as weighing up different alternatives; while decision-making involves choosing a specific course of action to follow between alternatives (Lamb and Sevdalis, 2011). Hence, (Undre et al., 2009) define efficacious judgement and decision-making as skills that go beyond clinical knowledge and technical competence, highlighting the fact that nursing judgement and decision-making contribute significantly to the safety and quality of patient care (Traynor et al., 2010). However, several studies have high-pointed that when given the same information, and undertaking the same decisions, nurses will make consistently different judgements and decisions (Thompson et al., 2008; Thompson and Yang, 2009). Differing judgement and decision indicate different types of reasoning, in situations where time is not constrained, newly qualified nurses will make structured judgments with a rational-analytical decision. For those situations where time is limited, information is perceptual, and the nurse has some perceived expertise, it is appropriate to use intuition as the basis for judgement (Hammond et al., 1987). Thompson et al (2008) suggest that the key to successful reasoning is to adapt reasoning to the demands of the task. However, such adaptive reasoning by nurses is sometimes absent. Thus, good decisions and judgements are not independent to the cognitive process but can be influenced by how information is prioritised and the nurse’s ability to identify and respond to vital aspects of the clinical situation (Pearson, 2013). Thompson et al (2013) state that recent studies have shown positive benefits associated with the introduction of Computerised Decision Support Systems (CDSS) to support nursing decisions. Hence, helping to promote patient’s safety and improve their outcome. Reflecting on the scenario related to this domain, future decisions making process, whether they are based on normative, prescriptive or descriptive theory must include clinical expertise, patient value and best available research evidence (Sackett, 1996). because evidence by itself, does not make the decision, but it can help support the patient care process. In the same order, Marquis and Huston (2015) suggest that to be effective as a leader, one needs certain skills for making decisions, such as self-awareness, fairness and transparency which are skills also needed in decision making. This is supported by Thompson and Dowding (2009 p5) affirming that “One of the distinguishing features that mark out exceptional nurses is their skills in judgement and decision making”. Decision making is considered important leadership skills and is recognised by Sofarelli and Brown (1998) as qualities associated with transformational leadership. Now what? I have realised that decision making, particularly in nursing, is vital as it influences patient safety and outcomes (Ellis and Bach, 2015). It has been mention earlier that experience is a factor that affects decision making. To gained experience in judgement and decision making, I will use every opportunity during NP7 to practice evidence base in nursing practice and decision making by always based my decision on useful information sources like clinical guidelines, protocol and policy and patient preference. After what I will actively seek feedback from my mentor and others healthcare professionals and of course to patients to check their satisfaction about their involvement in the decision-making process about their own care at mid- and end-point reviews. . Domain 4: Leadership, management and team-working What? My leadership, management and team working skill are measured in appendix 2 and appendix 6 which are both leadership self-assessment tools. The first one showing aspects of my leadership that needs to be improved and the second one showing my leadership style which is “guiding” needing improvement to become more empowering. These are further supported by appendix 4: mentor end NP3 comment. During the leadership module, I took part in several group activities, which enabled me to understand team role importance and that there is no leader without followers. This part relates to NMC (2010) stating that nurses must work independently as well as in teams; be able to take the lead in coordinating, delegating and supervising care safely, managing risk and remaining accountable for care given. So what? Tomlison (2012) states that self-assessment helps individuals to appreciate their qualities, strengths and weaknesses thereby, enabling better transformational leadership. Bass (1985) found that transformational leadership contributes to individual performance and motivation. Whereas transactional leadership (Burns, 1978) is short-lived, and task-based, with the leader intervening with negative feedback when things go wrong. Adair (2002) proposed a three-circle model of strategic leadership, with the circles being the needs of the task, the individual and the team. This is a democratic model of leadership matching the NMC code, where Individuals and groups are involved in decision-making processes concerning their work (Adair, 2002). Management skills are as important as leadership skills in addressing some failings like those identified in the Francis report (Kerridge, 2013). Kerridge suggests they are closely linked, effective management and leadership both require putting first thing first. The King’s Fund report (2011) concurs, defining leadership as the art of motivating people toward a shared vision and management as getting the job done, suggesting that the exercise of leadership across shifts could be extended to management practice; pointing out that every member of healthcare team has some management and reporting functions as part of their job (Baker et al., 2012). Lord Darzi (2008) said: ‘Leadership is not just about individuals, but teams’. A successful leader will see each person as an individual, recognising their unique set of needs, as not everyone will perform at the same level (Hackman and Johnson 2013). This rejoins the description of team role by Belbin (1996) as he described a team role as ‘a tendency to behave, contribute and interrelate with others in a particular way’. Suggesting that Belbin assessment would be an ideal way for a team to examine: the roles they play, how these fit in with the team and the contribution of roles to the team (Frankel, 2011). Therefore, it would be advisable that team members use the questionnaire to helps identify individuals’ preferred roles, their manageable roles and their least preferred roles within the nine teams’ roles as described by Belbin in-order-to improve the success of teamwork. Nurse leaders need also to be able to respond to an ever-changing healthcare environment (Frankel, 2011). The literature suggests that leadership, effective communication and team working are among the most important elements for planned change (Schifalacqua et al., 2009a). Kurt (1951) identified three steps of change: unfreezing, moving and refreezing. This work was modified by Rogers (2003) who described five phases of planned change: awareness, interest, evaluation, trial and adoption. Another change theorist, Ronald Lippitt (Lippitt et al., (1958), identified seven phrases. Mitchell (2013) advises that Lippitt’s work is likely to be more useful to nurses because it incorporates a detailed plan of how to generate change and is underpinned by the four elements of the nursing process: assessment, planning, implementation and evaluation. Now what? To improve my Leadership, management and teamwork skills, I will use the first week of my MP7 to observe my mentor and nurses in charge leading some shifts, then, I will seek clarification on grey areas of my understanding and ask to have my own patients. This will enable me to practice leading others, managing patients and working with the multidisciplinary team. I will actively seek feedback till mid-point review, then, I will lead and manage my mentor whole set of patients under her observation and correction whenever needs arise till end-point. This will help me to move toward an empowering leadership style. Conclusion I have learnt that: a good leader or manager remains grounded in the values, beliefs and behaviours that guide professional nursing practice; understanding your role and that of other will nurture clear communication thus improving the success of the team; safe decision-making must be evidence-based; and effective leadership fosters a high-quality work environment leading to positive safe climate that assures better patient outcomes.

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195 week 2 - 195

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N195 Week 2 Assignment Concept: Leadership Task Think of your clinical experiences and if you work in healthcare, and list at least three ways LPNs are leaders of their care. 1. Delegating APProPriAte Skills TO The UAP like ADLS vitals 2. Collect Subjective B Objective Data TO efficently Care for The Patient 3. Collaborating communicating with other Healthcare Team members TO Appropriately Care for Their see Pts needs Task Assessing systematically and comprehensively Predicting and managing potential complications The first step in managing care and leading others is to get an accurate picture of what needs to be done for each patient during the time that patient is under your care. Review the case of Mr. William Edwards. His information is posted in your CAMs Lecture Documents. The National Patient Safety Goals which ones relate to Mr. Edwards? Safety B fall Prevention Proper Identification medication SAfety Is Mr. Edwards at risk for dysphagia? How do you know? yes his doct is Thickened loquids Solt Foods Week 2 NUR195 Assignment Updated 1 Is he at risk for aspiration? What signs and symptoms will you see in a patient who has aspirated? Yes. The are frequent Coughing with MUCOUS, Blood or Pus Wheezing with Shortness of Brea th 3 Wheezing A fever Other risk factors and potential complications that apply to Mr. Edwards: Dysarthria incontinence memory loss depression ConTractures Balance coordination issues DUT Task Setting priorities Delegating Using legal, ethical, professional guidelines Based on your identification of potential problems, which of the nursing interventions have you identified, and can you delegate to a nursing assistant? Provide your rationale for delegating such a task using the information from Carroll and Collier, Chapter 17. Rationale for Assigning this Nursing Task to Nursing Task to Delegate the Nursing Assistant ensure Pt Doesnt choke Assist ersure AdeQuate nutrition Week 2 NUR195 Assignment Updated 2 Task Meds Metformin How does Metformin work? lowers Blood glucose levels Reducing ha much shouse is Released from The liver helps Cells to Absorb glucose What specific disease is it usually used From Blood stream for? T2 Diabetes f Gestational Drabetes Why is the product to be discontinued for procedures and that need to use contrast dye? Can increase Chance of causing lactic Acidosis in Pts with Decreased kidney functin What does the of a drug mean? The Tome it takes Rer The Amant of Medicartens Active Substance to be Reduced half What is the of regular metformin? hours What is the of extended release metformin? hars What is the black box warning for, for this med? lactic Acid What would the ABGs look like for this problem? Ph Below 7 Normal Bicarb HCO3 Below 22. Week 2 NUR195 Assignment Updated 4 LISINOPRIL What is the category for this medication? Ace inhibiter Name 5 uses for this med: 1. Hypertension 2. Heart failure 3. Diabetes 4. Stroke Prevention 5. Heart Attack What is the black box warning for this medication? Causes ham TO fetus or Pregnancy loss iftaken During Pregnancy Name five severe side effects (they are in red.) 1. Hyper Kalemia 2. Proteinuring 3. Hepatic Failure 4. Parcreatitis 5 HePatic Necrosts Define angioedema RaPid edema or Swelling of Te Area Renearth The Skin or mucosa Task Prior to class, review the Test Plan. Determine which of the detailed objectives were part of your homework including the readings. Be prepared to share with the class. This must be completed to receive points for the assignment. Basic comfert 3 care Physiological integrities Reduction of Potential Rosle Coordinated Care SAfety B infection CAre Week 2 NUR195 Assignment Updated 5

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Leadership in Nursing Practice Essay (Critical Writing)

Description of key insights, description of leader/ situation and examples, effectiveness and impact on workplace.

There are several formal leadership theories, including transformational, democratic, laissez-faire, autocratic, and servant. Targeted leadership development in nursing will ensure that future health workers will be well prepared to meet the challenges of an overburdened health care system (den Breejen-de Hooge et al., 2021). Among the many types of leadership, transformational leadership is probably one of the most desirable (Broome & Marshall, 2021). Leaders of this type inspire change and create an environment characterized by trust and innovation (Broome & Marshall, 2021). In nursing, leadership helps to build a friendly and healthy-promoting environment (Furunes et al., 2018). How effective the leader’s actions largely determine the quality of the treatment (Sfantou et al., 2017). The importance of this phenomenon for health care settings should be underestimated.

When I interned at the clinic, my mentor seemed like an example of an effective transformational leader. She used different techniques to keep her staff motivated. Her talent was in distributing tasks in such a way that all employees were satisfied. In situations where difficult decisions had to be made, she used critical thinking skills. For example, when she once had difficulty diagnosing a patient, she checked a large number of sources, then discussed with more experienced colleagues, and only then shared her conclusion.

Leadership is what increases employee performance and has a positive impact on the workforce. The team is much more effective in achieving its goals if it is the leader who develops the methods and means for accomplishing them. This function can include immediately identifying steps and developing long-range plans for activities. Leadership increases staff productivity and creates a culture of caring (Furunes et al., 2018). Good leaders keep employees motivated, prevent turnover, and easily achieve long-term goals (Sfantou et al., 2017). With good leadership, tremendous results can be achieved in a short time.

den Breejen-de Hooge, L. E., van Os-Medendorp, H., & Hafsteinsdóttir, T. B. (2021). Is leadership of nurses associated with nurse-reported quality of care? A cross-sectional survey. Journal of Research in Nursing, 26 (1–2), 118–132. Web.

Broome, M., & Marshall, E. S. (2021). Transformational leadership in nursing: From expert clinician to influential leader. Springer.

Furunes, T., Kaltveit, A., & Akerjordet, K. (2018). Health-promoting leadership: A qualitative study from experienced nurses’ perspective. Journal of Clinical Nursing, 27( 23-24), 4290–4301. Web.

Sfantou, D. F., Laliotis, A., Patelarou, A. E., Sifaki-Pistolla, D., Matalliotakis, M., & Patelarou, E. (2017). Importance of leadership style towards quality of care measures in healthcare settings: A systematic review. Healthcare , 5 (4), 1-17. Web.

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