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 and different from similar organizations, and specifies where the leaders hope the organization is going. The mission statement describes how the organization will fulfill its vision and establishes a common course of action for future endeavours. See Figure 4.1^[1] for an illustration of a mission statement. A values statement is the organization’s stated values that assist with the achievement of its vision and mission and provide strategic guidelines for decision-making, both internally and externally, by members of the organization. The vision, mission, and value statements are expressed in a concise and clear manner that is easily understood by members of the organization and the public.^[2]

Organizational culture refers to the implicit values and beliefs that reflect the norms and traditions of an organization. An organization’s vision, mission, and value statements are the foundation of organizational culture. Because individual organizations have their own vision, mission, and value 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 meet the needs of 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]

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, the two-challenge rule, and constructive assertive statements are important tools to promote patient safety.

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.

Table 4.2a Management and Leadership Characteristics^[12]

Leadership Theories and Styles

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

Authoritarian leadership means that 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 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 theories of leadership in health care, such as passive-avoidant, transactional, transformational, servant, resonant, and authentic.^[19],[20] Many of these theories have overlapping characteristics. See Figure 4.3^[21] for a comparison of various leadership styles in terms of engagement.

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. They tend to react only after problems have become serious to take corrective action 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]

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]

Table 4.2b Characteristics of Leadership Styles

Outcomes of Various Leadership Styles

Leadership styles affect team members, patient outcomes, and the organization. A recent research study using a systematic review of the literature 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 its 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 Table 4.2c describing classifications of errors using the Just Culture model.
• 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” when a medication error occurs or a client falls according to agency policy. Reporting errors also assists the agency in performing risk management actions to 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.

Table 4.2c 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. Systems leadership is comprised of three interconnected elements:^[35]

• 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
• The System: An understanding of the complex systems shaping the challenge to be addressed