Leaders of the Pack
The nature of their roles places nurses in a position of influence among health care team members

By Kathy Sanford, RN
April 1, 2003

When Dawn Payment, RN, reported to work one week at Harrison Memorial Hospital in Bremerton, Wash., she had a lot on her mind. Even before she took off her coat, she was planning the evening shift on her busy oncology unit. She was thinking about gathering information about her patients, orchestrating their care and assigning duties to her assistive personnel. She was mapping out the work that needed to be done and devising a plan for ensuring quality care in the midst of the controlled chaos that defines a hospital acute care unit. In short, Payment was practicing the leadership skills of a competent bedside nurse.

"I've never consciously thought about what I do as leadership," Payment said. "I just do what needs to be done to ensure my patients get quality care. If that's leadership, then every nurse is a leader."

Most staff nurses don't think about their organizational, team and delegation skills as leadership. That's exactly what they are, though. As Payment pointed out, every staff nurse is a leader.

Leadership is an integral part of professional nursing because the role of the nurse automatically places him or her in a position of authority or influence over others. Patients, visitors and other staff members look to the nurse for guidance, assurance and direction. It is most often the nurse who coordinates each patient's care.

Whether she or he is designated a team leader, primary care nurse or total care nurse, his or her competency in leadership strongly influences patient outcomes, the work environment and job satisfaction of both the nurse and his or her colleagues.

Sue Favero, RN, a surgical staff nurse from Phoenix, agrees that nurse leadership skills are important in the operating room. "When nurses aren't practicing good leadership skills in the OR, patient care can be compromised," she said. "Priorities can be affected, as other personnel don't know where to turn for help. Attitudes become less positive and the operating room takes on a negative atmosphere."

A lack of nurse leadership competency can cause problems for a nursing unit. Sandi McIntosh, MA, RN, director of emergency and medical/surgical care services at St. Luke's Hospital in Cedar Rapids, Iowa, has been amazed over the years at the variations in unit teamwork depending on the nursing leadership. "You know immediately when you walk onto a nursing unit and see who has the lead role for the shift," she said. "That tells you how smooth the shift will be."

So what are these staff nurse leadership skills that can make such a difference to patients and staff? Payment says they are communication, teaching and the ability to delegate appropriately after an assessment of team members' strengths and weaknesses. Favero emphasizes communication, good listening skills and the assertiveness needed to be a patient advocate.

Rumay Alexander, Ed.D., MSN, RN, of Nolensville, Tenn., works as a consultant on leadership and diversity issues. She sees the need for leadership throughout organizations and says the skills needed by staff nurses are the same as those for nurses in management positions. "Nurses have to solve problems for patients," she said, "so they need to know how to ask the right questions in order to get the best information for problem solving. They need to have critical thinking skills, coaching, counseling ability, negotiation skills and knowledge of consensus building."

Linda Daum, MBA, RN, of McAllen, Texas, agrees with the need for critical thinking, which she further defines as the ability to prioritize tasks and to think logically, viewing all facts before taking action. "Nurses need to serve as role models for other staff," she said, "and they need to treat all members of the team as important to patient care."

Becoming competent in leadership doesn't sound as difficult as becoming certified in a clinical specialty, but both staff nurses and nurse administrators recognize that some nurses are more competent than others in the skills necessary to lead a patient care team. Some nurses seem to be natural leaders who balance expert clinical ability with excellent interpersonal skills, while others may need to learn how to do both.

Leadership skills can be learned. Carol Watson, Ph.D., RN, senior vice president at Mercy Medical Center in Cedar Rapids, Iowa, feels that mentorship is an important part of developing an individual's skills. "The didactic information about leadership is everywhere," she said, "but it's practicing the skills that is important. Nurses should find a mentor who exemplifies the skills they're seeking and learn from them."

Daum echoes that skills are developed because of role models. She advises nurses to look at both formal and informal leaders in their own environments and emulate the attributes they admire. She's quick to point out that education does not always come from an outstanding leader. "Even a poor leader can teach you skills," she said. "They may teach you how not to be. Two of my best role models were poor leaders. I vowed that when I was a leader, I would not treat employees or peers like they did."

McIntosh points out that nurses can ask for feedback on how they perform from managers and peers. If they want to focus on improvement, they can seek information and educate themselves.

Some leadership skills can be learned in formal classes. Seminars like "Dealing with Difficult People" and "Assertiveness Training" are really about learning techniques of communication, from understanding what works best with different personality types to improving oral, written and listening skills. Classes can augment what nurses learn from role models. Seeking new assignments also can help broaden knowledge and strengthen skills.

Learning opportunities

Favero credits some of her growth in leadership to what she learned during her OR nurse certification process. Her skills also grew when she had an opportunity to serve on a regional committee appointed to determine the core values of her organization.

Payment took on extra work when she agreed to serve as her unit's representative to the hospital's nurse practice committee. Now in her second term, she's been named to co-chair the committee with a nurse manager. "This experience has made me more well-rounded," she said. "I get to work with and learn from both staff nurse leaders and nurse managers. I've learned that hospital problems are complex and that there are different ways to approach and solve them. I'm able to use what I've learned to help other staff members become informed and to be a bridge between management and staff."

However leadership is learned, both managers and staff nurses agree that the best leaders share common attributes. Caring, respect for others, flexibility, integrity, honesty, consistency and fairness are traits of successful nurse leaders. Payment is clear about who the best leaders are. "They're the nurses with positive attitudes about our profession and what we do," she said. "They don't gossip or participate in the rumor mill. Their professionalism and dignity set a tone on the unit that makes it a better place for patients and staff."

Nurses may not think about their leadership competency as critically as they consider their clinical competency. Not every nurse chooses to take on the role of formal leadership as a nurse manager, but all nurses are in leadership positions. If they are competent in leadership skills, they can influence patient care and their environment positively. If they are incompetent leaders, they will contribute to a negative workplace and decrease the probability that their patents receive quality care.

Favero first realized this truth when her nursing school counselor said to her, "Sue, you're a born leader, but where are you leading?"

Contact Kathy Sanford at kathleensanford@hmh.westsound.net