Ethical Leadership by Advanced Practice Nurses

22 Pages·2013·0.78 MB·English

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Chapter 5
Ethical Leadership by Advanced
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Nan Gaylord and Pamela J. Grace
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NOT FOR SALE OR DISTRMIBaUy IT stIrOessN the need for courageous, iNnteOlliTge nFt,O anRd dSedAicLatEed lOeaRde rDshiIpS…TLeRadIBersU TION
of sound integrity. Leaders not in love with publicity, but in love with justice.
Leaders not in love with money, but in love with humanity. Leaders who can sub-
ject their particular egos to the greatness of the cause.  
—Dr. Martin Luther King, Jr., “Challenge of a New Age,” Speech on the
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Prayer Pilgrimage for Freedom in Washington, DC, May 17, 1956
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Introduction
Nurses have responsibilities for individual and societal health. These respon-
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sibilities are to further the profession’s goals of promoting, protecting, and
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restoring health. Nursing has a central unifying focus on these goals that is
evident in the discipline’s collective and historical literature (Willis, Grace, &
Roy, 2008). This focus is primarily on humanization in the context of a per-
son’s health needs throughout his or her lifespan. Nurses over the decades and
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respect accorded to women, racism, dehumanization of the poor, expediencies
of war, and ignorance of (or disregard for) the roots of ill health in societal con-
ditions. Pioneering nurses recognized the deeply entrenched nature of many
hea©lt hJcoarnee psro &bl eBmasr itnl ethtte Loregaanrniziantigo,n L oLf sCociety and the special in©te rJesotsn oefs & Bartlett Learning, LLC
thoNseO inT pFoOweRr aSnAd LwEer eO cRon DceIrSnTedR eIBnoUuTghIO toN marshal political suNppOorTt fFoOr R SALE OR DISTRIBUTION
change using formal and informal knowledge, skills, and political savvy. Many
of these nurses exhibited a courage that put them at risk.
The fact that that almost all of these leaders were women at a time when
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175
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176 ■ ChAPtEr 5 Ethical Leadership by Advanced Practice Nurses
rem©a rJkoabnlee. sH o&w B diadr tthleeyt td Lo eita? Wrnhiantg m, oLtiLvaCted them? And most imp©o rJtaonntley,s & Bartlett Learning, LLC
whNatO caTn FbeO leRa rSneAdL frEo mO tRh eDir IlSeaTdRerIsBhiUp,T aIsO wNell as from new undersNtaOnTdi nFgOs R SALE OR DISTRIBUTION
and philosophies of leadership, in order to empower modern day advanced
practice nurses (APNs) in their desire to enable good practice? Nursing is no
longer essentially a female profession; males, including APNs, are becoming
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purposes in contemporary healthcare environments requires constant efforts
and solid leadership skills. APNs should not necessarily subject themselves to
the sorts of serious risks that some of their predecessors did; however, among
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including the healthcare delivery system, and calculating acceptable levels of
risk is an inevitable part of their decision-making process.
This chapter provides some definitions of leadership that are pertinent
for meeting the professional responsibilities of APNs regardless of their
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role (direct or indirect patient care). It discusses characteristics needed for
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facilitating nursing goals, including skills of collaboration, communication,
mediation, and where necessary, referral. Several types of leadership are
explored and related to the essentials of advanced practice, as delineated spe-
cifically in the United States (American Association of Colleges of Nursing
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[AACN], 2011; Zaccagnini & White, 2011), and explicitly as well as implicitly
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in other countries where the APN role has been developed (Pulcini, Jelic, Gul,
& Loke, 2010). Although advanced practice roles are relatively new in terms
of the broader nursing profession’s development, evidence supports the
increasing need for nurses who are well educated, skillful, knowledgeable,
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and motivated to meet the healthcare needs of their populations (Aiken,
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Clarke, Cheung, Sloane, & Silber, 2003; Benner, Sutphen, Leonard, & Day,
2009; Institute of Medicine [IOM], 2010; International Council of Nurses
[ICN], 2010). Finally, because it is critical that APNs advocate for justice in
health care and in healthcare access and that they influence policies that
neg©at Jivoelny eims p&a cBt tahretilre ptto pLuelaatrinonins,g s,o LmLe Cpast and current projec©ts oJfo pnioe-s & Bartlett Learning, LLC
neeNr OAPTN Fs OarRe h SigAhLligEh OtedR a DndIS uTseRfuIBl lUeaTdIeOrsNhip strategies are discNuOssTed F. OR SALE OR DISTRIBUTION
Leadership Defined
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tion; they motivate people toward a shared goal (Curtis, de Vreis & Sheerin,
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Leadership Defined ■ 177
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ship from management. A review of studies on the psychology of leadership
defines leadership as “a process of social influence in which one person is
able to enlist the aid and support of others in the accomplishment of a task
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the support of followers; build relationships with those followers that moti-
vate them to contribute their energy and resources to the collective effort;
and manage, direct, and apply those collective resources to accomplish the
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major types derived from studies are transactional and transformational
leadership, and there are elements of overlap between the two. Different
leadership styles may be successful depending on whether there is a spe-
cific task that needs to be completed or an ongoing process of change. For
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example, elements of transactional leadership may be needed to achieve a
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task within a process of transformational leadership for change.
Transactional Leadership
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system where one person has more power in the process than others. There
are three discernible styles of transactional leadership as discussed by Howell
and Avolio (1993). In one scenario, the leader rewards participants for a job
well done—contingent leaders. In a second, the leader sets the terms and
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rules and takes to task those who do not perform well—active leadership. In
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a third, the leader does not set the rules but expects certain outcomes, pas-
sively watches what is going on, then when things go wrong takes remedial
actions. Criticisms of transactional leadership include the idea that it is task
oriented rather than visionary (Howell & Avolio, 1993; Murphy, 2005).
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Transformational Leadership
Transformational leadership is aimed at change. The leader has a vision
or mission to achieve certain goals. To reach those goals the assistance of
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leaders energize and motivate their followers to achieve their goals, share
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178 ■ ChAPtEr 5 Ethical Leadership by Advanced Practice Nurses
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leadership: (1) Transformational leaders have charisma—others are fasci-
nated by them and inclined toward their ideas; (2) they are self-motivated in
relation to their goals (internal locus of control) and inspire others accord-
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the needs of followers. They act as mentors and coaches (Chemers, 2001;
Grimm, 2010; Judge & Piccolo, 2004; Murphy, 2005).
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There are certain leadership traits that are found in many good leaders.
Kirkpatrick and Locke (1991) identified six core characteristics that the
majority of effective leaders possess:
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3. Honesty and integrity—Leaders are truthful and do what they say
they will do.
4. Self-confidence—Leaders are assertive and decisive and enjoy
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adventurous.
5. Cognitive ability—Leaders are intelligent, perceptive, and concep-
tually skilled but are not necessarily geniuses. They show analytical
ability, good judgment, and the capacity to think strategically.
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6. Business knowledge—Leaders tend to have technical expertise in
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their businesses.
In addition to these characteristics, the nature of the APN role inevi-
tably also requires well-honed communication and mediation skills.
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caused by individual personality and perspectival differences within a group,
especially a multidisciplinary group. Interdisciplinary collaborative efforts
require that all members of a working group have their perspectives and ideas
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The Goals of Nursing: Advanced Practice Leadership ■ 179
fac©ili tJaotens ecosl l&ab oBraatritvlee ettff Loretsa trhnaitn agre, eLgLaClitarian (Grace, Willis, &© Ju Jrcohnaek,s & Bartlett Learning, LLC
200N7O). TO tFhOerR c oSmAmLeEn tOatRor sD (IGSrTimRmIB, U20T1I0O; LNachman, 2007) on leNadOeTrs hFiOp R SALE OR DISTRIBUTION
for nursing purposes have added the characteristic of moral courage. Moral
courage is a necessary characteristic of nurse leaders who “hold true to their
beliefs and convictions” (Grimm, 2010, p. 75) even when it is risky to do so.
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that underlie their own thoughts and actions with the intent of under-
standing prejudices and biases and accounting for them.
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Throughout this text, the responsibilities of APNs are described as firmly
grounded in the idea that first and foremost an APN is a member of the
nursing profession and bound by the code of ethics of the profession. Codes
of ethics are developed by the profession as public articulations of the ser-
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vices provided and the expected conduct of nurses in the course of their
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nursing work. Although the nursing bodies of many countries have devel-
oped their own country-specific codes of ethics, the nursing organizations of
these countries also had input in and affirm the ICN’s code of ethics (ICN,
2012). The internationally specified goals of nursing are to promote health,
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prevent illness, restore health, and alleviate suffering (ICN, 2012). Meeting
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these goals for individuals and groups may require anticipatory proactivity
(analyzing the status quo or proposed policy changes for their likely effects),
ethical perception or discernment (that things are not right and why), and
moral agency (actions toward change). Every nursing action taken should be
© Jones & Bartlett Learaniminegd, aLt LfuCrthering one of these nu©rs iJnogn geoasl s& fo Br aanr tinledtitv iLdeuaalr, na ipnagrt,i cLuLlaCr
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global issues). When working conditions, the environment, or other influ-
ences block the ability to further these goals, nurses have further obliga-
tions (Grace, 2001). At the APN level, these responsibilities include ethical
lead©e rJsohinpe fsor & ch Banagretl. eEttth Liceala lrenadinergs,h LipL bCy the APN means that h©e Joor nshees & Bartlett Learning, LLC
useNs OknTo wFlOedRg eS, AskLilEls, OanRd DinIfSluTeRncIBe tUoT lIeOadN a group of persons N(pOerTh aFpOs R SALE OR DISTRIBUTION
other nurses or perhaps an interdisciplinary group) toward a shared goal
of improving an aspect of health care or healthcare delivery. Many experi-
enced and thoughtful nurses without advanced preparation have proven
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180 ■ ChAPtEr 5 Ethical Leadership by Advanced Practice Nurses
lea©de rJso. Tnhees I&CN B’sa nrtulerstet pLreacatrintioinnger,/ LadLvCanced practice nursing© n eJtownoreks & Bartlett Learning, LLC
hasN rOecTo gFnOizeRd SsoAmLeE u nOifRyi nDgI SasTpRecItBs UofT tIhOe Nrole internationally: NOT FOR SALE OR DISTRIBUTION
Integrates research, education, practice and management,
High degree of professional autonomy and independent practice,
Case Management/own case load,
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Recognized advanced clinical competencies,
Provision of consultant services to other health providers,
Plans, implements and evaluates programs,
Recognized first point of contact for clients. (ICN, 2009)
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leadership abilities. Advanced education is widely recognized as critical for
the APN role.
The Doctor of Nursing Practice
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In tNhOe UTn FitOedR S tSatAesL, tEh eOreR h aDs IbSeeTnR aI rBecUeTntI OdrNive to educate APNs aNt aO hTig hFeOr R SALE OR DISTRIBUTION
level. Initially the goal was that all master’s degree programs would convert
to the Doctor of Nursing Practice (DNP) degree by 2015. The DNP degree
is distinguished from a research doctorate in that it is aimed at preparing
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Since the DNP was formally approved by the AACN in 2004, well over 90
programs have been launched (Edwardson, 2011). The focus of the practice
doctorate is to improve outcomes “for individuals or populations, including
the direct care of individual patients, management of care for individuals and
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populations, administration of nursing and healthcare organizations, and
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the development and implementation of health policy” (AACN, 2004, p. 1).
The DNP degree is controversial, having both critics and supporters. The
“pro” positions assert that added education helps nurses fill certain gaps
or shortcomings in healthcare provision. Magyary, Whitney, and Brown
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(2006) assert that the existence of a DNP degree is very important in that it
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will equip nursing leaders and managers with the wherewithal to critically
question practice status quo and underlying assumptions in order to influ-
ence future practices. To this end, the degree includes additional courses in
leadership, management, financing, health informatics, and policy (AACN,
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2006). A major focus is on improving health outcomes and engaging in
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practice improvement projects. Additionally, DNPs are able to fill clinical
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The Goals of Nursing: Advanced Practice Leadership ■ 181
fac©ul tJyo pnoseitsi o&n sB. Ian rtthlee Uttn Liteeda rSntaintegs,, t LheLrCe is a serious shortage of© qu Jaolifnieeds & Bartlett Learning, LLC
facNulOtyT ( AFAOCRN ,S 2A0L12E) . OMRo rDeoISveTr,R itI BisU tThoIOugNht that this advanceNdO edTu FcaO-R SALE OR DISTRIBUTION
tion will remove barriers to autonomous practice for nurses with advanced
knowledge and skills. One other argument is that nursing master’s degrees
are already very course heavy beyond that of almost any other academic
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DNP in line with other professional practice doctorates such as pharmacy
and physical therapy.
The “con” arguments are from various sources both within and outside
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role will increase confusion for patients as nurses’ roles and physicians’ roles
are more closely interactive than those of other professions (Miller, 2008).
Additionally, nurse scholars worry that these APNs will lose their focus on
nursing goals. Concerns about interprofessional conflicts include the del-
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eterious effects on patient care and collaborative relationships, which are
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essential for projects that require both nursing and medical knowledge for
their success (Miller, 2008).
While it is important for U.S. APNs to understand the issues related
to the DNP so that they can discuss them in interdisciplinary forums, the
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most important point for any nurse who is working in an APN role is to
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stay mindful of the fact that it is a nursing rather than a medical role and, as
such, be guided by nursing’s perspectives and goals regarding human health.
Moreover, the leadership responsibilities that accompany these roles mean
that APNs may need to help and collaborate with others in order to envision
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good practice and work toward good outcomes. In the inevitably interdis-
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ciplinary settings where advanced nursing is practiced, staying focused on
nursing goals and perspectives may be the most difficult task. There will be
many distracting influences. Another difficult task is articulating to others
what it is that nurses bring to patient care and policy discussions that is
diff©er Jenotn ferosm &, aBnad rctolemttp lLemeaernntainryg t,o L, LthCe contributions of allie©d hJeoanltehs & Bartlett Learning, LLC
proNfeOssTio FnaOlsR a nSdA pLhEys iOciRan sD (IGSrTaRceI Bet UalT., I2O0N07). NOT FOR SALE OR DISTRIBUTION
The Institute of Medicine’s Report
In the United States, a recent exploration of the status of nursing commis-
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sioned by the IOM, an independent, nonprofit, multidisciplinary organiza-
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tion, resulted in the report, The Future of Nursing: Leading Change, Advancing
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182 ■ ChAPtEr 5 Ethical Leadership by Advanced Practice Nurses
He©alt hJ (oIOnMes, 2&01 B1)a. rTthlee trte pLoerat remnipnhga,s iLzeLsC the importance of the p©ro fJeossnioens & Bartlett Learning, LLC
to NthOe nTa FtioOnR’s hSeAalLthE. IOn Rth eD pISreTfaRceIB itU isT aIsOseNrted “[W]e believe nuNrsOesT h aFvOe R SALE OR DISTRIBUTION
key roles to play as team members and leaders for a reformed and better-
integrated, patient-centered health care system” (IOM, 2011, p. xii). A sum-
mary of the report (IOM, 2010) outlines four key messages; two of them
© Jones & aBrea erstpleecttia Lllye aforcnuisnegd ,o LnL aCdvanced practice. Key M©e sJsaogne e#s1 c&o nBteanrdtlse ttht aLt earning, LLC
NOT FOR SnAurLseEs sOhRou DldI SbeT aRbIlBe UtoT pIOraNctice to the full extenNt OofT t hFeOir Red SucAaLtioEn O anRd D ISTRIBUTION
training. Over a quarter of a million nurses are now educated at an advanced
level. Thus legal restrictions placed on nursing practice by individual states
should be questioned. Leaders in nursing are called upon to advocate and
© Jones & Bartlett Learlnoibnbgy ,f oLrL stCate boards of nursing an©d J leogniselast u&re sB taor rtelmetot vLe epararcntiicneg r,e sLtrLicC-
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nurses should be considered full partners with physicians and other health
professionals in redesigning health care in the United States. Full partner-
ship implies equality of voice and influence. That is, nursing’s perspective on
the health of persons should receive parity of expression and consideration
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in multidisciplinary assemblages. As discussed earlier, the DNP is one move-
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ment aimed at enhancing nursing practice and making visible the particular
perspective and expertise of nurses.
Enhancing APN Leadership
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There are ongoing questions about who is or can be a leader. Some people
are obvious leaders; some might even say they are “born leaders.” But the
question remains if leadership is possible for all APNs. The answer has to
be yes. Leadership is possible for all, but the level of leadership may differ
© Jones & Bartlett Leardneipnegn,d LinLgC on setting and goals. E©ar lJieor na eresm &in Bdear rwtlaest gt iLveena orfn tihneg n, aLtuLrCe
NOT FOR SALE OR DISaTnRd IeBxtUenTtI OofN APNs’ responsibilitieNs OfoTr i nFdOivRid SuaAl LanEd OsoRci eDtaIlS hTeRalItBh.U TThIiOs N
is what makes all leadership ethical. APNs must have some capacity for
taking the lead in furthering these goals. Otherwise they cannot be said
to have ethical responsibilities. In order to be held ethically responsible,
cho©ic eJso inn easct i&on B maurtslte etxti sLte. Maranniyn, gm,a LnLy Cbooks have described le©ad Jeroshnieps & Bartlett Learning, LLC
moNdOelsT a FnOd Rle aSdAerL cEh aOraRct eDriIsStTicRs oIBr UtrTaiItOs.N Seminars to developN lOeaTd eFrOs R SALE OR DISTRIBUTION
are offered within institutions, outside institutions, sometimes even by
employers or contracted by employers for their employees. Nurses should
avail themselves of opportunities to develop and refine their own leader-
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Enhancing APN Leadership ■ 183
lea©rn eJdo onre wsh &et hBear rntalteutrta Ll peearrsnoninagl t,r LaiLtsC are required for leaders©h iJpo cnone-s & Bartlett Learning, LLC
tinNueO; hTo wFOevRer , SleAadLeErs hOipR b eDhIaSvTioRrsI BthUatT aIrOe rNegularly practiced canN bOeTco mFOe R SALE OR DISTRIBUTION
well-honed skills, just like other skills developed for nursing practice. Case
examples of leadership behaviors and the education and skills underlying
them are given shortly.
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This next part of the discussion assumes that leadership by APNs is both an
expectation and an ethical activity. For nursing, all leadership activities have
ethical content. They are directed toward the ultimate goals of protecting
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and promoting health and relieving suffering using nursing’s perspectives,
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whether at the individual level or at unit, clinic, or health-policy levels. The
Canadian Nurse Practitioner Core Competency Framework (Canadian
Nurses Association [CAN], 2010, p. 10) is directed at the nurse practitioner
(NP) role but exemplifies (with the exception of the NP-specific criteria)
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leadership expectations for APNs in general. They include: effective ”man-
ageNmOenTt FofO cRlin SicAalL caEr eO aRnd D [sIeSrvTeRs aIBs]U a TreIsOoNurce person, educatorN aOndT r FolOe R SALE OR DISTRIBUTION
model”. The NP mentors other nurses, peers and interdisciplinary team
members. He or she should be able to explain the nuances and benefits of
advanced practice roles to others including allied “health-care providers,
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NOT FOR SAAs LanE e OsseRn tDiaIlS aTspReIcBt UofT tIhOe Nrole, the NP “[A]dvocNatOesT f oFrO aRnd S pAarLtiEci pOaRtes D ISTRIBUTION
in creating an organizational environment that supports safe client care,
collaborative practice and professional growth” and “provides leadership
in the development and implementation of standards, practice guidelines,
© Jones & Bartlett Learqnuinalgit,y LaLssCurance, and education© a nJdo rneesesa r&ch B inairttilaetitvte Ls”e. aArtn tihneg p, uLbLliCc
and health policy level the NP is responsible for activities that inform and
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influence decision-making.
To insist to the new APN graduate that leadership is an expected respon-
sibility within the role may be unrealistic initially. The new graduate in a
direct patient care role is orienting to a new clinical environment, with many
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processes and expectations to master. One antecedent of good leadership is
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an understanding of the environment. However, once an APN is in the role
for a period of time, clinical or policy concerns become evident. It is at this
time that leadership skills are needed to implement the needed changes.
One of the assumptions reinforcing this reality is stated in the Canadian
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184 ■ ChAPtEr 5 Ethical Leadership by Advanced Practice Nurses
Nu©rs eJ oPrnaectsit &io nBera rCtolerett C Loemaprentienngcy, LFrLaCmework (CAN, 2010, p©. 7 J, o#1n0e):s & Bartlett Learning, LLC
“NNewOlyT g FraOduRa tSedA LnuEr sOe Rpr aDcItSitiToRneIBrsU gTaiInO pNroficiency in the breNadOthT a FnOd R SALE OR DISTRIBUTION
depth of their practice over time, with support from employers, mentors and
health-care team members.” Sherman (2013), however, encourages younger
nurses to seek leadership opportunities and describes a competency model
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American Organization of Nurse Executives, the Association of periOp-
erative Registered Nurses, and the American Association of Critical-Care
Nurses. The model’s key domains include the science and art of leader-
© Jones & Bartlett Learsnhiinpg a,n Ld LthCe development of the “l©ea dJeorn weitsh i&n. ”B Sahritrleeyt’st (L2e00a7r)n dinisgcu, sLsiLoCn
NOT FOR SALE OR DISaTcRcoIrBdUs wTiItOhN Sherman’s argumenNt. OShTe FliOkeRns S leAaLdeEr sOhiRp dDeIvSelToRpmIBeUntT tIoO N
that found in Benner’s work on the development of nurses from novice
to expert that occurs over time. However, Shirey’s leadership development
model maintains that the successful attainment of leadership competen-
cies is more important than years of experience. Leadership abilities are
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developed on the same continuum from novice to expert, and leaders are
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frequently in roles where they have no particular leadership competencies.
To progress to competence, these leaders need access to leadership learning
opportunities or to identify mentors who can guide them. The American
Nurses Association (2013) is building a cadre of nurse leaders through its
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Leadership Institute, which offers a series of five webinars (interactive con-
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ferences). This institute covers five key areas: strategic thinking, results-
oriented leadership, leading people, personal leadership, and unleashing
innovation and creativity. Implied qualities or skills underlying the key areas
are those of making connections with others, communicating well (skills
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of listening and articulation), mediating conflicts, and motivating others.
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Models of Leadership Useful for Nursing
EMPowERMENT
In t©h eJ poanste, sth &e nBuarsritnleg tpt rLofeeassrinoinn agn,d L iLtsC members have sometim©e sJ boenene,s & Bartlett Learning, LLC
or NhaOveT sFeeOnR th SemAsLeElv eOs Ras DbeISinTgR, dIBisUemTpIOowNered for a variety ofN rOeaTso FnOs R SALE OR DISTRIBUTION
including that nursing is a predominantly female profession (Manojlovich,
2007; Matheson and Bobay, 2007). Thus, an empowerment model of leader-
ship make sense to use when educating nurses to be leaders. The theoretical
© Jones & bBaasirst floert tth Lee emarpnoiwnegr,m LeLntC model is found in Paulo© F rJeoirne’es csr i&tic Bal apretdlaegtot gLye arning, LLC
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