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]

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]

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.

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: 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.

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]

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 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.

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.

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 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