Academic health centers must play an active role in the development, implementation, and ongoing refinement of effective leadership styles for nurse managers. The Institute of Medicine posits that academic health center hospitals in the 21st century must develop leaders at all levels who can manage the organizational and systems changes using innovation in health professions education, patient care, and research; improving integration and fostering cooperation; and improving reduction of health disparities and responses to bioterrorism or ethical issues that arise in healthcare, research, and education.1 However, the number of qualified nurse managers who are able to employ the leadership skills necessary to manage the increased responsibilities and complexities of the academic health center hospital continues to decrease.2

The organizational environment of the hospital itself may serve as a barrier: Organizational processes often substitute for leadership, and change is difficult due in part to the inertia of bureaucracies, norms, and traditions.3 The resulting nursing management practices may be characterized less by progressive leadership and more by trade-offs and status quo thinking. In high-stress areas of nursing practice, such as the emergency department (ED), the lack of effective nurse leadership skills serves to exacerbate the staff nurse shortage.2

ED nurse managers have seen their roles and responsibilities change considerably over the past few decades. The increasing volume of paperwork, changes in the Emergency Medical Treatment and Labor Act, and enforcement of other regulatory and practice rules all contribute to high stress levels. U.S. academic health centers represent a special challenge as a practice setting for the ED nurse manager. These nurse managers are tasked with balancing the management of nurses in a high-stress environment with the mission of teaching healthcare professionals with different training needs. The teaching mission must be accomplished while maintaining a safe level of service as a safety-net facility for the community and patients who use the ED as their primary source of care.

In many nursing practice settings, including high-stress settings such as the ED, the increasing challenges of managing higher acuity with fewer nursing resources have led to administrator burnout and the premature exit of skilled nurse managers from practice.4 In high-stress areas, capable nurse managers will need to incorporate an extensive knowledge of unique regulations and patient complexities. They must understand the roles and interpersonal relationships of staff nurses and integrate peer networking into their management and leadership decisions and actions if they wish to be an effective leader.

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Transformational leadership practices are centered on demonstrating outcomes of increased staff perceptions of extra effort, effectiveness, and satisfaction through actions that engage them. Transformational leaders use a combination of behaviors as they work on raising the level of staff performance.5,6 These behaviors include:

[white diamond suit] Idealized influence, or charisma. Cultivating charisma (the ability of the leader to communicate and articulate a vision or belief through observable passion and ambition) in nurse managers is an important component of an initiative that includes a transformational leadership style of management. Educational initiatives provided to nurse managers should promote knowledge concerning group presentation techniques that are designed to foster staff nurse awareness and to show how staff directly and indirectly contribute to the mission of the unit and the organization.

[white diamond suit] Inspirational motivation. A leader must have the ability to inspire belief in her cause through use of emotional appeal.6 Nurse managers should be taught to value the importance of encouragement and techniques for eliciting staff involvement in unit activities through volunteerism and small projects with short timelines that are focused on producing observed and measurable outcomes.

[white diamond suit] Individualized consideration. Preceptorship and one-on-one mentoring should be tailored to suit the professional developmental needs of the individual.6 Orientation to the role of nurse manager should include time and focus from senior leaders. Similarly, the nurse manager must use techniques that provide staff nurses with opportunities for focused professional development. Nurse managers who are responsible for a large group of staff nurses may wish to consider restructuring the direct reporting responsibilities, creating resource nurse/educator support positions, or developing train-the-mentor times to teach small groups of staff nurses to assist in this function. This type of individualized, custom mentoring can facilitate staff nurses' knowledge and increase confidence.

[white diamond suit] Intellectual stimulation. Staff must have the desire to engage in problem solving.6 Successful implementation of evidence-based practice changes is a form of intellectual stimulation that's resulted in a change in professional practice beliefs.

The road to effective leadership

Reinforcing nurse manager leadership styles that can promote and support nurse-valued models of practice and work environments is a necessary strategy for manager and staff nurse retention.7 By offering more formal education and job training programs that teach the core practices of transformational leadership-incorporating work/life balance techniques into nursing management role expectations, providing adequate relief periods from 24/7 unit on-call responsibilities, and providing adequate support staff infrastructure based on unit size and employee oversight responsibilities-the nurse manager shortage, especially in high-stress practice settings, can be addressed.

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