course material

1. Leadership Styles of Nursing Home Administrators
Does style affect the Quality of Care ?IntroductionLeadership is an essential quality in
governance in any particular institution. Leadership cuts across all areas and units within
an institution and its effects can either affect the members and the clients positively or
negatively. Evidently, poor leadership affects the quality of care in a negative way and the
reverse of this statement is also true that positive results of care will be given once the
leadership conditions are favorable. The Nursing home organization has its own failures
and success which are categorized by the ground forces of the institutions’ leadership and
culture.In order to explore the concept of leadership various authors undertook a literature
review of leadership existing between the nurse management and nurses in the critical care
units and how the leadership affects those admitted under highly effective care units. An
analysis of abstracts observed that a handful of published literature focused on leadership
within the nurse-nurse manager relationships.Several papers referred to leadership within
the staff relationship and later observed how the leadership trickled down and affected the
nurse-patient relationships under care. Undoubtedly, twenty relevant journal articles were
chosen and used in this literature review for inclusion. Leadership as shown from most
researches is instrumental in creating a foundation that supports and enables nurses in
health care practices to use research findings (Angus et al. 2003, Stettler 2003, Rycroft-
Malone et al.2004, Newhouse 2007). Davies et al. (2006) in a follow-up study of 37
organizations described leadership as the fundamental measuring stick of nurses’ frequent
use of guideline recommendations from different clinical research topics. From all levels of
the organizations leaders who included managers, executive directors and direct care staff
among others were suggested to be the most influential in using guidelines (Davies et al.,
2006). A comparison was made by Gifford et al., (2006) as he found out that those leaders
who followed guidelines were better placed in keeping the care units operations effective
and successful as compared to those who do not follow guidelines the reverse is true. This
paper starts with an overview of the leadership concept before it embarks on themes
emerging from the literature review.Themes centered on would include, leadership and
trust in critical care units, training challenges, the leadership framework, the working
environment fostering favorable leadership in medical organizations and trustworthiness,
leadership activities emerging from facilitation of staff through support and communication,
creation of a positive environment through role modeling and vision statements and the
influence of organizational links and processes through monitoring, policies and resources.
In addition there is need to allow for the enforcement of international and national policy

2. imperatives to be used as research evidence and decision making tools and the use of
clinical practice guidelines. Consequently, findings from the literature reviews stated that it
is only through support from leaders, the vision and regulatory standards that would
influence the translation of research findings into clinical practice (Gifford et al., 2007) it
had been noted that most research findings go unnoticed and unattended to because of
neglect from some nurses. In addition, it seems clear that the relationship which exists
between leadership and use of innovations can facilitate utilization and acceptance within
the health care units (Howell & Avolio 1993, West et al, 2003, Elenkov & Manev,
2005).Relevant agreements have been developed which exist between adoption of leaders
involvement, commitment and attitude towards the adoption of innovation (Damanpour
1991, Greenhalgh et al, 2004), definition and clarification of roles (West et al, 2003),
leadership styles (Howell &Avolio 1993; Elenkov & Manev, 2005), the use of management
systems of data, managerial relations and vision (Greenhalgh et al., 2004).Chapter One:
Types and Characteristics of Leadership stylesIt is without a doubt that throughout history
what mankind has been captivated with is the traits and concept of leadership (Avolio,
1999).The characteristics of leaders who are effective have been a contentious issue in the
world today (Marquis & Houston, 2002). History has it that hospitals have taken advantage
of transactional leadership as a way of implementing their visions and mission statements.
According to Burns (1978), most systems of bureaucracy use transactional leadership.
However, he argues that effectiveness comes as a result of this kind of leadership and
results are produced but it never provides the nurses with a chance to building on their
urge for productivity or creativity.Leadership is characterized by an inclusion of clarity in
communication, teamwork, good preparation, optimism, courage and a firm system of belief
is all that it takes for one to become an effective leader” (Moiden, 2002, p.67). A leader is
known in the way he strives with the willingness and the drive towards achieving the goals
and objectives of an institution (Weihrich & Koontz, 2005).According to Kelloway et al.,
2010, the outcomes of Health psychology occupation are seen to be widely associated with
organizational leadership and are perceived as the most paramount pillars to the well-
functioning of a leader. Empirical studies have shown that, positive employee attitudes can
be derived from a leadership that is active and transformational hence they will be in a
position to perceive an organizational climate which is characterized by safety (Kelloway et
al., 2006).The two most distinctive entities in leadership are the passive and
transformational safety specific leaderships in any kind of organization (Kelloway et al,
2006). However analysis have indicated that a leader can have both the passive and
transformational traits but limited evidence shows that leadership can be unchanging
within an individual or it can be as a result of an inborn trait. Kelloway et al. (2006) brings
out the aspect of inconsistent leadership that is as a result of alternating passive and
transformational leadership or an individual portraying both types of leadership at the
same time. The outcomes of such inconsistent leadership styles would affect the safety
behaviors of employees within the institution and would produce negative results when it
comes to service delivery.Furthermore, researches have indicated that the increase in
workplace injuries and the negative perceptions towards the working environment have
been associated with the laissez-faire type of leadership which is closely inclined to the

3. passive styles of leadership (Zohar, 2002a). A laissez faire leadership is characterized as the
absence type where the leader disregards responsibilities that constitutes supervision
(Bradford and Lippit,1945), a leader who is unavailable when employees need him the
most,perfomance expectations are not clarified, responsibilities as a leader and decision
making are overlooked (Bass,et al.1990).In the research article by Argyris,Leung and
Murningham (1976) it is hypothesized that, laissez-faire leadership have a negative impact
because it leads to poor working relations between the staff and the employee and the
quality of care is likely to be underutilized, patient satisfaction tends to be underpinned due
to poor job satisfaction and lack of motivation from the employees (Judge &
Piccolo,2004),nurses commitment and follow-ups on clinical research results becomes a
challenge (Skogstad et al.,2007) and the overall performance of the health care units suffers
loss in regards to poor administrator-nurse relationships displayed (Howell &
Avolio,1993).Chapter two: Leadership versus FollowershipResearch has indicated that
workplace safety and improvement can be as a result of the influence of transformational
leadership which is categorized into intellectual stimulation, motivation that is
inspirational, influence that is idealized and consideration to individual members (Kelloway
et al, 2006). An influence that is idealized would inspire leaders to develop into role models
who focus on doing what is commendable other than focusing on pressures related to
performance. In other words, he becomes a leader who is people-driven and considerate to
those around him (Barling et al, 2002).He further adds that leaders who display an
inspirational motivation are those who challenge people to surpass their needs in order to
achieve a safety performance level which goes beyond the safety standards that are
perceived as minimum and unattainable. Leaders who are driven by a consideration
towards individuals tend to portray a large percentage of concern for the well-being and
safety of the employees. These leaders are able to seek approval to those around them and
are usually open towards critics (Barling et al, 2002). A transformational leader goes the
extra mile towards promoting and inspiring positive behaviors and attitudes in the working
environment (Barling et al, .2002). In addition, Mullen and Kelloway (2009) argued that a
leader who was well-trained was able to display a positive amount of ethics and values that
would be essential to trickle down to the employees.According to Burns (1978), there are
quite a handful of leadership styles and qualities but the most recognized was the
transformational kind of leadership. Burns (1978) stated that leadership which is
transformational is suitable to its followers since it creates a value of morals as a means of
raising their knowledge about issues that deals with ethics and as a way of mobilizing their
energies towards reforming the institution. Its concern was largely to do with employees
behaviors in comparison to transactional leadership where employee traded compliance for
reward (Bass,1985).In order to inspire trust, stimulate self-confidence amongst the nurses
transformational leaders see it fit to adapt skilled communication as a critical tool.Chapter
three: Nursing Home StructureA nursing home constitutes of the staffing levels which are
formed to meet the concerns of the members in the nursing home. In order to meet
personal goals and institutional objectives staff members are required to undergo
supervision and training Four: Quality of care in nursing homeSullivan &Decker (2009)
suggested that, there was a huge difference between the skills of those who managed wards

4. and that of a good clinical nurse. In a research done by Mathena & Acre (2006), they
investigated that without enough resources, education or support, the nursing home
administrators were still in a position handle expanded responsibilities and roles.
Overlooked leadership responsibilities are likely to be executed upon limitation of support
and resources and competing roles in their working areas. According to Ralph (2008), he
argued that an increased level of patient satisfaction, an improved care standard, an
assurance of staff retention and the maintenance of standard nursing practice were the
critical ingredients of leadership skills in a healthcare environment which constantly
experience transformations. Leaders with the ability to have their employees empowered
and motivated were seen as key role models in this scenario (Medley & Larochelle ,1995).In
order to maintain a positive and a motivated working environment, transformational
leadership was seen as the ideal approach towards raising the morale of nursing home
administrators (Marquis & Houston, 2009)A variety of challenges are faced on a daily basis
by elderly homes administrators who work in the crucial care environment. Changes are
bound to happen in the medicine and science department and administrators are advised to
adhere to the international and national trends (Collins & Holton, 2004). Nurses were
encouraged to update and advance their theoretical and clinical knowledge so as to keep up
with the upcoming changes since they function in a complex clinical environment (Collins
&Holton, 2004). Nursing theories have reflected that administrators are agents of change
because they can hardly stay in one hospital for a long period of time, they keep leaving the
profession in the long run (Ribelin,2003).Nurse administrators with ages 25-34, opt to
leave hospitals in a short period of two years as compared to those with ages 35-54
years.(Ribelin,2003).Unfortunately, what makes them to leave the hospitals in early years is
plainly because of lack of support systems, poor training and poor communication skills
seen portrayed by the senior administrators. In a research article by Broome, Nash &
Shader (2001) it is hypothesized that some nursing administrators complained of huge
tasks of handling ailing patients’ records was placed upon them and that would receive an
unreasonable amount of payment.When work processes are reduced to mere routine tasks
and staff are refuted from taking part in decision making procedures and creativity then this
would lead to the administrators’ potentials and development being underutilized and
thus poor efforts would be made towards taking care of patients (Argyris, 1964).On the
other hand ,enlargement and enrichment of work would be promoted once the processes of
communication are improved, these includes good communication links existing between
administrator-nurses relationships, organization of patient care activities, which would
encourage creativity and innovation.(Argyris, 1964).In addition, Burns (1978) suggested
that, an institution can experience short term benefits when transactional leadership is
applied as a means of communication primarily but negative effects tend to occur on the
loyalty, morale of the staff and commitment to the organization upon the realization of the
long term effects. In the nursing profession, this can be manifested through the high
turnover rates (Burns, 1978).According to Castledine (2005), nutritional and personal
support as a way of care for patients was a boring and disregarded approach. However, it
has been noted that healthcare assistants (HCA) and nursing students were on a frequent
basis being delegated to these tasks.Kourdi (1999) saw this as a “ dustbin delegation”

5. which was geared towards underestimating and demining those who were delegated the
tasks. The results would be that they would end up being dissatisfied at their work places
and would perform poorly when it came to them attending to those who were vulnerable
under the care units. Poor performance would be contributed as a result of excess work
activities being manifested on others (Curtis & Redmond, 2009).There had been an
assumption that HCAs can undertake all the assigned tasks delegated to them and this
became a major challenge especially for the administrator who was in charge of the staffing
units (Curtis & Redmond, 2009).According to Fracaro (2004), there was compliance by the
nurses to undertake tasks not in line with their competence because they feared alerting
administrators about their limitations, were focused upon developing their careers, that
their work reputation would be damaged upon the disclosure of their inabilities and in
times of staff shortages they would not see it desirable to let down their colleagues though
they were aware of their shortcomings (Marquis & Huston, 2009). Nurse administrators
have assumed that education and training are provided at health education departments in
the respective colleges and universities (Marquis & Huston, 2009) so they end up not
providing the required training skills to the recruited nurses because they believe that they
have been equipped from the high learning institutions.Misunderstandings and
assumptions about the latter phenomena often lead to administrators and mangers slack in
their duties towards training of new recruits. According to Tubre&Collins (2000),
performances and the quality of care respectively were likely to suffer since the nursing
homes and health units would receive a large number of unskilled and unqualified nurse
attendants. Staff would feel dissatisfied and devalued once the socialization and employee
training duties are neglected. Deterioration of standards would be experienced since there
would be a bridge existing between people’ s aspirations and their working roles (Mcnesse-
Smith, 2000). Kotter (2009) argued that, motivating people and coping with institutional
challenges are the crucial abilities that a leader ought to possess in order to enhance proper
management of the institutions & Huston, 2009).Studies indicated that most elderly homes
administrators would only go to work in order to receive their paycheck thus lack of sincere
commitment to their work professions and to the ailing patients (Dunham-Taylor,
2001).Authors believed that, most organizations viewed elderly homes administrators as
expenses and not a crucial linkages towards quality care provided (Klein man, 2004).A
shortage of elderly homes administrators have led to hospitals hiring nurses who are
incapable of conforming to the facility’ s mission and vision statements (Dunham-Taylor,
2001).Chapter Five: Quality measures and indicatorsGuidelines ought to be revised on a
daily basis in case of any changes occurring in the health and medical environment. They act
as quality measures and indicators for effective operations within an organization. Medical
prescriptions ought to be approved by the head of the department’ s prior to any execution
to a patient (Healthcare Commission 2007 & CQC 2010). Nursing home administrators who
fail to abide by the set standards and principles would be penalized in accordance to the
Anecdotal policies and laws. (Department of Health (DH), 2002).The vision statement is an
ideal test for any successful institution because it defines the organizations goals in the
short or long term process. The ability to live in the minds and hearts of others is seen as
the true test of a successful vision (Blanchard & Stoner 2004).Therefore the need to ensure

6. that nurses needs are addressed, that their commitment towards patient handling is not
compromised and high quality care is provided lies in the clear definition of an institutions
vision and mission statement. Nurses ought to have a clear notion of what entails a mission
and vision statement so that their morale and commitment to the organization is not in
question and that they would be in a position to align their actions. It was stated that it was
only through its visionary statement that the values of the organization prevails (Blanchard
&Stoner 2004)Outcomes would successfully be realized upon the integration of
organizational goals, visions and missions with the learning objectives within and outside
the health care units (Collins & Holton 2004). Focus and determination are the main factors
that would be instigated towards attainment of such goals and objectives. It also shows that
the employees working in that organization have a direction and are willing to meet their
set targets and goals (Collins &Holton 2004).On the other hand patients are able to develop
confidence from the relationships that they would develop with the nurses.Apparently, the
needs of patients are effectively met and a number of skilled staff employed once the
managers play their role and execute duties in line with the institutions guidelines (Flynn &
Mckewonn 2009, Sanford 2010). It is crucial for every health department to have its own set
of guideline which acts as an accountability and transparency resource for the
institution.Unfortunately, there has been a contentious issue as to who has the required
skills in relation to the regarded training workforce (Flynn & Mckewonn 2009,Sanford
2010).The Former Health Minister Lord Darzi (DH 2008) suggested that when strong
management and leadership was being executed in the institution then the workforce
quality was being enhanced. He strongly believed that it would be crucial for the managers
to have clinical leadership skills because not all of them have skills that are accomplished.
Skills and knowledge are fundamental for nursing home administrators so that the
organization may acquire a cultural competence environment. Nursing homes
administrators must demonstrate leadership traits which are valid incase the delivery
systems found in the health care units undergo a rapid change. This environment is
categorized by technology that is sophisticated in the care units, patient outcomes no longer
becomes a challenge, working units becomes less constrained by time and cost and the
acuity of patients increases (Contino,2004 & Mathena,2002). The bond of leaders and the
culture of the organization over the past decades have been the front row in most literature
that deals with health care. As many scholars would put it that these are the measuring
sticks for an organization to either succeed or fail (Schein, 2004).Darzi’ s review (DH2008)
saw the introduction of new initiatives geared towards improving the proficiency of
leadership in the nursing home institutions. The national leadership council (DH2011) saw
it necessary to support levels of staff towards developing teamwork and self-awareness
skills through the introduction of tools and frameworks of self assessment from a personal
level and service-improvement programmes from an organizational point of view (Kouzes
&Pozner ,2009).Research studies derived from Kouzes & Pozner (2009) showed that it was
critical for health units to emphasize on leader-staff relationships as a crucial method used
for exploration of leadership initiatives which would address challenges related to training
and staffing. Weitzel et al (2004) suggested that, in some wards functional nursing is still
applied. It was seen as a way of providing care at an affordable and cheap way by

7. delegating to ancillary staff the functional tasks hence lowering the population number of
costly registered nurses (Weitzel et al., 2004). However, some authors had contended with
the functional nursing movement because it was seen as a cheap method and would later on
lead to unsupervised and haphazard care which overlooked the patients’ medical needs
and it further left the healthcare nurses dissatisfied and unappreciative with their
responsibilities (Tiedemann & Look inland, 2004).Role modeling was seen as the key aspect
in executing leadership skills since most of the junior nurses would prefer to learn from
example. This would further develop their professional competence. (Galvin, 2007).Support
given towards the staff members from their manager was the surest way of improving their
confidence, motivation and raising their morale. Nursing home administrators only needed
to be available, reliable and flexible in meeting staff needs Galvin and Timmins (2010).Laws
and regulations that govern general, advanced and specialty nursing practice are
determined and administered at the state level and they are categorized under the purview
of the state professional nursing associations’ .When the nurse practice act regulations and
legislation are challenged or amended these associations organized by the nurse
administrators are usually at the fore front. Apparently, the nursing practice acts and the
authority of the state boards of nursing faced a lot of challenges as the organized medicine
sought to restrict the scope of practice of any health care professional who was not a
medical doctor or doctor of osteopathy (Coalition for Patients’ Rights, 2010).A mentoring
program was deemed vital for the new hires and it acted as a leeway towards the provision
of proper support and training. According to Shader, et al., 2001 a 19% of turnover rate was
achieved to those hospitals that had a mentoring program implemented. That through the
implementation of mentoring programs and the training of transformational leaders,
hospitals were able to realize a reduction of their turnover unfortunately very few
institutions recognize these advantages (Ribelin, 2003).An organization can experience
greatness whenever the members of the institution share similar visions and there exists a
concrete bond between the leaders and the employees. Only then will they be dedicated and
encouraged to attainment of objectives and goals of the institution.International and
National Policy imperatives were formulated in order to assist nurses and doctors in
decision making processes after formulating research evidences (Canadian Nurses
Association 2002 & International Council of Nurses 2007).Unfortunately, it seemed that the
process still remained slow, inconsistent and unreliable because there was difficulty in
translating research findings into clinical practice (Grimshaw & Grol, 2006).Outcomes
related to the patients health condition and quality care would be a challenge to recognize
because the research results would take an unreasonable amount of time before its
disclosure. Translation of evidence forms into recommendations for practice and research
findings were seen to be useful once the clinical nurses used guidelines from the clinical
practice (Thomas et al., 1999).However evidence has it that what was thought to be an
effective and beneficial guide towards realizing goals in the clinical practice was simply
fraught with obstacles and highly fragmented (Grimshaw et al.,2004,Legare 2009) research
gives a clear description of the importance of evidence-based practice in relation
to leadership support. However, what remained uncertain was the interventions that
needed to be laid down that would influence administrators to support and promote

8. research use by the clinical staff (Collins &Holton, 2004).Chapter six: Impact of leadership
styles on the quality of careTransformational leadership displayed by the administrators in
the nursing homes are likely to reverse the focus from a controlled based practice to that of
positive adaptation through punishment or rewards (Barling, et al., 2000) towards an
environment that a leader communicates vision for a working area that would instigate
nurses to actively involve in proper safety and health practices. Other than avoiding
punishment through complying with policies, leaders are motivated towards the creation of
safe working environment. Safe working environments are usually conducive and
important areas in which the workers would effectively conduct their tasks (Barling &
Hutchinson, 2000).According to Howell & Avolio (1993), laissez-faire type of leadership
style is not efficient to the nursing homes since the needs of the nurses are not going to be
met. Furthermore service delivery would be an issue because the administrators who are
supposed to be in charge of delegating and supervising these services would not be
available. Most authors believed that this kind of leadership style will simply paralyze the
working environment and make the entire operations of the institution to suffer (Howell &
Avolio, 1993).Consequently, individuals who execute an ineffective leadership style are
considered ineffective and they display a character of passiveness and uninvolvement in
organizational activities. (Avolio & Bass, 1999) .These leaders are said to be the main
reasons for poor organizational unit performances because staff members who look up to
them will have low opinions about them and thus lack the confidence to approach and
associate with them (Howell & Avolio, 1993).In a research article done by Aasland, Enarsen,
Hetland, Skogstad &Torsheim (2007), it is hypothesized that when the well-being of the
employees are not met then the performance of the nursing home is affected negatively.
According to Judge &Piccolo (2004), lack of follow-up satisfactions from the leaders can
also lead to poor practices in the nursing homes and safety outcomes that are negative
(Kelloway et al.,2006 & Zohar, 2002a). The administrator-nurse relationship acts as a
leeway towards creating an assurance for the ill-patient to recover well (Howell & Avolio,
1993).The patients at the care units tend to believe that their precious lives are in the hands
of the nurses so failure to be attended to means that their health condition is at a major
risk.In a research article by Al-Mailam and Block (2003), they investigated that
administrators who have transformational leadership traits are likely to ensure that the
institution is effective and efficient. According to Robbins & Davidhizar (2007), this would
ensure that interactions within and outside the organization occur and that the staff are
empowered with the institutions’ vision. Transformational leaders are said to be
motivators towards creation of inputs from the staff members, encouraging a sense of
belonging to the organization as well fostering an empowerment programme for their
employees (Bass, 1998).Some leadership style methods utilized are as follows; creating
teams that are self managed, ensuring that data necessary to completion of tasks are easily
accessed, development of skills and self-confidence for the employee, ensuring that
authority is being delegated to members, enhancing a culture that is strong and ensuring
that unnecessary controls are being eliminated (Burns,1978).Empowering elderly homes
administrators means that specific tasks would be completed, freedom to confidently solve
problems would be encouraged and a sense of loyalty to the organization would be fostered

9. once issues of mistrust are fully dealt with (Burns, 1978).Chapter Seven: Impact of
leadership styles on administration in health service deliveryIn a research article done by
Gifford et al., (2007), it was hypothesized that there were intervention studies geared
towards developing future and current nursing home leaders was formulated in spite of the
unknown relevance of leaders to support the use of research. Recent reviews examined that
the participation of leaders in educational activities made a positive impact in the behaviors
of leaders.(Cummings et al.,2008).Initiating specific skills at work places such as promoting
interactions that were relation oriented and initiating structures were seen as proper
foundations that would greatly influence leadership development (Cummings et
al.,2008).When opinion leaders were used as key factors to influence nursing care research
programmes no effect were made on the outcomes(Hodnett et al.,1996).Notably, 83 studies
from a Meta analysis showed that training of leaders resulted to a significant improvement
in skills and knowledge and this was a key ingredient towards leadership development
although the effects were not similar across different studies (Collins & Holton, 2004).The
participants knowledge outcomes were evidently seen to have one of the greatest effects.
The meta-analysis further suggested that the outcomes can only be effective and efficient if
only the training strategies and workshops programmes were selectively meeting identified
and individual needs. Results indicated that it was only when the elderly home
administrators received support and strong managerial leadership from the clinical nurse
managers then they would be in a better position to work well. (O’ Brien-pallas et
al.,2006).A recent study showed that the elderly home administrators would only exhibit
better services once they observed from their managers how they exhibited their leadership
skills in practice (Galvin &Timmins, 2010).The Patients Association Report (2009) indicated
that about 5000 people had contacted charity help lines to report cases of failings in the
health care units and poor care. The most common reasons given included poor
communication in relation to fatal results, Nursing home administrators’ staff lacked
compassion for the