jurnal carper 2

8/11/2019 Jurnal Carper 2

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TH E H E A LT H S E RV I C E S I N D U S T RY

is a rapidly changing envi-ronment; subsequently,innovative leadership char-

acteristics and roles are re q u i re dfor the nursing profession. Port e r-OGrady and Malloch (2006)noted that the impact on nursingmanagement and leadership isjust beginning to be defined in thisc o n t e m p o r a ry and unsettledhealth care arena. Furt h e rm o re ,changes resulting from enhanced

t e c h n o l o g y, proliferating inform a-tion available on the Intern e t ,i n c reasingly informed health careconsumers, ongoing constraints ofmanaged care, a worsening nurs-ing shortage, and the ever evolv-ing health care delivery systemsa re converging to create unpre c e-dented challenges for nursingleadership (Aiken, 2007; Ameri-can College of HealthcareExecutives [ACHE], 2005; Arm i n gHealth Care Consumers, 2006;Dendaas, 2004). Additionally,The number and magnitude ofchallenges facing healthcare or-ganizations are unpre c e d e n t e d .G rowing financial pre s s u res, ris-

ing public and payor expectationsand the increasing number of con-solidations have placed hospitals,health networks, managed careplans and other healthcare org a n i-zations under greater stre s s (ACHE, 2005).

The Institute of Medicine(IOM, 2004) published its re p o rtKeeping Patients Safe: Tr a n s-f o rming the Work Environment ofNurses, noting a decline in chiefnurse executives, directors of

nursing, and nurse managers, andsubsequently recommended theadoption of transformational lead-ership and evidence-based man-agement (EBM) to increase patientsafety and reduce errors in thework environment. Echoing thecall for change, Sofarelli andB rown (1998), Clegg (2000),Valentine (2002), and DeGro o t(2005) advocated transform a t i o n a lleadership theory for nursing lead-ers.

B u rns (1978) seminal theoryof transformational leadershipdefined a process in which leader-ship is transcendent, uplifting,moral, and often charismatic. It

EX E C U T I V E SU M M A RYIn a time of chaotic and unpre-d i c t a ble health care, it is vital fo rnursing to employ a nu r s i n gleadership theory that is specifi-cally applicable to nurses andwill holistically, and comprehen-s i vely address and support boththe science and art of this hon-ored profe s s i o n .

The authors propose thatNursing Leadership Know i n gcan address and impact the my r-iad issues confronting managersand administrators within the tur-bulent health care industry, withthe ultimate goals of quality com-p r e h e n s i ve patient care andi m p r oved employee satisfa c t i o n .

T h ey believe that N u r s i n gLeadership Know i n g, gr o u n d e din the realties of nursing ex p e ri-e n c e, is a logical theoreticalextension that can be tra n s l a t e dinto nursing leadership pra c t i c e

A particular and specific fo c u son empirics and ev i d e n c e - b a s e dp ractice will not attend to ther o bust and mu l t i d i m e n s i o n a l

u n d e rpinnings of the lived ex p e-rience that is so vital to nu r s i n gas a caring profe s s i o n .

The ideal of nursing leadershipt h e o ry is not a single-fo c u s e ds h a d ow of its history, but a ri c h ,i n c l u s i ve, mu l t i - faceted netwo rkof know i n g .

As such, Nursing LeadershipK n ow i n g p r ovides a fo rum fo rleaders to enhance their pra c-t i c e, as well as their relationshipwith their employe e s, which ulti-mately translates into optimalcare for the patients we serve.

Janet P. JacksonPaul T. Clements

Jennifer B. AverillKathie Zimbro

Pa t t e rns of Knowing: P roposingA Th e o ry for Nursing Leaders h i p

JANET P. JACKSON, MSN, RN, is AdjunctFaculty, School of Nursing, Old DominionUniversity, Norfolk, VA.

PAUL T. CLEMENTS, PhD, APRN, BC, isan Assistant Clinical Pro f e s s o r, Dre x e lUniversity College of Nursing and HealthProfessions, Philadelphia, PA.

JENNIFER B. AVERILL, PhD, MSN, RN, isan Associate Pro f e s s o r, College ofNursing, University of New Mexico,Albuquerque, NM.

KATHIE ZIMBRO, PhD, RN, is Director,Clinical and Business Intelligence,Sentara Healthcare, Norfolk, VA.


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o ffers broad direction, strong com-mitment, and raises both leadersand followers to principled levels ofjudgment. Ivancevich, Konopaske,and Matteson (2005), establishedpioneers in the field of corporateo rganizational management de-scribed transformational leader-ship theory as one that includes av i s i o n a ry leader who motivatesfollowers to work for intern a lre w a rds of achievement and self-actualization, rather than extern a lre w a rds of transaction and securi-t y. This is a comprehensive, gener-al leadership theory that isapplied in many disciplines; how-e v e r, the authors ask whether

t r a n s f o rmational leadership isa p p ropriate for nursing leaders inhealth care settings.

Nursing is a unique pro f e s s i o nbecause of its synthesis of prac-tice, multidimensional assess-m e n t / i n t e rvention, interpersonalcommunication, case manage-ment, and re s o u rce-linking on

behalf of patients. Nursing prac-tice revolves around tenets of car-ing within an overarching altru i s-tic framework. In fact, nursing is a

multi-faceted science and art witha rich history steeped in the ro o t sestablished by Florence Nightingalethat embodies caring for vulnera-

ble populations at the highestlevel (Clements & Averill, 2006;Gill, 2004). Nursing typicallyattracts people who are alre a d ymotivated by internal re w a rds ofself-actualization and achieve-ment; there f o re, the goals of trans-f o rmational leadership may not bee ffective for selected members of

the nursing profession. Nursinghas borrowed a leadership theoryf rom a non-nursing discipline thatmay not embrace and motivatenurses. In a time of chaotic andu n p redictable health care, it isvital for nursing to employ a nurs-ing leadership theory that isspecifically applicable to nursesand will holistically, and compre-h e n s i v e l y, address and support

both the science and art of thish o n o red profession. Underlyingthis science and art is the knowl-

edge base from which nursesdevelop their practice, includingtheir leadership principles.

Overview

Historical underpinnings. C a r p e r(1978) identified the now familiarfour Fundamental Patterns ofKnowing in Nursing in heracclaimed manuscript. The pat-t e rns included empirics, esthetics(aesthetics), personal knowledge,and ethics, and she proposed thatthey re p resented the complexphenomenon of knowing thatnurses use when caring for theirpatients. In an eff o rt to include thecontexts of care, White (1995)

added sociopolitical knowing asthe fifth pattern of knowledge.Recognizing the need to maintainopenness to new knowledge andideas, Munhall (1993) postulatedthe sixth pattern of knowingwhich she titled unknowing, andHeath (1998) further expanded thep a t t e rn of unknowing to re p re s e n ta dimension of all patterns. Morere c e n t l y, Chinn and Kramer (2008)added emancipatory knowing toengage the issues of equity, justice,

and transformation in all arenas ofpractice, including nursing leader-ship. When used in synchro n y,the seven patterns of knowinghave a goodness of fit for nursingleadership theory, part i c u l a r l y

because they were created bynurses and for nurses. Specif-i c a l l y, in the contemporary era ofhealth care :

...the infrastru c t u re charg e dwith managing human disease,illness, and well-being is chal-

lenged beyond its limitsAsmembers of the health carec o m m u n i t y, professional nursesseek a balance between fiscalimperatives and social re s p o n-s i b i l i t y, and the f o u n d a t i o n a lknowledge base for the disci-pline The patterns of know-ing which, when applied in anintegrated manner, provide aholistic way of deeply under-standing the client, nursingpractice, and the nurse as anindividual. Additionally, the

p a t t e rns re p resent a pro f e s-sional commitment to valuediverse approaches to thequestions and problems thatarise within the nursing disci-pline (Clements & Av e r i l l ,2006, p. 268).For example, they dire c t l y

a d d ress goals and challenges fornursing leaders in the re l e n t l e s s l yevolving health care arena such asthe deepening nursing short a g e ,job satisfaction issues, compre-hensive patient care across set-tings, and the politics of nursingleadership.

T h e o retical assert i o n s . O r i g i-n a l l y, Carper (1978) did not iden-

tify the four patterns of knowingas theories; however, the potentialthat each pattern of knowing may

be re g a rded as theory has re c e n t l ybecome evident because they indi-vidually and collectively re p re s e n tontological and epistemologicalfoundations of the discipline ofnursing (Fawcett, 2006; Fawcett,Watson, Neumann, Wa l k e r, &Fitzpatrick, 2001). Although s o c i o-political knowing, unknowing,and emancipatory knowing have

not been explicitly examined astheories, they re p resent valuablep a t t e rns of knowing for nursingleaders; after all, sociopoliticalissues and background pro v i d erich contexts for what occurs inthe nursing profession, includingleadership and management.A d d i t i o n a l l y, unknowing invitesthe option of responsiveness tonew ways of thinking or re s o l v i n gp roblems.

For example, the pre v i o u s l y

mentioned IOM re p o rt (2004)identified a critical need for nurs-ing leadership and leadership the-o ry. The development of policiesand pro c e d u res from an appro p r i-ate theory that specifically appliesto nursing and its knowledge basewill have sociopolitical implica-tions, including questions of fair-ness and integrity. Since nursingholds the largest number of healthc a re professionals in its ranks, itshould inherently be an equalmember of the overall driving


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f o rce in health care planning andd e l i v e ry, including aware n e s s ,recognition, and utilization of thefifth pattern of knowing, sociopo-litical knowing, which incorpo-rates an understanding of society,politics, justice, and culture(Chinn & Kramer, 2008; White,1 9 9 5 ) .

Another example of signifi-cant importance includes the eco-

nomic implications of the nursings h o rtage that confronts and chal-lenges nurse leaders, part i c u l a r l ysince the current nursing short-age is a serious problem at all lev-els of nursing (Valentine, 2002, p.1). Nurse experts presented dataon the value of nurses and the eco-nomics of the nursing shortage at ac o n g ressional briefing on May 2,2006 (Hnatiuk, 2006). It was notedthat the cost of replacing onenurse is $42,000 to $64,000, andan average facility with 400 beds

replaces 80 RNs per year. Theminimum cost is $3.36 million pery e a r, per facility. One appro a c hcited for hospitals to impro v equality and reduce costs is toi n c rease nurse staffing. Studieshave demonstrated the re d u c t i o nof adverse patient outcomes andextra hospital days (Aiken, 2007),and additionally, that incre a s e dpatient satisfaction will off s e t

i n c reased labor costs (Needleman,B u e rhaus, Stewart, Zelevinsky, &Matte, 2006). Recruitment andretention are significant factorswith serious economic implica-tions for facilities (Hnatiuk, 2006;Milliken, Clements, & Ti l l m a n ,2007). Furt h e r, the additional lackof nurse leaders exacerbates thenursing shortage (Andrews &Dziegielewski, 2005; IOM, 2004).We propose here that N u r s i n gLeadership Knowing can addre s sand impact the myriad issues con-

f ronting managers and administra-tors within the turbulent healthc a re industry, with the ultimategoals of quality compre h e n s i v epatient care and impro v e demployee satisfaction.

The Patterns

How do nursing leaders knowabout leadership? An obviousneed exists for nursing leadership

founded on plausible theory toamend and facilitate staff supportand communication. We pro p o s ethat Nursing Leadership Knowing,g rounded in the realties of nursingexperience, is a logical theore t i c a lextension that can be translatedinto nursing leadership practice(see Figure 1). Specific examplesof such application follow.

E m p i r i c s . The first pattern ,re f e rred to as empiric leadershipk n o w i n g (empiric L.K.), is basedon the science of nursing and

Figure 1.Nursing Leadership Knowing (N.L.K.) Model

EmpiricL.K.

Outcome-Based

EMB, EBL

UnknowingL.K.

Openness

NursingLeadershipKnowingEthical

L.K.Justice, Ethics

Personal

L.K.Relationship

SociopoliticalL.K.

Strategy, Culture

AestheticL.K.

Art, Vision

NursingStaff

E m a n c i p a t o ryL K .

Tr a n s fo r m i n g

Wo r k p l a c e


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includes a body of empiricalknowledge that is re s e a rch basedand systematically org a n i z e d .Empirical knowing is factual,objective, and verifiable by out-come measures (Carper, 1978;Fawcett et al, 2001). The IOMre p o rt (2004) recommended theadoption of EBM, and was fol-lowed by DeGroot (2005) whoindicated that evidence-basedleadership (EBL) is nursings newmandate. EBM and EBL are simi-l a r, but various philosophical andoperational definitions exist ford i ff e rences between managers andleaders. For example, Sofare l l iand Brown (1998) explained that

managers have legitimate powerand control, enforce policy andp ro c e d u res, and emphasize org a-nizational goals over concern foremployees. To contrast this, theysay leaders use empowerment andchange, communicate a vision,and have great concern for teammembers. However, not all leadersa re managers and not all managersa re leaders (DeGroot, 2005). In thechanging health care enviro n m e n tand increasing nursing short a g e ,

the profession of nursing needsleaders.One exemplar, the Patient

C a re Staffing Report (2002),described the practices of Middle-sex Hospital in Connecticut bydeveloping an annual re p o rt cardto keep staff engaged and pro m o t eEBL. This re p o rt card pro v i d e dobjective evidence of pro g re s st o w a rds goals, demonstrated lead-e r s h i p s accountability, and edu-cated staff about practice. The four

dimensions covered in the re p o rtc a rd included functional, fiscal,clinical, and patient/nurse/physi-cian satisfaction characteristics.

Evidence-based leadership alsouses evidence-based practice.Fawcett et al. (2001) declared thatEvidence-based practice is in thef o re f ront of many contemporarydiscussions of nursing re s e a rc hand nursing practice (p. 115).S h i rey (2006) suggested that evi-dence-based nursing practice isthe solution to sustaining quality

and access in health care .Leadership that uses data collec-tion, analysis, and evaluation ofevidence-based practices exempli-fies EBL (Sullivan, Bre t s c h n e i d e r,& McCausland, 2003). Thesemethods illustrate the pattern ofempiric leadership knowing; how-e v e r, empiric leadership knowingre p resents only one pattern ofknowing for nursing leaders andshould be used in unison with theother patterns.

A e s t h e t i c s . Often evident innon-verbal expressions, therapeu-tic actions, and unconditionalp resence, empathy is the primarymode or manner of the second pat-

t e rn of knowing which Carper(1978) called aesthetics, or the artof nursing. Although this patterninitially pertained to nurses andtheir empathy toward patients,aesthetic leadership knowing( a e s-thetic L.K.) presumes leaders whodemonstrate empathy towardtheir nursing personnel. This is acritical aspect to engaging andretaining nursing staff. Aestheticleadership knowing is subjectiveand should focus on the perc e p-

tion of what is significant andmeaningful for each nurse whilesimultaneously giving substantived i rection to nursing practice.Leaders should meet with staffindividually to ask what is moti-vating and re w a rding for eachnurse. Diff e rent nurses may findsignificance in advanced training,mentoring, flexible scheduling,s h a red governance, or monetaryre w a rds. Roy (2000) argued thatnurse administrators should focus

on human potential and pro v i d eo p p o rtunities to foster and nurt u rehuman growth. If nurse leadersdiscover what has meaning fornursing professionals, they may

be able to effectively stimulate theg rowth potential of each personwhile simultaneously enhancingjob satisfaction (Milliken et al.,2007).

Aesthetic leadership knowingalso emphasizes aesthetic mean-ings and inspiration for develop-ing and expressing the art of nurs-

ing (Fawcett et al., 2001).C o n g ruent with this thinking,Kouzes and Posner (2002), leadersin the field of organizational lead-ership theory, presented scientificdata to support their re c o m m e n-dations. They posited that leader-ship is also an art, one which isoften beyond empirical measure .Nurse leaders can benefit fro mdevelopment and creation of evi-dence for the art of leadership.Schmidt, Nelson, and Godfre y(2003) described the art of nursingto include degrees of clinical judg-ment, mentorship ability, estab-lished standards of perf o rm a n c e ,successfully completed perf o rm-

ance evaluations, and cogentscheduling of personnel. Thesea re all forms of the art of leader-ship that nurse leaders may sharewith others by their examples andmentorship.

T h e re are many areas wherenurse leaders experience, in apractical manner and setting, theo p p o rtunity to develop their aes-thetic knowing, and arg u a b l y, thea rt of leadership is also the gro w t hof wisdom as evidenced by the fol-

lowing statement:A true leader has the con-fidence to stand alone, thecourage to make tough deci-sions, and the compassion tolisten to the needs of oth-ers[and] does not set out to

be a leader, but becomes oneby the quality of [her/his]actions and the integrity of[her/his] intent (unknown).Personal knowing. P e r s o n a l

leadership knowing ( p e r s o n a l

L.K.) may be one of the most diff i-cult patterns to master and teachbecause it is an expression of self-knowing in the context of theinterpersonal process (Carper,1978; Chinn & Kramer, 2008). Fornurse leaders, this pattern may bedeveloped by means of openingand centering the self to thinkingabout how one is or can be authen-tic, by listening to responses fro mothers, and by reflecting on thosethoughts and responses (Fawcettet al., 2001, p. 116). Perra (2000)


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a ff i rmed the need for nurseexecutives to have clearlydefined professional and per-sonal values, integrity, tru s tand tru s t w o rthiness, courage,and vision. She asserted thatattentive listening, followt h rough, sharing inform a t i o nand personal experiences,and providing tools/re s o u rc e sfor staff to be successful can

build a trusting relationship thatcan last through adversity (p. 59).In short, personal knowing entailsconsistency between what oneknows and what she does. Laure n t(2000) suggested the nurse leadermust release some control to the

employee and develop risk-takingbehaviors. Releasing control to theemployee is a positive re f l e c t i o nof the interpersonal process sinceit conveys trust in the part n e r s h i p ;s p e c i f i c a l l y, leadership is a re l a-tionship between those whoa s p i re to lead and those whochoose to follow (Kouzes &P o s n e r, 2002, p. 20).

E t h i c s. According to theACHE (2005), Now, more thane v e r, the healthcare org a n i z a t i o n

must be managed with consistent-ly high professional and ethicals t a n d a rds. This means that theexecutive, acting with otherresponsible parties, must fosterand support an environment con-ducive not only to providing high-q u a l i t y, cost-effective healthcare ,

but also seek to ensure individualethical behavior and practices.

The fourth pattern, e t h i c a lleadership knowing(ethical L.K.),is primarily guided by the

American Nurses Association(2005a) Code of Ethics for Nurseswhich clearly delineates ethicalnursing behaviors, expectations,and leadership roles. This codeincludes respect for human digni-t y, right to self-determ i n a t i o n ,relationships with colleagues,acceptance of accountability andre s p o n s i b i l i t y, self-respect, influ-ence of environment on nurses,advancement of the pro f e s s i o n ,and assertion of values. Thro u g hanalysis and clarification of

s h a red values, nurse leaders canbring attention to the ethics ofnursing practice, and increase thep robability for congruence be-tween nursings core values andnursing conduct (Carper, 1978;Chinn & Kramer, 2008). Ethicalleadership knowing also includes

a moral obligation to respect nurs-ing staff and treat each personwith justice and compassion. Toenhance employee satisfaction inf renzied health care settings, thesequalities should not be undere s t i-mated. One nursing theory thats u p p o rts such an ethical appro a c hto organizational culture is Rays(2006) Theory of Bure a u c r a t i cCaring. Emerging from the opin-ions and viewpoints of nurses inpractice, this model describes car-

ing as the major construct andconscience of nursing, even at theo rganizational level. Ray calls onp rofessional nurse leaders to sup-p o rt the values that underlie ourdiscipline, awaken our conscious-ness to each other and to ourpatients, and to help heal a healthc a re system that is on the verge ofcollapse.

M u rray (2007), in his re c e n tc o m m e n t a ry on creating andmaintaining ethical enviro n m e n t sin nursing, provided the followingw o rds of both wisdom and warn-ing for nurse leaders re g a rd i n gtheir important role in upholdingworkplace ethics:

S t rong leadership isessential to producing andsustaining an ethical enviro n-ment. As individuals, eachnurse is subject to countlessinfluences When leadersexpect and consistentlydemonstrated the highest pro-fessional and personal stan-

d a rds of conduct and ethicalbehaviors individuals canrealize their greatest p o t e n t i a l .C o n v e r s e l y, when s t a n d a rd sa re unclear and questionable

behaviors are tolerated... indi-viduals may find themselvesquestioning profoundly heldvalues. For this reason, lead-ers must remain on guard con-stantly to ensure an ethicale n v i ronment. Once standard sa re set, even the slightestd i v e rgence can be tro u b l e-some (p. 49).Sociopolitical knowing. S o c i o -

political leadership knowing(sociopolitical L.K.) is framed

within the context of the leaderand nurse, as well as the contextsof nursing as a profession in socie-ty and politics. Sociopolitical lead-ership knowing includes anunderstanding of impact factors onthe nursing profession. Examplesof such factors include the work

behavior culture that surro u n d snursing, the politics that govern it,and the complex physical, fiscal,and psychological enviro n m e n t sof each health care institution.

Savage (2003) believed that thefundamental challenge in nursingis addressing the impact of cul-t u re societal, org a n i z a t i o n a l ,and professional that keepsnursing executives tied to the tacti-cal when their energies should bed i rected to more long-term, strate-gic outcomes (p. 1). She addedthat organizational culture exert sunspoken assumptions aboutnursing leadership that pre v e n t snurses from becoming a powerf u l

f o rce. These assumptions includethe significant and ongoing gro w t hof nursing in a paternalistic hierar-chy and the historic nature of ap redominantly female pro f e s s i o n .

Jennings and colleagues (2001)a ff i rmed that nursing leadership isshaped dramatically by politicsand policy, and that effective nurs-ing leadership is an org a n i z a t i o n a lvehicle in which nursing policyand practice can be shaped andchanged. Trent (2003) pro p o s e dthat change in nursing practice

Nursing is a holisticprofession; similarly,nursing leadership shouldalso be holistic, dynamic,inclusive, flexible, and

a d a p t a b l e .


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reflects the values of society. Beingcognizant of these influences anda d d ressing them are examples ofsociopolitical leadership knowing.For example, nurse leaders need toactively participate in their pro f e s-sional organizations, become off i-cers on governing boards, and cre-ate policy for their institutions tostay abreast of national and localissues and trends in nursing.

Roy (2000) emphasized that itis imperative for nurse administra-tors to plan and predict the futureof nursing. Nurse leaders oftenmake decisions based on thechanging environment in a healthc a re system that is highly integrat-

ed, continuum-based, and multi-faceted (Port e r- O G r a d y, 1999).These re p resent overarc h i n gsociopolitical issues, such as gen-d e r, diversity, culture, and powerthat must be examined andengaged to enhance effective lead-ership.

Unknowing. The sixth patternof knowing is paradoxically calledunknowing leadership ( u n k n o w-ing L.K.). Munhall (1993)described unknowing as a condi-

tion of openness and an under-standing, which as Heath (1998)f u rther commented, can con-tribute toward remaining alert tothe changing perspective of thesituation. Unknowing invitesa w a reness and release of the par-ticular biases, prejudices, pre c o n-ceptions, stereotypes, and ass-umptions that most people (in-cluding nurse leaders) carry intothe daily life of the workplace.Instead, a sense of possibility and

real acceptance between points ofv i e w, persons, disciplines, or cul-t u res unfolds. The IOM (2004) re c-ommended that health care org a n-izations acquire nurse leaders forall levels of management who willfacilitate input of dire c t - c a renursing staff into operational deci-sion making and the design ofwork processes and work flow (p.8). Front-line personnel havea w a reness and knowledge about

bedside nursing and patient carethat is valuable for nursing lead-

ers. Consistent with the unknow-ing pattern, leaders should meetwith staff in an open, nonjudg-mental atmosphere to elicit theiropinions and then act upon theknowledge they are given. Leaderswho invite input from nursing

s t a ff are recognizing theirunknowing about the staffs per-spective of the situation. Regard-less of their education and train-ing, nurse leaders need to re m a i nopen, receptive, and aware.

Unknowing leadership re q u i re sh u m i l i t y, flexibility, adaptability,change readiness, and the abilityto listen intently to others. Kouzesand Posner (2002) emphasizedthat leaders need to listen to mul-tiple voices in the org a n i z a t i o n ,

w a rning that a closed-mindedleader will not develop trust withthe staff and will not be successfulin retaining staff for the org a n i z a-tion. Ultimately, this pro b l e ma ffects patient outcomes. Whennursing leaders recognize they donot know all the answers, whenthey are open to the input andfeedback from nursing staff, whenthey listen to the concerns andplan change accord i n g l y, they arehonoring the intent of the

unknowing dimension of leader-ship. The insight re q u i red forunknowing leadership is exempli-fied by the anonymous words pre-sented in Figure 2.

As nurse leaders maintaintheir re c e p t i v i t y, it allows them tocontinue in their personal andp rofessional growth. If theyremain in an all-knowing stateof mind, the results can be stagna-tion, complacency, and constrain-ing judgment. Unknowing allows

both the leader and the nurse the

f reedom to shed new light on thedawn of each day.

E m a n c i p a t o ry knowing. T h eseventh and most recently estab-lished pattern is emancipatoryknowing which is based on both atraditional social idea and a devel-

oping dimension of nursingknowledge (Chinn & Kramer,2008). Building upon the aware-ness and knowledge seeking of theother patterns, e m a n c i p a t o ry lead -ership knowing ( e m a n c i p a t o ryL.K.) moves nurse leaders to thenext step, which is actively chang-ing the workplace enviro n m e n tand impacting outcomes for bothpatients and nurses. Key strategiesfor this pattern involve grassro o t sc reative development pro c e s s-

esin small groups (Chinn &K r a m e r, p. 94), aimed at raisinga w a reness of unfair and perh a p sunethical situations, collectivelyreflecting on the meaning of suchthings, and deciding to transformthe situation. As with the otherp a t t e rns, introducing and infusingthe emancipatory way of think-ing/knowing may take months oryears. Nurse leaders with a visionof the future in health care sys-tems may find this pattern espe-

cially valuable in leveling theo rganizational playing field; theywill need to develop eff e c t i v e ,i n f o rmative measure s / s t r a t e g i e sfor tracking the effects of emanci-p a t o ry changes.

E m a n c i p a t o ry leadership know-ing provides flexibility for adapta-tion to contemporary trends andissues as they emerge. For exam-ple, the decision to reduce hospi-tal reimbursement for serv i c e srelated to hospital-acquired infec-tions presents transform a t i v e

Figure 2.Insights Required for Unknowing Leadership

Watch your thoughts, for they become words.

Choose your words, for they become actions.

Understand your actions, for they become habits.

Study your habits, for they become your character.

NOTE:Author unknown


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o p p o rtunities for nurse leaders tore d i rect their energies towardl o n g - t e rm strategic outcomes.With the emergence of methicillin-resistant Staphylococcus aure a s(MRSA), a compelling publichealth problem in health care set-tings, there are significant chal-lenges to care and clinical prac-tice. MRSA is one of the leadingcauses of hospital-acquired infec-tions. These unnecessary compli-cations result in sicker patientswhile threatening financial viabil-ity of health care agencies. Changetechnologies, such as Lean SixSigma and Positive Deviance,o ffer nurse leaders a vehicle to

shape nursing policy and practice.Lean Six Sigma is a systemat-

ic approach to improving pro c e s sre l i a b i l i t y. Care is enhanced andclinical practice improved byidentifying and eliminating opera-tional barriers along with unwant-ed variation within a process orsystem dovetailed with integratingthe voice of the customer (SixSigma, 2005). Positive Deviance isa social and behavioral changep rocess where nurse leaders

engage front-line staff in impro v e-ment eff o rts. Specifically:Positive Deviance is a

development approach that isbased on the premise thatsolutions to community pro b-lems already exist within thec o m m u n i t y. The positive de-viance approach thus diff e r sf rom traditional needs b a s e d or problem-solving appro a c h-es in that it does not focus pri-marily on identification of

needs and the external inputsn e c e s s a ry to meet those needsor solve problems. Instead itseeks to identify and optimizeexisting re s o u rces and solu-tions within the community tosolve community pro b l e m s(Positive Deviance Initiative,2001, para. 1).Within this paradigm, there

a re individuals (or groups) withino rganizations who function as

positive deviants. Congruent withthe foundational underpinnings of

the empancipatory patters ofknowing, grassroots cre a t i v edevelopment processesin smallg roups of positive deviants canpotentially implement better solu-tions to intractable problems com-p a red to their peers with access tosimilar re s o u rces (Chinn &K r a m e r, 2008, p. 94; PositiveDeviance Initiative, 2001).

Nurse leaders often need tomake decisions without the bestlevel of evidence. Failure to act isnot an option. Lean Six Sigma andPositive Deviance embody eman-c i p a t o ry leadership knowing tominimize operational and cultural

b a rriers to care and clinical prac-

tice. Evidence is presented andl e a rning fostered. Early adoptionof strategies to enhance care andi m p rove clinical practice isencouraged. Empowerment thatPositive Deviance can bring toengaging front-line staff is a pow-e rful adjunct tool for advancingquality and safety initiatives.

Discussion

Nurses in leadership enviro n-ments can benefit greatly by

embracing a theory to guide prac-tice that, created by nurses fornurses, additionally addresses thegestalt or unified whole of the pro-fession. The patterns of knowinga re one such theoretical appro a c hwhich can encompass the multi-faceted domains of nursing andnursing leadership (see Figure 1).S p e c i f i c a l l y, Fawcett (2006) notesthat if nurses are to provide thehighest quality of care that comesf rom practicing nursing as both

science and as art, employing thep a t t e rns of knowing must be fos-t e red, emphasizing the speciali m p o rtance of the patterns for get-ting to really know the peoplewho seek our careduring nurse-patient encounters (p. 276).

The extant health care litera-t u re currently emphasizes EBMand EBL, which re p resent theempirical way of knowing; how-e v e r, this is only one pattern ofleadership theory and inhere n t l yexcludes some of the more person-

al and aesthetic factors that addi-tionally impact health and illness.Carper (1978) stressed that eachp a t t e rn of knowing is not a com-plete approach in itself, whileChinn and Kramer (2004, 2008)and Fawcett et al. (2001) furt h e remphasize the danger of re l y i n gon one pattern too heavily ore x c l u s i v e l y, which they call a pat-t e rn gone wild. Curre n t l y, thisdanger has become a reality witho v e ruse of the empirical pattern ofknowing, professionally re f e rre dto as evidence-based practice andoutcome measures. Although thisp a t t e rn has value, a singular oro v e rused focus on empiric leader-

ship knowing can lead to the min-imization and/or exclusion of theother patterns encompassingvision, creative experience inpractice, interpersonal re l a t i o n-ships, ethics, culture, context, andchange. Consequences of exclu-s i o n a ry thinking apply equally toany pattern. For instance, theimpact of the lived experience ofpostoperative pain and its eff e c ton length of hospital stay ofteninvolves empirical scales. Al-

though pain scales may pro v i d eempirical data on postoperativere c o v e ry, clearly the use of theother patterns can enhance assess-ment and understanding of theholistic re c o v e ry of the client, aswell as provide insight into theempirical measures of pain man-agement and length of stay.C o n g ruent with the foundationaltenets of the patterns of knowing,nursing leadership knowing mustutilize all the patterns in unison,

which contributes to pre v e n t i o nof nursing leadership theory fro mbecoming wooden, insensitive,and ineffective. In addition toEBL, integrating the pattern sincludes assessing leadershipskills for empathy and vision (aes-thetic L.K.), mutual respect andauthenticity (personal L.K.), ethicsand morality (ethical L.K.), p o l i t i-cal strategy and diversity (sociopo-litical L.K.), humility and flexibili-ty (unknowing L.K.), emancipatoryand transformative actions (eman-


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c i p a t o ryL.K.). Additional re s e a rc his needed to determine the impactof the other patterns of knowingon nursing leadership, includinghow those patterns can contributeto evidenced-based practice andoutcome measure s .

Nursing is a holistic pro f e s-sion; similarly, nursing leadershipshould also be holistic, dynamic,inclusive, flexible, and adaptable.EBL, in and of itself and used inisolation, ignores the heart andsoul the overall lived humanexperience of leadership. Thiswill not serve the leader, the staffnurse, the patients, or the pro f e s-sion of nursing. Nurse leadersneed to guide the nursing pro f e s-sion into leadership theory that isas comprehensive as the pro f e s-sion. Foundational facets with

brief descriptors of Patterns ofKnowing as leadership theory andrelated implications are pro v i d e din the Table 1.

Implications for NursingLeadership Practice

A review of the extant litera-t u re shows a paucity of re s e a rc habout applying the patterns ofknowing as leadership theory.Schmidt and colleagues (2003)applied Carpers patterns of know-ing to develop a successful clini-cal ladder program for Ta m p aGeneral Hospital. Staff interest inthe program exceeded pro j e c t i o n sand career advancement wasestablished. This ladder pro g r a mis believed to be the first one toutilize Carpers work for pro g r a mdevelopment; however, it does not

a d d ress nursing leadership. Thestudy provides insight for leader-ship strategies that dovetail withthe foundational assertions of theleadership knowing theory; spe-c i f i c a l l y, they re p resent the multi-dimensional leadership appro a c h-es inherent to use of the first sixp a t t e rns in unison, simultaneous-ly addressing the needs of both theleader and the employee. Add-itional contemporary studies,identifying the facets of job satis-faction for nurses and subsequentresponses sought by employeesf rom management, can be easilyincorporated into the patterns ofknowing (see Table 2). Of note,most re s e a rch concerning primarynursing and job satisfaction has

been based on the assumption thatall nurses as professionals find job

Figure 3.Comparison of Nursing Leadership Knowing to Transformational Leadership

EmpiricL.K.

Outcome-Based

UnknowingL.K.

Openness

Transformational

Leadership

Ethical

L.K.Justice, Ethics

Personal

L.K.Relationship

SociopoliticalL.K.

Strategy, Culture

AestheticL.K.

Art,Vision

NursingStaff

NursingLeadershipKnowing

E m a n c i p a t o ryL K .

Tr a n s fo r m i n g

Wo r k p l a c e


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satisfaction in intrinsic factors.This assumption must be ques-tioned in the contemporary era,p a rticularly when consideringmethods of leadership that pro-mote job satisfaction, which int u rn can significantly enhanceunit efficiency and optimizepatient care (Malkin, 2008).

C u rrent national re c o m m e n-dations from the IOM (2004)

include use of transform a t i o n a lleadership theory and EBM.H o rton-Deutsch and Mohr (2001)a rticulated that nursing leadershipis fading, and that nursing hasmorally and ethically failed itspatients (perhaps re p resentative ofthe empirical pattern havinggone wild). People do not entera hospital with the hope of beingc a red for by EBM; rather, theywant care from nurses practicingh o l i s t i c a l l y, perhaps using all thep a t t e rns of knowing? If the curre n t

emphasis on solely using EBL (theempirical pattern of knowing) andt r a n s f o rmational theory is founda-tional in nursing leadershipa p p roaches, it is suggested thatnursing leadership will continueto fail its staff and patients byusing borrowed and, subse-q u e n t l y, inadequate methods. Acomparison of Nursing LeadershipK n o w i n g to EBM/EBL (evidence-

based practice) and transform a-tional leadership gives evidencethat although each approach hasvalue, they do not address theuniqueness and totality of thenursing profession (see Figure 3).

Tr a n s f o rmational theory maybe ineffective for individualsi n h e rently motivated by intrinsicre w a rds as it does not address thescience of nursing (see Figure 3).F u rt h e rm o re, in a recent detailedl i t e r a t u re review of nursing man-agement and leadership compe-

tencies, Jennings, Scalzi, Rodgers,and Keane (2007) concluded thatinadequate distinction exists ford i ff e rentiating the two sets of com-petencies. The authors suggestthat the strength of using the pat-t e rns of knowing as nursing lead-ership theory is they include boththe visionary qualities of transfor-mational leadership and objectivedata of evidence-based practice,

and they incorporate the addition-al patterns which are so vital toholistic leadership. For example,Scott and Caress (2005) indicatednew forms of leadership arere q u i red to engage staff in deci-sion making and promote clinicale ff e c t i v e n e s s .

Conclusion

A particular and specificfocus on empirics and evidence-

based practice will not attend tothe robust and multidimensional

Table 1.Patterns of Knowing in Nursing Leadership Theory: Description, Qualities, and Examples

Pattern ofKnowing

Nursing LeadershipKnowing Description and Qualities Examples

Empirics Empiric LeadershipKnowing

Evidence-based nursingleadership

Factual, objective

Annual report cardEmpiric research, outcome-basedpractice, EBM

Aesthetics Aesthetic LeadershipKnowing

Art of nursing leadershipEmpathetic, subjective,

visionary

What is significant for nursingstaff? Perceptive leadership

Personal Personal LeadershipKnowing

Relationship-based nursingleadership

Listening, being authentic,empowering

Mutual respect

Interpersonal relationshipbetween leader and staff. Validatestaff concerns. Maximize individ-ual potential.

Ethics Ethical Leadership

Knowing

Ethical nursing leadership

Values, standards, morality

Code of ethics, professional

organizations, accountability,justice

Sociopolitical Sociopolitical LeadershipKnowing

Politics of nursing leadershipStrategic, cultural, diversity,

gender-based

Laws, regulations, external andinternal health care environment

Unknowing Unknowing Leadership Openness in nursing leadershipHumility, awareness, flexibility

Leaders do not know all theanswers. Open-minded, adapt-able leadership

Emancipatory Emancipatory LeadershipKnowing

Motivational nursing leadershipConsciousness raisingTransformative workplaces

Governance partnershipsPolicy changes


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underpinnings of the lived experi-ence that is so vital to nursing as acaring profession (Averill &Clements, 2007). How do nurseleaders, both novice and seasoned,

know about leadership? They exam-ine and embrace a way of thinking,or theory, that they believe re f l e c t stheir ideals. The ideal of nursingleadership theory is not a single-focused shadow of its history, but arich, inclusive, multi-faceted net-work of knowing. As such, N u r s i n gLeadership Knowing p rovides af o rum for leaders to enhance theirpractice, as well as their re l a t i o n-ship with their employees, whichultimately translates into optimalc a re for the patients we serve. $

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Approach Patterns of Leadership Knowing

Criteria for advancement should pos-sess sufficient flexibility to account forindividual experiences.

Personal, Ethical, Aesthetic,Sociopolitical, Emancipatory,Unknowing

Increased control with scheduling. Personal, Unknowing

Individually meeting with employees toexplore their goals and views of thenursing profession and their own pro-fessional trajectory.

Personal, Aesthetic, Emancipatory,Unknowing

Providing opportunities for shareddecision making on unit issues.

Personal, Aesthetic, Emancipatory,Unknowing

Support for educational activities (con-tinuing education, flexibility with aca-

demic/work schedule, facilitatingonline education, regularly scheduledon-unit educational in-services basedon employee-identified topics).

Personal, Empiric, Emancipatory,Unknowing

Public recognition for service andproductivity.

Personal; Aesthetic

Acknowledgment of work/familyroles/responsibilities.

Personal, Sociopolitical, Unknowing

Active examination of and interventionwith staff dynamics: facilitation ofproactive conflict resolution versusreactive passive-aggressive problemsolving.

Personal, Ethical, Aesthetic,Emancipatory, Unknowing

Sharing of plans and goals in a clearand definitive manner

Aesthetic; Unknowing

Table 2.Nursing Leadership Approaches to Engage Staff and Promote

Clinical Effectiveness and Enhance Employee Satisfaction


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ADDITIONAL READINGS

Aiken, L.H., Clarke, S.P., Sloane, D.M., Lake,E . T., Sochalski, J., & Silber, J.H. (2002).Hospital nurse staffing and patient mor-t a l i t y, nurse burnout, and job dissatis-f a c t i o n . J o u rnal of the American

Medical Association, 288 (16), 1987-1 9 9 3 .A n t robus, S., & Kitson, A. (1999). Nursing

leadership: Influencing and shapinghealth policy and nursing practice.J o u rnal of Advanced Nursing, 29( 3 ) ,7 4 6 - 7 5 3 .

Clements, P., & Averill, J. (2004). Patterns ofknowing as a method of assessment andi n t e rvention for children exposed tofamily-member homicide. A rchives ofPsychiatric Nursing, 18(4), 143-150.


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