Leaders, managers, and followers: Working in harmony : Nursing2023

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Feature: New Horizons

Leaders, managers, and followers

Working in harmony

Valiga, Theresa M. EdD, RN, CNE, ANEF, FAAN

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Nursing 49(1):p 45-48, January 2019. | DOI: 10.1097/01.NURSE.0000549723.07316.0b
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OVER THE COURSE of their prelicensure program, many nurses had a class titled something along the lines of Leadership in Nursing. Typically, this course is taken in the final semester, along with a precepted clinical experience. It may have been taught by a former nurse manager or another healthcare administrator, focusing on the following:

  • organizational structures
  • delegation to certified unlicensed assistive personnel
  • roles and responsibilities of nurse managers or charge nurses
  • workings of the healthcare team
  • performance evaluation
  • job descriptions
  • unit budgets
  • personnel issues.

While these courses are valuable, they do not necessarily prepare nurses to be effective leaders or followers. But that is what all nurses should strive to be: leaders and effective followers. This article examines the differences between leaders and managers, describes the role of effective followers, and applies those qualities to nurses across the spectrum of healthcare.

Who leads?

Leadership literature is plentiful both inside and outside of the healthcare industry, but these often focus on the role of a CEO or another manager or administrator who deals with employees. This suggests that the term leader applies only to individuals in top-level administrative positions, that only a small number of individuals might be considered leaders, and that those who are led have a limited impact on the success or future direction of their organization. In reality, nothing could be further from the truth. Leaders can be found in every walk of life, any position or role, and every field. Those expected to follow leaders must know how, when, and whom to follow for success.

Over the years, evolving leadership theories provided new perspectives on leadership, but they failed to acknowledge the complexity of leadership and the importance of followers (see Changing perspectives on leadership). More contemporary theories acknowledge that effective leadership depends on the person, the situation, and the qualities and maturity of the followers.1-4 Leadership is not a random occurrence in these theories; rather, it is purposeful and involves communication, vision, engagement, and inspiration to energize a group.

One of the best-known perspectives on the complexity of leadership came from James MacGregor Burns in 1978.5 His influential work, Leadership, addressed the importance of followers and urged appreciation for the two forms of leadership: transactional and transformational. According to Burns, transactional leaders “approach followers with an eye to exchanging one thing for another: jobs for votes or subsidies for campaign contributions.” In contrast, transformational leaders “[recognize] and [exploit] an existing need or demand of a potential follower... [seek] to satisfy [their] higher needs, and [engage] the full person...” to pursue “compelling causes.”5 This distinction, along with the acknowledgment of transformation and collaboration, has led to a careful analysis of the similarities and differences between leadership and management.5

Leadership vs. management

When many talk about leadership, they refer to individuals in positions of authority, such as the president of a professional association, a CNO, the dean of a school of nursing, and so on. Followers are often thought of as sheep expected to accomplish whatever tasks the leader sets. A careful assessment of the distinctions between leaders and managers, as well as those between sheep and effective followers, is required for an awareness and effective execution of these different roles.

Many have built on the themes of Managers and Leaders: Are They Different? by Abraham Zaleznik in 1981.6 His work helped to distinguish leaders from managers:

  • Leaders have a vision and draw on passion to engage others.
  • Managers typically work with others to realize the goals of an organization—often with great skill, but not always with passion.

Leaders communicate their vision to inspire others to effect change for the benefit of those around them. The vision for leaders in nursing may result in patients being admitted to the unit in a more effective and compassionate way, families being integrated into the patient-care process for a more positive experience, and staff having greater input on the policies and practices that affect them.

By comparison, managers often communicate policies and expectations that have been established by the organization for compliance. Typically, the task is still accomplished, but sometimes due to fear rather than a healthier motivator. It may also be that the staff feels as though they have no choice in the matter. Effective followers choose to follow because they also see value in the vision and are inspired by the passion with which an idea is communicated.

In their relationships, leaders utilize the strengths and talents of those around them to influence positive change, often empowering others to take on leadership roles of their own. They encourage, support, and mentor their followers. In turn, followers challenge leaders and suggest alternatives to their ideas. Managers also work effectively with teams but are expected to accomplish tasks and stay on budget by directing others.

Leaders achieve their status because followers have allowed them to take the lead; managers are appointed to their positions. As such, leaders' power comes from their credibility, passion, and knowledge. Managers are in a position of authority, with their power coming from the ability to hire, fire, evaluate, and recommend employees.

Knowing their vision will not be achieved easily or overnight, leaders are creative and comfortable with disorder, take risks, and stay focused on their goals. By comparison, managers seek to limit risks, often preferring order to maintain the status quo. As evidenced by “The Best Performing CEOs in the World 2017,” an article in the Harvard Business Review that ranked CEOs based on their company's success in production and financial returns, the primary objective of management is the health and future of the organization.7

Areas such as employee performance, organizational structure and operations, branding, big data, strategic planning, and the longevity of an organization weigh heavily into management decisions. These are important factors to consider, but they are not always of great significance to leaders. Leaders focus on getting people involved to develop and realize a vision based on passion, rather than just the bottom line, and they are exactly what is needed in nursing.

Despite seemingly opposite characteristics, the two are not mutually exclusive. Many nurses who are effective leaders serve in management positions, but leaders do not require a position of authority. Given the current state of healthcare, increasingly diverse patient populations, the complexities of practice, and the tremendous explosions in knowledge and technology, all nurses must accept responsibility to be leaders in their respective organizations, communities, and professional associations.

Taking up the mantle

Assuming a leadership role may seem overwhelming, and many think they do not have the time, energy, or qualities to take on the challenge. But those who hesitate can still rise to the challenge with some guidance. Consider the following:

  • Engage in honest self-reflection regarding individual strengths and weaknesses, including clinical expertise and proficiency, communication skills, or mentoring activities.
  • Attend seminars or workshops on leadership development and allow time for careful reflection.
  • Read books, articles, and blogs on leadership.
  • Carefully observe leaders both inside and outside of the nursing field to identify their habits and characteristics, then work to develop or strengthen those abilities.
  • Speak up in the presence of injustice, disrespectful behavior, clinical errors, or ineffective practices. This means clearly identifying an issue, offering a solution, and suggesting approaches to improve the situation.
  • Seek out mentors and apply to participate in leadership development academies, such as those offered by Sigma Theta Tau International.8
  • Start small in familiar areas. Leadership does not mean becoming president of the American Nurses Association or tackling a major issue. Instead, it can be achieved by being an active, contributing member of a committee, submitting a proposal on a different way to do things, or writing an article for your institution's newsletter.
  • Ask for feedback from peers and colleagues regarding how particular situations were handled.
  • Function as an effective and exemplary follower by supporting colleagues who are attempting to shape a better future.

Strong followers

Being an effective follower is one route to becoming a leader. Followers are often thought of as sheep, yes-people, or cheerleaders, and some do play those parts. But realizing a vision and addressing compelling causes cannot be accomplished by the leader alone.5 In fact, there would be no leaders without followers.

Individuals who are effective as followers think critically about ideas, proposals, and problems; offer different points of view; invest in the group and its goals; and know who and when to follow.9 They both give and receive counsel and support, share responsibility for the group, uphold high values and standards, understand their strengths and weaknesses, and stay true to their own values; in addition, they will not abide individuals who abuse their position as a leader. These individuals are strong, actively engaged, and primed to take on leadership roles. Like leaders, they are willing to take risks, communicate effectively, take initiative, and think for themselves.

Time to step up

Nurses who have served as effective followers and attended to strengthening and developing their leadership qualities and characteristics may be ready to take on a more active role. Nurses can provide leadership in their units or organizations in several ways, including:

  • chairing a unit-based team or council for professional governance
  • providing alternate approaches for process improvement initiatives
  • identifying practice or care issues to peers and supervisors to ensure that they are not ignored
  • seeking out and advocating for the development of evidence-based approaches to resolve an issue
  • promoting the professional development of nurses and volunteering to help orchestrate these opportunities
  • standing up to injustice or inequity and working to create a culture that will not tolerate such behaviors
  • serving as a preceptor and mentor for new staff members or students.

Many paths to leadership

There are many ways to identify, develop, and strengthen leadership skills. Sometimes an educator, nurse manager, or colleague will see leadership potential in an individual and provide the encouragement, support, and opportunity for him or her to develop in that role. Nurses in this position should consider themselves fortunate and take full advantage of the situation. More often, however, nurses are not tapped by someone else and must take the initiative to move forward.

Each nurse makes a difference in the lives of patients and their families, but they should also seize the opportunity to have a broader impact on healthcare and the nursing profession as a whole for the benefit of patients and colleagues alike. Consider what kind of difference can be made by advocating for:

  • local quality improvement projects
  • access to follow-up care for the homeless population after discharge from acute care settings
  • representation of clinical nurses on all major boards and committees within an institution
  • a new approach to scheduling that allows nurses to pursue advanced education or research.

There are approximately three million nurses in the US.10 They are trusted and valued by the public and guided by their commitment to others.11 Imagine the impact nurses could have if even half of them truly functioned as leaders. Who would be in a better position to make significant changes in healthcare?

Changing perspectives on leadership12

Views on leadership have changed over the years. Initially, only individuals born into a noble family were thought of as leaders, having inherited those roles, but leadership involves more than having noble blood.

  • The great man theory did not resonate well with the rest of the population, and scholars started to determine different characteristics possessed by those viewed as leaders.
  • Trait theories evolved from this and identified some common leadership characteristics, but none were universal because the qualities of a leader varied based on circumstance.
  • Situational theories recognized the significance of an individual's environment or situations. These events may lead him or her to step up as a leader.




      followers; leaders; managers; transactional leaders; transformational leaders

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