Leadership and management are popular subjects across many realms, and it is often discussed in the context of politics, economics, military and organizations. The two terms are often used in popular culture interchangeably, however there are important differences. These differences are important to understanding the task of advanced nurse leadership, and can be applied to the concept of nurse staffing ratios.
Nayar describes three simple questions which one can ask oneself in order to determine whether one is acting as a leader or a manager: whether one is counting or creating value; whether one is creating circles of influence or circles of power; and whether one is leading people or managing work (Nayar, 2013). In each of the cases listed, the first option describes leadership while the second describes management. Leaders create visions of the future, whereas managers create organized and efficient plans to achieve the objectives of leadership. Excellence in nursing and its administration and governance requires both nursing leadership as well as management; however the practice of each involves distinctly different skills (Tomey, 2009). When one refers to a leader in nursing, particularly advanced nursing leaders, it is likely that the skills required include both leadership and management, as the process and practice includes not only detailed understandings, summary and forecasts of performance and routine information, such management skills are used to leverage and lead change and transformation of the healthcare system.
Nurse staffing ratios are an issue which provides a case study for the examination of leaders in comparison to managers. The issue presented is a serious one. On one hand the costs of healthcare have spiraled out of control, and reductions in cost are needed to keep healthcare financial viable and sustainable. On the other hand, insufficient nurse staffing is associated with higher mortality of patients as well as nurse burnout and leaving (Needleman et al., 2011). Where a manager would seek to solve the problem as defined by finding the target level of nurse patient ratio and determine staffing with a view to keeping to that target ratio, the nurse leader has a responsibility to look more deeply into the issue, and to understand the underlying factors which are systematically working against, or could work for, a solution.
With regard to dealing with the problem of nurse staffing ratios, nursing managers have as the objective a defined understanding of the target ratio, and a mandate to find ways to meet the required mathematically constructed formula of ideal nurse staffing ratios. Nurse leaders have a responsibility to advocate for the inclusion of multiple perspectives and factors which are not prioritized in the current model. In other words, the leader frames the problem and instructs on the desired solution, which in this case is the requirement to achieve a standard nursing ratio in order to avoid problems such as patient mortality. The manager must institute a plan to achieve such goals while paying careful attention to costs and resource use.
My personal and professional philosophy of nursing is one in which leadership is leveraged by all stakeholders. The role of the advanced nursing leader is to not only understand the various perspectives of stakeholders and to leverage their voices and contributions, but also to see the whole picture in evidentiary terms, and to envision solutions to problems of care based on this data. Some of this philosophy was developed while working in the area of healthcare and information management. Information and technology can do many things, but it cannot analyze information from a nursing perspective in order to increase the quality of care and the nursing environment. Excellence in data capture and summary does however provide the nurse leader or manager with significant tools that can be used to measure progress and determine the state of issues, trends and the need for prioritization.
As a manager, I tend to emphasize teamwork and the principles of lean six sigma methodology. Benchmarking, managing performance and continuous analysis of ways to improve performance figure prominently in my experience in this area. I excel in defining, measuring and validating information and ideas through data, and then translating this understanding into implementation strategies over a project lifecycle. This has given me an advantage in the area of training and curriculum development, particularly one that has dynamic and ongoing needs. For determining new goals and adjusting existing ones, a switch is made to what might be termed skills that are more recognizable as leadership.
As a leader I have had the experience of motivating teams to achieve excellence. I have shown considerable skill in developing teams, and I have found that a team mentality is a benefit to facilitating group performance. I am also able to build on my managerial skills, particularly in quantitative analysis, in order to better understand status of performance and possibilities and opportunities for improvement.
Leadership and management skills are both needed in nursing, and in my case I have shown that I can apply both to envisioning and meeting goals. It was leadership skills that aided my initiative to establish a co-op program with Northeastern University in Boston for Trainers, and it was management skills which resulted in $3 million dollars in cost savings. I have been able to exercise my more creative side in the development of effective training programs for large academic institutions with measureable high quality results.
In the case of nurse staffing ratios I see both management and leadership skills as necessary parts of the solution. Management is necessary in order to ensure ongoing and interim compliance with the information at hand, that being that nurse staffing ratios are an essential component of excellent care and a great factor in patient mortality. Leadership is necessary in order to construct a more robust vision of what is possible given the situation and the factors which lead to it. It is necessary to understand the ratio and its relation to care as more than a calculation. Further factors which help or hinder the cause must be uncovered along the way, and this requires careful attention to detail in management of processes. Management alone cannot resolve the problem, as it is constricted by the vision of the problem as one based on the nurse ratio, rather than looking into the factors which create higher statistical risks of problems when staffing levels are low. Other supports which may be uncovered in seeking a solution could lower patient mortality across a number of settings. Leaders define problems, and the issue defined as nurse staffing ratio levels requires leadership as well as management.
I have confidence that I have both the management and leadership skills necessary to take on the objectives of advanced nursing practice. I have the technical skills required for performance management and continuous improvement, with a focus on lean tools and frameworks but I am also capable of focusing on the larger picture and constructing my own research, frameworks and visions with regard to finding opportunities and solutions. As a nurse leader I will also need to practice and use my skills in management, in order to implement the objectives of the field as well as those related to my position and professional interests. I do not foresee a separation of my leadership and management skills, although I clearly see they are for different purposes and composed of different skill areas. I will need both in order to fulfill the vision of a healthcare system which works more efficiently to provide the continuously improving quality of care to all patients in an environment that allows nurses to develop and thrive in their skill areas.
- Nayar, V. (2013). Three Differences Between Managers and Leaders. Harvard Business Review.
- Needleman, J., Buerhaus, P., Pankratz, V. S., Leibson, C. L., Stevens, S. R., & Harris, M. (2011). Nurse staffing and inpatient hospital mortality. New England Journal of Medicine, 364(11), 1037-1045.
- Tomey, A. M. (2009). Nursing management and leadership. Elsevier, Missouri.
