A Multidisciplinary Intervention to Reduce Post-Craniotomy Surgical Site Infection Rates

Running head: TRANSFORMATIONAL AND SHARED LEADERSHIP 1

Transformational and Shared Leadership Theories: Comparison and

Application During a Surgical Department’s Cultural Change

Traci McGee

University of Charleston, School of Business

Doctor of Executive Leadership Program

TRANSFORMATIONAL AND SHARED LEADERSHIP 2

Abstract

This document contains the results of a literature review of

transformational and shared leadership theories through the lens

of a nursing leader in a perioperative setting, using theory

context and application. Transformational leadership is the

preferred form of leadership for nursing. The author selects

and defends transformational leadership with strong emphasis on

shared leadership, as the best and most effective leadership

style to use when enacting change in a hostile nursing

environment where there is overt resistance to change.

Involving followers and converting them into leaders of change

is an effective and powerful way to evoke follower support and

sustainability of changes in nursing practice and adoption of

best practices.


Transformational and Shared Leadership Theories: Comparison and

Application During a Surgical Department’s Cultural Change

The purpose of this document is to compare and contrast the

leadership theories of transformational leadership and shared

leadership; and, the context is presented through the lens and

perspective of a nursing leader in a perioperative setting. The

lens of the nursing leader includes a brief introduction in to

the American Nurses Credentialing Center and the magnet model,

which supports transformational leadership as their chosen and

preferred nursing leadership style. Main themes and highlights

from a scholarly literature inquiry are presented, for both

leadership styles. Similarities and differences in

transformational leadership and shared leadership will be

discussed. The writer will select and defend the theory most

significant to my personal practice—leading and navigating a

group of novice surgical charge nurses through the cultural

change of a toxic work environment, where there is a long-


standing culture of lateral violence, low employee morale, and

employee disengagement. Finally, lessons learned will be

summarized; and, gaps in research and future research needs will

be outlined.

Magnet Hospitals

Margaret Sovie, a nursing pioneer, was a member of the

American Academy of Nursing Task Force, in 1981. The task force

mission was to identify the qualities and common threads of

hospitals that shaped nursing excellence. Sovie is credited

with creating the term ‘Magnet Hospital’ to describe hospitals

that attract and retain the best nurses. This term later

evolved, and was accepted by the American Nurses Credentialing

Center as the Magnet Recognition Program—a program that is still

popular and in use today. During a nursing shortage in the

1980s, McClure et al. (1983), began two decades of research on

the characteristics of magnet hospitals, and the relationship to

nurse and patient outcomes.


The Magnet model endorses transformational leadership, where

leaders embody vision and influence. Transformational leaders

exhibit and model strong clinical and professional practice, and

they are proactive and inspiring in meeting challenges.

Transformational leadership “has been shown to be particularly

effective in turbulent and uncertain environments” (Messmer &

Turkel, 2011, p. 239). A trusting work environment of magnet

hospitals was identified as a common thread among magnet

hospitals. McClure found that facilitation of trust by nursing

leadership, and strong clinical competence among nurses, was key

in achieving a trusting work environment in nursing units.

Transformational Leadership

Leaders, practicing transformational leadership, excite and

motivate their team through charismatic influence, and by

communicating a vision that inspires and connects to individual

values. The leader stimulates their followers to work towards

the accomplishment of goals. The followers accomplish their


work, and will actually perform beyond what is necessary when

inspired by a transformational leader. Bacha and Walker (2013)

suggest that there are four dimensions of leader behavior with

regard to transformational leadership theory. The four areas

involve ways in which the leader’s behavior causes the follower

to pursue the mission, aligning with the desires of the leader.

According to Bacha and Walker, the transformational leader

exemplifies and role models the following four dimensions of

behaviors to inspire followers:

Transformational Leadership:

Four Dimensions of Leader Behavior

Individualized consideration Degree to which the leaders attends to each follower’s needs

Intellectual stimulation Degree to which the leader challenges assumptions, takes risks and solicits followers’ ideas

Inspirational motivation Degree to which the leader


articulates a vision that is appealing and inspiring to followers

Idealized influence Highest level of transformational leadership—behavior of leaders that results in there being role models for their followers.

Trust

Many organizations accomplish projects and daily work

through teams. Therefore, it is imperative that transformational

leaders be able to influence and inspire groups of people as

well as individuals (Chen, Kirkman, Kanfer, Allen, & Rosen,

2007). In 2011, Lord and Dinh, found that transformational

leadership has the greatest influence over group motivation as

opposed to individual motivation. Schaubroeck et al. (2011)

identified a link between team perception of a transformational

leader’s trustworthiness and team performance. Mayer et al.


(1995) wrote that the competency areas of benevolence, ability,

and integrity enhance leader trustworthiness.

Intragroup Trust. There is a lag in research examining the

existence of trust between team members—and the impact of

trusting and distrusting relationships between team members and

the impact upon group productivity (Lau & Liden, 2008). As a

nursing leader, this author has personally observed obstacles in

productivity when individual members of a charge nurse team have

had varying degrees of trust between members. The deficit or

varying degrees of trust between individual team members creates

Leader

Trustworthi

Benevolenc

Integrity

Ability(Mayer et al.,


a dysfunctional and broken circle of trust among the

perioperative nursing leadership team. It is the author’s

opinion that building trust within a department begins with the

leadership team, and that there is a trickle down effect with

the staff members.

Work Performance. When intragroup trust exists—trust among

team members and trust of the leader, work performance and job

satisfaction shift in a positive direction. There is a

correlation between job performance and trust. Both the

individual trust in their leader and group trust, enhance

individual and group job performance, respectively (Braun, Peus,

Weisweiler, & Frey, 2013). The team and front-line leaders are

more apt to be inspired, and to embrace the influence of the

transformational leader with trusting relationships have been

established.

Competence. A component of building trust is the

establishment of leadership competence. Trust can be viewed as a


two-way street. Leader trust in the abilities of employees to

perform their job depends upon belief that the individual has

the competence and decision making capabilities required to

complete assigned work. Leader interactions with the employee

are to a great degree dictated by the employee’s degree of

competence. On the flip-side, employee perception of a leader’s

overall competence is based upon the leader’s “ability,

benevolence, and expertise (Page, 2004, p. 117). Trust is in

part, built upon the group or individual employees’ perception

of leader competence.

Fairness. Scholarly research on leadership focuses upon the

behaviors and actions of leaders. An important factor in

transformational leadership behavior is the existence and

perception of leader fairness towards followers. Fairness is an

essential element in having the follower act upon the directive,

influence, and desire of the leader. Bacha and Walker found a

correlation between follower perception of fairness of the


leaders actions, and employee engagement and satisfaction,

confidence in the leader, and job performance. Followers

respond well to leaders who treat all individuals with respect

and fairness. Overall performance is improved, when followers

believe that their leader respects their individual needs and

opinion.

Engagement

Followers value clear, timely, and truthful communication,

as well as the opportunity to be involved in decision-making

(Parry and Proctor-Thomson 2002; Bacha and Walker, 2013).

Transformational leaders show support and cooperation towards

individuals and groups, both privately and publicly, which helps

to gain the support and engagement of followers. Another way to

gain engagement of followers is through intellectual stimulation

—where the leader inspires and encourages followers to examine

current work methods. Transformational leaders encourage

innovation among followers—producing new ideas and fresh


approaches. Transformational leadership theory places high

value upon integrity, ethical behavior, and where leaders place

others’ needs ahead of their own (Parry, Proctor-Thomson, &

Parry, 2002). Key to determination of leadership success is the

degree in which change is completed and follower needs and

desires are fulfilled (Page, 2004).

Shared Leadership

Shared leadership consists of two or more members of a team

participating in the leadership of a group. Leaders efforts are

typically focused on capitalizing productivity and effectiveness

of the team. Shared leadership this through participation of

all members of the team, and empowers the group in

accomplishment of work, and decision-making. The skills that

the group leaders and members hold collectively would be

difficult for a single leader to match. Shared leadership holds

that overall team effectiveness and performance may depend on

its ability to draw on the leadership skills of its members


(Bergman, Rentsch, Small, Davenport, & Bergman, 2012). Yukl

(2010) classified shared leadership into wide classes of

behavior: task-oriented, relations-oriented, and change-

oriented. A fourth class of spanning was recently added. All

are crucial in team leadership situations, whether the goal is

oriented to task, relations, change, or organizational context:

Initiating structure behaviors are task-oriented

Consideration behaviors are relations-oriented

Envisioning behaviors are oriented toward change

Spanning behaviors are operational within organizational

context

Trust

Trust influences performance in shared leadership. Enhanced

trust within the team means better group performance (Drescher,

Korsgaard, Welpe, Picot, & Wigand, 2014). A certain degree of

trust among team members is exhibited by their sheer agreement


to take part in shared leadership, which is the first step in

establishing intragroup trust. Members render themselves

vulnerable by taking the risk of taking part in shared

leadership and through the acceptance of influence by other team

members (Engel Small & Rentsch, 2010). Over time, trust within

the group, as well as individual roles will change with the

desired team outcome being communicating, influencing, making

suggestions, and holding people accountable (Drescher et al.,

2014).

Enhanced Team Function. Intragroup conflict causes decreased

productivity, difficulty in reaching consensus, and laborious

decision-making. Teams practicing shared leadership experience

less socio-emotional conflict; thereby increasing consensus

building, intragroup trust, team cohesion, and job satisfaction.

Teams practicing shared leadership theory reach consensus

quicker than teams who do not share leadership. Team member


performance and satisfaction is higher, as more members have an

opportunity to participate in leadership. Accountability and

commitment grow, with more positive team functioning and

outcomes than non-shared leadership models (Drescher, et als.).

Competence. Research supports the finding that perceptions

within shared leadership teams include a sense of shared respect

for each other’s competence (Simons & Peterson, 2000). A study

by Bertman et al. in 2012 revealed the following survey

responses from members of shared leadership teams: “We

absolutely respect each other’s competence,” and “We are all

certain that we can fully trust each other.” Sharing leadership

functions accelerates trust between team members, and trust is

higher than in teams with no shared leadership (Drescher,

Korsgaard, Welpe, Picot, & Wigand, 2014).

Empowerment

Team empowerment is a motivational and inspirational concept.

Group empowerment in shared leadership elevates engagement of


the team members, to complete tasks in meaningful and

constructive ways (Kirkman & Rosen, 1997). The team’s level of

empowerment is dependent upon the team’s maturity and

development, and the empowerment level is constantly evolving

(cf. Marks, Mathieu, & Zaccaro, 2001). Attention must be given

to the influence of external leaders upon shared leadership, as

they may inhibit the empowerment of the team. In shared

leadership, empowerment requires that all team members be

willing to offer leadership, rely on leadership by multiple team

members, and to have a voice.

Common Threads and Contrasts

In contrasting transformational and shared leadership, it

is important to note that shared leadership is actually a

component of transformational leadership. Trust is important in

the success of both transformational and shared leadership.

Trust positively influences transformational leaders’ ability to

motivate and inspire individuals and groups. In shared


leadership, trust influences effectiveness of the group in

accomplishing shared goals and objectives. In both types of

leadership, trust between team members and the leader are

important in the success of leadership and team success.

Without trust, neither style of leadership would be successful

in moving forward to achieve desired work.

Work performance and job satisfaction are influenced by

trust and cohesion in both leadership styles. Trust in the

leader and group trust augment team inspiration and influence by

the transformational leader. Shared leadership teams who

possess functional, trusting relationships, are able participate

in leadership and to achieve a higher degree of accountability

and commitment.

Competence is an essential element in building trust, and

in achieving the capacity or aptitude needed to fulfill work

tasks. In transformational leadership, followers need to feel

confident in the leaders level of competence as a leader, with


competence in their area of expertise. In turn, leaders must be

comfortable with the level of competence, both collectively and

individually, of shared leadership teams. In addition to trust,

mutual respect between members enhances work relationships and

the achievement of work.

In both transformational and shared leadership, followers

have the chance to be involved in decision-making. Engaging the

team, and empowering them gives followers an opportunity to add

value and to contribute input into how work is accomplished.

Both theories involve the engagement of followers.

Transformational leaders inspire and motivate followers. In

contrast, shared leadership allows the leader to inspire and

motivate through teams of followers, who represent and influence

the work group.

Preferred Leadership Style and Application

There is considerable change currently underway in

healthcare organizations. Hospitals and other healthcare


organizations are challenged today to provide more patient care

services and improved patient outcomes, while utilizing fewer

resources. To achieve this, healthcare organizations are

rapidly seeking innovative changes that will challenge the old

ways of accomplishing work tasks and patient care. The

innovative process of assessment and process improvement will

include adopting best practices. Many procedures and practices

were established decades ago, without consideration of patient

outcomes and quality indicators. Healthcare in the United

States will morph and change significantly over then next

decade, as reimbursement dollars shrink, and the number of baby

boomers needing healthcare peeks.

In order to meet these challenges, nursing leaders must help

nurses and other healthcare practitioners embrace the need for

change, and to adapt and incorporate best practices into their

patient care delivery. I believe that transformational

leadership theory is the best choice in applying theory into the


practice of change management in healthcare. The nursing

profession in the United States has recognized transformational

leadership as the leadership theory and style of choice.

When tasked with changing a negative work culture, the

author prefers transformational leadership with an emphasis on

shared leadership. Shared leadership is actually a component of

the transformational leadership model. Shared leadership is a

valuable tool in transforming healthcare, as this style involves

and gains the buy-in of followers. By emphasizing the shared

leadership component, leaders enable followers to be inspired to

act and to become leaders of change (Bennis & Nanus, 1985).

Members of shared leadership teams have the opportunity to

become role models for professional and organizational values

(Kouzes & Posner 2003). Transformational leaders persuade

individuals to rise above their own biases and desires; and

multiple leaders within the shared leadership team can provide

the same persuasion to their peers (Hutchinson & Jackson, 2013).


The author is leading change within a hostile and toxic work

environment, where there exists fear and negative push back from

informal leaders of cliques who resist change, and who actively

lead and seek to protect the status quo. Values within a

workplace create the culture or work environment. Employee

behavior is a primary influence on culture (Marinova, Dyne, &

Moon, 2015). When a new leader challenges status quo this can

be perceived as a threat to the informal leaders of a

dysfunctional work group (Morrison & Phelps, 1999; Marinova et

al., 2015).

Nursing leaders have the role of motivator and generator of

inspiration, while also having accountability for patient care

standards. Some decisions will be unpopular. Relationships

with followers can be built and maintained through fair and

consistent leadership. Rolfe (2011) recommends treating

pessimists with respect and compassion, while moving forward

with the majority to accomplish traction with work and


attainment of vision. “The naysayers can stagnate without input

into their future, or they can join forces, making the group

even more powerful as they move toward the vision” (Rolfe, 2011,

p. 55). Morale in the work environment can improve when there

is no blame, and followers can express their

concerns and desires. Follower collaboration and involvement in

implementing improvements can increase morale. Transformational

leadership and evidence-based management to improve patient

safety can be accomplished in ways that satisfy follower’s

values (Page, 2004).

The writer believes that transformational leaders should

emphasize and deploy shared leadership when working as a change

agent in a challenging environment—and where the change is vital

to obtain safe and optimal patient care. In complex teams, such

as the charge nurse team in the writer’s surgical department, it

is difficult for one leader to implement all of the necessary

functions. By involving and including the charge nurse team in


a shared leadership model, the author will be able to

successfully accomplish change, for a number of reasons.

First, by using the shared leadership model, trust in the

leader and ownership of the initiative would be obtained from

charge nurses and followers. The charge nurses possess

historical data relevant to the organization and the individuals

within the department, making it easier to maneuver the

political landscape. Second, this would allow an opportunity

for the charge nurses to grow and develop—both individually and

as a team. Possible improvements include building a

relationship of trust between the leader and the charge nurses,

from charge nurses to the leader, with improved teamwork and

trust between charge nurses. The relationship of trust between

followers and the leader would be enhanced, as well as improve

the professional perception and respect of the charge nurses by

staff (Carson, Tesluk, & Marrone, 2007, p. 1217).


The author is developing a model that visually expresses the

desired changes and characteristics brought about by

transformational leadership with strong utilization of shared

leadership means such as: shared leadership teams, nursing

practice councils, and shared governance. At the focal point of

all actions and initiatives, is patient-focused care. The

opposing force is lead by dysfunctional or weak nursing leaders,

where informal leaders and cliques manipulate and manage the

operations of the nursing unit. This group of opposition

includes disengaged and toxic employees, who focus upon their

own individuals versus the needs of the patient. These

individuals cause loss to the organization in terms of lost

revenue, waste, property damage, horizontal violence, patient

errors, safety violations, billing errors, and recruitment costs

of nurses related to high turnover in a toxic environment.


Traci McGee, 2015

Conclusion

Endorsements for the transformational leadership style

include the American Nurses Credentialing Center and the magnet

model, as well as the Registered Nurses Association of Ontario’.


In today’s environment of rapid change in healthcare delivery,

well-skilled nursing leaders are vital (MacPhee & Bouthillette,

2008). Transformational leadership and shared leadership both

involve teamwork and collaborative exploration and implement of

strategies that can address followers’ issues. Morale will

increase, when followers feel empowered by seeing their ideas

transformed into reality.

While transformational leadership has been widely adopted in

nursing, evidence of effectiveness related to clinical outcomes

and quality of working environment are lacking (Hutchinson &

Jackson, 2013). Attention and research is needed in order to

gain understanding of the follower’s role in the effectiveness

of leaders. In the author’s opinion, this gap in research and

understanding is emphasized in the nursing sector, where ‘nurses

eat their young’ (Hutchinson & Jackson, 2013). Nurses and

informal leaders of cliques working on a nursing unit will

defend the status quo by safeguarding formal and informal


organizational procedures; and they perceive the leader’s change

management as a lack of relational concern. The informal

nursing leaders’ motives are in conflict with the leader’s

goals, and they will demonstrate their loyalty and support of

the group and personal objectives versus accepting the leader’s

desired changes (Marinova et al., 2015).

Today many organizations are adapting to change by

increasing the use of team based structures (Hoch, Pearce, &

Welzel, 2010). Transformational leadership and evidence-based

management help nurses make practice changes related to patient

safety (Page, 2004). A patient-centered culture improves the

quality of patient care as well as the nurses’ work environment

(Hutchinson & Jackson, 2013).

Future Research

A great deal of research exists on the topic of

transformational leadership. However, a gap exists in the study

of transformational leadership and leader fairness to followers


(Bacha & Walker, 2013). Nursing teams in the surgical setting

are very task oriented, and more research on efficacy of shared

leadership on this specific group would be very enlightening

(Künzle et al., 2010). There has been little research on the

foundations of shared leadership (Carson et al., 2007). More

research is needed to examine impact of team factors in shared

leadership, such as task complexity, team size, team maturity,

demographic diversity, team member desire to lead, and

leadership self-efficacy (Bergman et al., 2012). Trust is a

critical element in predicting performance in both leadership

styles, yet available scholarly research is limited. In the

expansive globalization of the economy, research to compare the

impact of shared leadership on teams in various cultural setting

would be useful (Hoch et al., 2010).


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A Multidisciplinary Intervention to Reduce Post-Craniotomy Surgical Site Infection Rates

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