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Abstract the current healthcare system is slowly evolving into a new system built on a vision of health promotion, primary care and community-based home care, with hospitals still being a core pillar of the healthcare system but not its primary service. this transfor- mation requires a new approach to practice, namely, strengths-Based Nursing Care (sBC). sBC is about mobilizing, capitalizing and developing a person’s strengths to promote health and facilitate healing. for nurses to practise sBNC requires strong nursing leadership that creates conditions to enable them to do so. strengths- Based Nursing Leadership complements and acts in synergy with, sBNC. this paper describes eight principles of strengths-Based Nursing Leadership to support sBNC.
Principles of Strengths-Based Nursing
leadership for Strengths-Based Nursing
Care: A New Paradigm for Nursing and
Healthcare for the 21st Century
laurie N. Gottlieb , RN, phd professor, flora Madeline shaw Chair of Nursing, school of Nursing, McGill University Nurse-scholar-in-Residence, Jewish General hospital Montreal, QC
Bruce Gottlieb , phd project director, Lady davis institute for Medical Research, Jewish General hospital Adjunct professor, school of Nursing, McGill University Montreal, QC
Judith Shamian , RN, phd president and CEo, VoN Canada president, Canadian Nurses Association (2010–2012) ottawa, oN
SPECIAl FoCUS oN StrENGtHS-BASEd NUrSING
principles of strengths-Based Nursing Leadership for strengths-Based Nursing Care 39
After two decades of mergers, restructuring and reorganizing, the current health- care system is gradually giving way to a new healthcare system. The new system is being built on a vision of health promotion, primary care and community-based home care, with hospitals still being a core pillar of the healthcare system but not its primary service (Hancock 1999; IOM 2012). The vision also includes a system in which people and communities assume greater control and responsibility for their own health and healthcare decisions (Frist 2005).
During this 20-year period, the health of Canadians deteriorated despite signifi- cant government reinvestments following a period of severe budgetary cuts to the healthcare system (OECD 2011). Moreover, the old healthcare system, essentially a disease/illness model, became more fragmented, more depersonalized and less accessible. Both events can be attributed, in part, to nurse burnout and the under- mining of nursing and its leadership (Vahey et al. 2004). Further, the introduction of program management to address the inefficiencies of the healthcare system was accompanied by a serious decline of nursing leadership from among the senior ranks of healthcare teams.
If there is to be a transformation that puts people and communities at the centre of healthcare, we need to move to a new approach to practice and to nursing leadership. There is a growing body of literature that such an approach needs to address the importance of inter-professional practice (Gilbert et al. 2010; McKay and Crippen 2008). Within this context, we also need to consider a new approach to nursing leadership that will support a more comprehensive nursing role that will fulfill nursing’s mandate to the health of society. One such approach to nurs- ing practice is called Strengths-Based Nursing Care (SBC) (Gottlieb 2012). This approach also complements an inter-professional practice approach. Both focus on the holistic, complex health needs of people and empower them to take charge of their health and healthcare decisions.
SBC is about recognizing, mobilizing, capitalizing and developing a person’s strengths to promote health and facilitate healing. For nurses to practise SBC requires strong nursing leadership that creates conditions to enable them to do so. We call this new model of leadership Strengths-Based Nursing Leadership and Management, which embraces, complements and acts in synergy with SBC.
In this paper we propose that strengths-based leadership can lead to strong inter- professionalism and higher-quality, effective and efficient, cost-effective care, with better health outcomes. We describe some of the features of SBC and the eight principles of Strengths-Based Nursing Leadership to support SBC.
principles of strengths-Based Nursing Leadership for strengths-Based Nursing Care 41
SBC is about understanding, uncovering, discovering and releasing biological, intrapersonal, interpersonal and social strengths to deal with challenges and to meet personal, team and system goals. This new approach does not ignore prob- lems nor pretend that weaknesses and deficits do not exist. Rather, a strengths approach is about working with strengths to deal with problems and deficits. It is about working with people, teams and systems to get the most out of what is important and meaningful to them. It is about restoring the centrality of the nurse–person relationship to promote health and to facilitate healing and in so doing, enhance professional nursing practice.
SBC is a theoretical perspective to guide system transformation under one umbrella (Gottlieb 2012). This theoretical perspective
- places the person and family at the centre of care (Person/Family-Centred Care);
- empowers the person/family to achieve their own goals and find new meaning in their lives (Empowerment Movement);
- requires an understanding of the whole person and considers human unique- ness from cells to citizens to communities (Whole-Person Care, Holistic Care, Personalized Care);
- requires that issues be understood within their context, taking into account history and circumstances (Context-based);
- encourages the person to take charge of, and be responsible for, his or her own health, recovery and healing (Health Promotion and Illness Prevention, Self-Care);
- requires a collaborative relationship between the person/family and the health- care provider (Collaborative Partnership).
Just as nurse clinicians have to create environments to help people become empow- ered to take control over their healthcare, in the same way nurse leaders must create environments to enable nurses to become empowered to practise SBC.
Strengths-Based Nursing leadership Strengths-Based Nursing Care and Strengths-Based Nursing Leadership are not completely new concepts. In fact, the foundations of modern nursing are rooted in strengths-based thinking. Upon reflecting on Florence Nightingale’s approach to nursing and what made her a visionary, we see elements of a “strengths-based approach” in her thinking and in her solutions to long-standing problems. We just have to consider Nightingale’s most famous quotation, in which she sets down the role of nursing “to put the patient in the best condition for nature to act upon him” (Nightingale 1860: 133). To fulfill this mandate, nurses require knowledge of people’s innate healing mechanisms, i.e., biological and psycho-social strengths, as well as knowledge of how to create environments to enable them to heal. In tack- ling problems of public health, Nightingale used a strengths-based approach based
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on knowledge of people, their environments and the political and social structures to create policy (Dossey et al. 2005). Over the years, nursing got sidetracked from Nightingale’s vision. SBC is a way to help nursing regain its foothold in the health- care system, to move it forward and steer both nursing and the healthcare system in a new direction.
Although not explicitly identified as strengths-based, the nursing leaders who created the magnet hospitals were in effect practising elements of Strengths-Based Nursing Leadership. Before the healthcare crisis, magnet hospitals held enormous promise of what nursing could do and the impact nurses could have on human- izing the healthcare system and meeting the healthcare needs of populations (Kramer 1990). The late Joyce Clifford, nurse maverick, in her role as chief nurse of Boston’s Beth Israel Hospital, showed how to transform a system by creating organ- izational structures and work environments that empowered nurses to practise to the full scope of their knowledge, competencies and skills (Clifford 1998). Magnet hospital nursing leaders created positions and a workplace environment that gave nurses the opportunities, resources, power and status to shape and control their own practice (Kramer et al. 2007). More recently, the concepts of empowerment and transformational leadership have some strengths-based elements as their underpinnings (Laschinger et al. 2006; White and O’Brien-Pallas 2010).
Principles of Strengths-Based Nursing leadership The principles of Strengths-Based Nursing Leadership are consistent with the values underlying SBC (Gottlieb 2012). Principles are a reflection of the leader’s vision and serve as the compass to guide decisions and direct actions.
There are eight principles of Strengths-Based Nursing Leadership. Although the principles are interrelated because they are built on ideals of empowerment and equity, each has its own distinct focus.
principle #1: strengths-Based Nursing Leadership works with the whole while appreciating the interrelationships among its parts A defining quality of a leader is that he or she must have a vision. Leaders, through communication and action, impart the vision and help nurses to understand how the pieces contribute to the whole. In other words, leaders help others to “find meaning in piecemeal actions and to make those connections for others so they can see the macro level while dealing with the micro level” (McBride 1994: 284).
Leaders also understand the interrelationship between the whole and its parts. What constitutes the whole and its parts depend on the issue. For example, the whole can be the institution and its parts are then the organization’s units. The whole can also be the healthcare system or the community, while the part is then
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a decade of research, the positive and negative effects of healthy and unhealthy workplaces on nurses and patients have been well documented. Unhealthy work- place environments have contributed to high rates of nurse burnout, dissatisfac- tion and absenteeism, poor physical and mental health and difficulty attracting and retaining nurses (Laschinger et al., 2003; White and O’Brien-Pallas 2010). Moreover, unhealthy workplaces have compromised patient safety and put patients at risk for higher rates of morbidity and mortality (Aiken et al. 2002). Following these disturbing revelations, a decade of research ensued to identify characteristics of healthy environments and the organizational structures and leadership practices that made this happen (Armstrong et al. 2009). Strengths- based leaders know how to put structures in place to empower nurses to control their own practice by encouraging autonomy and positive professional relation- ships, particularly with physicians.
Another aspect of Strengths-Based Nursing Leadership is subscribing to the idea of health as a process of becoming (Gottlieb 2012). Every individual and depart- ment in an institution or agency needs help to develop and grow if they are to realize their potential. When nurses are given the opportunities to do their best and be their best, they will reciprocate in kind (McBride 2011). Strengths-Based Nursing Leadership also values creating healing environments for nurses, where nurses feel physically and emotionally safe and secure (Shirey 2006).
Strengths-Based Nursing Leadership goes beyond attending to structures. Leaders treat nurses as assets to be developed, not managed. They encourage relationships and create experiences that bring out the best in their nurses and in which nurses strive to do their best. They do so with purpose and with compassion, humility, curiosity, mindfulness and self-reflection (Gardner et al. 2011; Gottlieb 2012). Thus, strengths-based leaders “get it.” They understand that their best investment is investing in people and relationships and securing resources to do so.
principle #4: strengths-Based Nursing Leadership understands the significance of subjective reality and created meaning One of the major challenges of leadership is how best to deal with multiple perspectives. Leaders are constantly challenged to examine and entertain many different viewpoints, some that may be consistent and compatible while others that may be contradictory. Why is this so?
Humans “construct” knowledge, create their own reality, find different ways to find meaning and “dwell” in different situations. People operate from their own worldview of reality that has been constructed or has arisen from their own unique experiences, knowledge and understandings.
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The same principle operates within and across a profession and within and across departments of an institution. For example, even within the same profession, individuals and groups of individuals can hold different viewpoints and values, subscribe to different interpretations of the same event and operate from different patient care models. These differences often affect how issues are framed, deci- sions made and solutions advanced.
Strengths-Based Nursing Leadership is aware of and works with this aspect of human development to advantage. Strengths-based leaders strive to understand multiple positions, find common ground in differences and make a concerted effort to consider multiple viewpoints. They are able to entertain and hold contradictory perspectives because they understand that, often, opposable ideas give rise to the most creative and innovative solutions (Martin 2007). In other words, Strengths-Based Nursing Leadership celebrates and encourages diversity in thought because of its inherent strength in creating an innovative and exciting climate for professional nursing development.
principle #5: strengths-Based Nursing Leadership values self-determination Self-determination is the ability to choose without coercion. It is required to meet an individual’s basic needs for autonomy, competence and relatedness (Deci and Ryan 1985). These are critical strengths that define professional nursing practice (Scott et al. 1999).
People who are able to engage in self-determination are more likely to be moti- vated to do their best. This is because they experience greater freedom to act in accordance with their own values and beliefs, meet personal and professional goals, act in ways that reflect aspects of themselves and are interested in and enjoy what they do (Williams et al. 1996). Work environments that promote self-deter- mination have employees who report high job satisfaction, have positive work- related attitudes, are more effective and creative in their job and have higher levels of psychological health and well-being (Gagné and Deci 2005).
Strengths-Based Nursing Leadership creates conditions to further develop skills of autonomy, competence and relatedness by providing positive and meaningful feedback and opportunities to exercise and engage in choice.
principle #6: strengths-Based Nursing Leadership recognizes that person and environment are integral and that nurses function best in environments where there is a “goodness of fit” that capitalizes on their strengths During the past 40 years, there has been an impressive body of research into the pivotal role of nursing leadership for creating the structures and climates that foster healthy or toxic workplaces (Kramer et al. 2010; Pearson et al. 2007).
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understand the importance of dedicating resources and putting structures in place to encourage employees’ ongoing learning (Kramer et al. 2010).
Another characteristic of Strengths-Based Nursing Leadership is the ability to anticipate change and to prepare staff to be ready for change. Indeed, all organiza- tions, whether in the public or private sector, need to be able to respond appropri- ately with the right skill set and at the right time. However, while strengths-based leaders can prepare their organization and staff for change, a critical strength is knowing when it is the right time to make a decision.
principle #8: strengths-Based Nursing Leadership invests in collaborative partnerships Strengths-Based Nursing Leadership values collaborative partnership because, in almost every partnership, all partners benefit to varying degrees (Gottlieb and Feeley 2006; Zwarenstein et al. 2009). This is particularly the case when partnerships are built on negotiated goals, shared power, openness and respect. Collaborative partnership is consistent with a strengths-based approach. It is built on elements that bring to the table each partner’s respective talents and expertise to meet goals and work with purpose and intention in a meaningful way.
Collaborative partnership focuses on what each partner does best. It involves help- ing the other partner maximize his or her talents and potentials. It is an approach that engenders confidence by promoting competence. It is premised on investing in relationships and learning to trust in oneself and in one’s partner (Sofarelli and Brown 1997). Collaborative partnership requires that each partner finds his or her own voice, defends his or her position and brings evidence on which to base sound clinical decisions (Schmalenburg et al. 2005).
Imagining the Future Both the healthcare system and nursing are at a crossroad. Nursing can and should become a major player in turning the healthcare system around. Nurses can do so by providing the vision, creating the direction and leading the way. As the health- care system transforms itself, nursing faces a choice. It can wait to see how things unfold and how nurses will fit into the new system once it takes shape; or, nursing can lead the way. The profession can do so by setting forth a new vision rooted in nursing values of holism and restoring the centrality of the nurse–person relation- ship as expressed through a strengths-based approach.
Nurses and nursing are well positioned to transform the healthcare system because of their numbers, their scope of practice to carry out many roles and their ability to care for people of all ages across the continuum of care in health and
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sickness and in different settings. They have a history of inspired leadership in Nightingale, who showed what could be accomplished with vision, conviction and the willingness to challenge the status quo.
Strengths-Based Nursing Leadership provides the model to move forward and for nurses and nursing to seize the day – carpe diem. The stars are in the right align- ment for nursing and nurses to step forward and create a more holistic, humanis- tic, integrated, health-based healthcare system for the 21st century by focusing on what is best, what works and what has potential.
Correspondence may be directed to: Laurie N. Gottlieb, professor, School of Nursing, McGill University, 3506 University Street, Montreal, Quebec, Canada H3A 2A7. E-mail: laurie.gottlieb@mcgill.ca. Phone: 514-398-4164.
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