Leadership Perspectives with dean Margaret Wilmoth, Georgia State University
Byrdine F. Lewis School of Nursing, Atlanta, GA
By Joy Bailey, RN, MSN, PhD(c), CRRN, BC, director of clinical research nursing, Emory Healthcare, Emory University Hospital, Atlanta, GA
Dr. Margaret Wilmoth, who has dual careers in nursing academia and military service, is the recently-appointed dean of the Georgia State University Byrdine F. Lewis School of Nursing and Health Professions. This 100-year-old public university established its BSN program in 1968 and a PhD studies program in 1986. The college has recently launched a new graduate program in Nursing Leadership. I sat with Dean Wilmoth to discuss her perspective on leadership in nursing and the applicability of transformational leadership as an appropriate model for the profession.
What do you see as transformational leadership and how do you prepare students for their future role as nurse leaders, taking this concept into consideration? Do you think transformational leadership is a good model for us to have in nursing? “I think it is an essential model for us to have. The problem is, do individuals truly demonstrate strong transformational leadership skills? I think people aspire to be true transformational leaders, but I do not think there are very many out there. The one true transformational leader in nursing that I am aware of is the current surgeon general of the army—Lieutenant General Patricia D. Horoho [who assumed command of the U.S. Army Medical Command on December 5, 2011 and was sworn in as the 43rd Army Surgeon General on December 07, 2011]. She, to me, exemplifies a transformational leader based on what she has been able to do in the Army Medical Department.”
What makes you think of her as being a true transformational leader? “She is someone who has inspired many. Because of her inspirational leadership, her energy and enthusiasm, she has led major changes in how nursing and health care is delivered across the Army Medical Department and the Military Health System. There are four elements to transformational leadership: individual, intellectual inspirational and idealized influence. I think Lieutenant General Horoho mentors and inspires across the systems. She is just a phenomenal transformational leader. I think many nurses aspire to do that, but I think it’s rare that someone truly does. I have not seen that many in nursing in my career.”
Do you think that it’s something that can be taught or do you think that one has to have the basic inner core that develops a transformational leader? “I think one of the core things to be any kind of a leader in any organization is that those you lead must have trust in you. You need to respect them as well as, hopefully, those that follow you, respect you as the leader. There has to be mutual trust and respect, as well as a strong character and strong sense of ethics. I think those are some of the foundational pieces; those speak to character. Some of those character-driven components are somewhat inherent, but I think becoming a leader is certainly a skill set that can be nurtured and taught. What I think has been missing in nursing up until the publishing of the Institute of Medicine’s Future of Nursing report is the sense of intentionally developing nurses as leaders and I think that has been missing in the profession for a long time.”
It is interesting that you say that because one of the foci of the AONE has been to try to develop nurse leaders. “AONE has a relatively new unit-level leadership curriculum and then we have senior executive level leader programs like the Robert Wood Johnson Executive nurse fellows and the American Association of Colleges of Nursing (AACN) just started another senior executive fellowship at the Wharton school at the University of Pennsylvania, but there is very little in between. Also lacking is a model for leadership development in nursing that focuses on developing nurses from the team/unit level, operational level and then strategic level.”
When I looked for a course in nursing leadership because that was where I saw my career heading, it was hard to find one. I did mine at Old Dominion University but a number of colleges are starting those now. Do you see that as an integral part of leadership development? “I think an essential discussion that the profession needs to have is about how the practice environment and academia need to collaborate in the development of nurse leaders. I think that one of the key differentiating pieces between two- and four-year nursing programs is that at least the four-year has a course on leadership; but we really focus on management and there is little focus on what it means to be a leader. Nor do the baccalaureate programs tie that aspect of didactic work in with actual leadership experiences. When they are in school, we don’t really give students a chance to apply anything we do discuss related to leadership. I have taught leadership courses so I am as guilty as the next person in having a didactic course with no real leadership application in it.”
Do you think there should be a leadership focus at the undergrad level or do you think they should just be introduced at that level and, if they wish, pick up something at the graduate level later? “Students at the baccalaureate level could begin to read about leaders and examine the leadership traits that make for a successful leader. [When] you leave school and go to the workplace, what is the workplace doing to identify nurses at the entry level who demonstrate leadership capacity? What is the workplaces’ responsibility to develop them as leaders, and is that the workplaces’ responsibility with maybe adapting a curriculum like AONE has developed? And what is the role of academia at the next level? Masters programs today focus on the clinical practice or nurse practitioners for the most part and some nursing administration. There is not necessarily leadership in there.”
There are some schools that do leadership. “They are few and far between. If you look at the American Association of Colleges of Nursing and other accreditation requirements that schools have to meet, there is no leveling of the leadership skills across [educational] levels, so again you cannot compare universities. They still have to get accredited so there has to be a conversation between accrediting bodies and schools of nursing. Do we need to change curricula to be more intentional about developing leaders? What are the critical curricula pieces that have to be in it if a program in nursing is to be accredited? I think everybody is doing almost their own thing. A lot of organizations are creating this leadership experience, but what is it tied to? What is the framework that they are tied to? I think that before everybody starts to do their own thing, we need to have a dialogue in the profession about what framework we are using to develop leaders. And I do not mean [the difference between transformational and transactional, but how we are looking at leveling the development of leaders.”
So do you see colleges and universities as having an integral role in leading that dialogue? “I think it needs to be a shared dialogue between the academic, practice and professional organizational environment and the accrediting bodies because they have to be involved in accrediting. There needs to be a four-way conversation.”
So how do we start this conversation? I became a nurse leader by the seat of my pants. I just happened to have some accounting experience so I knew something about finance and I had some education in personnel management and counseling. The average nurse leader at the unit level is required to have these skills to manage budgets, counsel and mentor staff, manage customer service, all while having transformational leadership skills. Who teaches them to do that or even have an understanding of that? “You have raised a very good point. I think there has to be a discussion about this. What is the role of the academic programs in providing some basic grounding of these things you are talking about? What is the role of the workplace? Who has the responsibility of preparing someone for a leadership role before they get there so you don’t do these seat-of-the-pants learning or on the job training only. These institutions need to provide people with some preparation and clearly some continued preparation as they adapt and move into the role. But it needs to be intentional and thoughtful. And so you should not promote somebody because they are a good clinician; they may be a terrible nurse manager!”
In reading the literature, my observation is that this is exactly what we continue to do. “There are tools out there where people can have leadership skills assessed. If as nurse leaders we identify a nurse who steps forward on committees or gets involved in a professional organization, that might be someone we could tap and funnel them into something that the organization has [available for leadership training]. But the current leadership has to have some ownership in this and the organization needs to decide how they want to better prepare leaders. I think it is a conversation whose time has come and as a profession we need to have some very serious dialogue across academia, accrediting bodies, practice organizations, major institutions and professional organizations such as AONE, the American Academy of Nurses and American Nurses Association. There needs to be a conversation about what we mean by leadership in nursing and what framework we want to use to talk about it. Do we want to talk about it from the unit level, mid-management or the strategic level? That would make sense, and then figure out how we then go about intentionally preparing nurses as leaders, not this haphazard process that we have historically.”
The skill sets and roles for nurses and nurse leaders have changed, yet many hospital organizations are not looking squarely at the impact of nursing. Yet this matters so much because patient outcomes and the fiscal viability of organizations depend a great deal on nursing. “The organization’s future ability to function and meet their fiscal responsibility is dependent upon it. Unfortunately too many people just look at the physicians because they are the ones who admit patients and generate the revenue, but nurses have a role in that and I think that too long the importance of nursing in that equation, what we bring to bear in improving revenue or not, has been overlooked.”
In your opinion how or where do we start this conversation? “I think this interview is one step. The passing of the Affordable Care Act and some of the financial incentives or disincentives have prompted the conversation. Also, the Future of Nursing report has included the need to prepare nurses as leaders. This coming together of events is driving more conversations about nurses’ role as leaders. I think quite frankly, the profession has not done a good job of intentionally (and I keep saying intentionally) preparing nurses as leaders. I have a manuscript under review on this very topic, so hopefully that will get published in the near future. I think the more people who question and have a conversation [about the importance] of nursing, the more it will help.”
To circle back to the basic nurse preparation, what do you think are the core components that a new graduate nurse should be getting out of a leadership curriculum? “Typically at the entry level into nursing, the responsibility is to prepare nurses to provide basic and safe nursing care, so a bachelor’s program is not necessarily going to prepare a nurse to be a leader because they first need to be competent to provide care. It is important to remember what the goal of the foundational curriculum is all about. But I think that a basic leadership course should not be the sort of leadership and management courses that are currently taught in BSN programs. I think there should be something intentional about reading about leaders, nursing or non-nursing, and giving some more thought about what they think are the characteristics that make a good leader and some reflection about leadership skills. There needs to be application piece included. Our current model of being a team leader in a clinical setting for a few days is not effective. Maybe [there can be] some kind of online gaming-type application that students could do that gives them a way to think about clinical decisions that relate to leadership.”
I am realizing just how much as nurses we work in organizations that are really business-oriented, yet we seem to be taught little about what creates and makes a healthy and viable business organization. “Yes, I agree, but I do not think that should be in the baccalaureate level. I have not looked at the AONE curriculum, but this might be something that leaders could adapt to help develop their [nurse] leaders. I think that education needs to include more [information] about health policy and some of the realities of life in the real world. But again, the goal of education at the entry level is to prepare nurses who can practice safely.”
Let me see if I can summarize your thoughts on this. We want basic education to prepare safe practitioners, but we want them to be reflecting on what leadership is all about, what their role might be in the future and maybe how to support their own leaders? “Exactly! [Understand] how to be a follower and what makes a good employee. We never talk about that! Also, it’s important that accrediting bodies be part of that conversation. I think it is great that nursing is finally having this conversation about how we intentionally think about nursing and how we prepare nurses at varying levels of leadership responsibility. I think we now need to have a profession-wide conversation about developing nurses as leaders.”
Do you agree that the transformational style is a model for future nursing leaders? “I think that as you become more skilled as a leader, you understand that you have to use different leadership tactics and that is part of maturing as a leader; [also] reading and thinking about leadership and thoughtfully thinking about what tactics and behaviors you use in what situation. I think that is all part of developing as a leader; given the situation, you must move back and forth. Young leaders tend to be more transactional and develop their skills to be a bit more transformational as they become more skilled and experienced, but I do not think that anyone can do one category or the other all the time. As you mature as a leader, you have a broader leadership skillset.”
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