12

Lisa Little; Joan Wagner; and Anne Sutherland Boal

Let whoever is in charge keep this simple question in her head (not, how can I always do this right thing myself, but) how can I provide for this right thing to be always done?

—Florence Nightingale (1860, p. 37)

Introduction

According to the Canadian Nurses Association, “Nursing leadership is about critical thinking, action and advocacy—and it happens in all roles and domains of nursing practice.” It exists across all domains of nursing (clinical, academic, administration, research, and policy) in every setting and at various levels. Leadership can occur in formal, appointed positions or in informal roles that nurses assume. In administration, it is

about innovative and visionary administrators from the first level to the most senior nurse executives—leaders who understand and hold themselves accountable for creating vibrant, exciting practice settings in which nurses can deliver safe, accessible, timely and high-quality care for the Canadians they serve. (CNA, 2009a, p.1)

This chapter will focus on the tools and resources required to support the first-level manager (nurse manager) and builds on the ethical nursing practices and professional nursing values discussed in Chapter 10.

 

Learning Objectives

  1. Recognize the role of nurse leaders, and nurse managers in particular.
  2. Integrate the role of the professional nurse into the role of the nurse leader or manager.
  3. Illustrate the importance of examining personal, professional, and organizational values in nursing practice.
  4. Describe how the CNA’s Code of Ethics can be used in your nursing practice to deal with environmental threats.

12.1 Nursing Leadership

“Nursing leadership plays a pivotal role in the immediate lives of nurses and it has an impact on the entire health system and the Canadians it serves” (CNA, 2009a, p.1). Perhaps nowhere does nursing leadership play a more pivotal role in the immediate lives of nurses than in the case of the nurse manager. A nurse manager is responsible and accountable for the day-to-day operations of the workplace. This includes employee selection, hiring, orientation, staff development and evaluation, resource allocation and management, risk management, patient safety, and financial accountability, among others. Nurse managers are also expected to provide inspiration, guidance, and direction to nurses and other health care providers. They supervise and influence the professional practice of the largest number of frontline nurses, and by that, the largest groups of health care providers in the health system. In 2015, more than 80 per cent of Canada’s nurses worked as staff nurses (CIHI, 2016). On average nurse managers have 56.9 direct reports, with many managers overseeing over 100 staff members (OHA, 2011). Those with a self-reported wide span of control are more likely to have:

  • more than 80 staff members reporting to them;
  • responsibility for three or more units (physical spaces, which can exist across multiple geographical sites);
  • budgetary responsibility; and
  • budgets exceeding $7 million.

As such, nurse managers have the greatest opportunity to instill the principles of professional nursing in the nursing workforce. The importance of the relationship between nurses and their leaders began to be explored in US hospital studies in the early 1980s, which found that achieving Magnet status results in higher nurse satisfaction and high-performing work environments with positive patient outcomes. The Magnet Recognition Program® recognizes health care organizations that (1) transform their work environments to create a culture that values excellence in nursing care and professional practice and (2) demonstrate the ability to attract and retain professional nurses.

Nurse managers are also expert knowledge brokers. They translate organizational policy directives into action at the forefront of health care while also bringing information regarding the delivery of health care and practice requirements to senior management to inform organizational policy. In this role, nurse managers are an essential intermediary. Without nurse managers, the knowledge translation of organizational directives would not occur. However, this unique position can be very challenging. It can be demanding, trying to meet organizational demands and priorities while also managing resources to enable staff to provide the highest quality of care. Nurse managers are constantly balancing their responsibilities and accountabilities between their staff and the senior leadership they report to. Increasing job satisfaction, decreasing nurse turnover, managing a multigenerational workforce, supporting research, and meeting quality targets are among the many functions they perform set against a backdrop of continuous quality improvement and, often, fiscal restraint.

12.2 Health System Transformation

Institute for Healthcare Improvement Triple Aim Framework

Health care is in a constant state of change, often with multiple change initiatives of various scales occurring simultaneously. Some are more successful than others, but all are designed to find solutions to complex problems facing the health care system. Many of these changes are aligned with the Institute for Healthcare Improvement’s Triple Aim framework, which has as its goals: (1) improving the patient experience, (2) improving the health of the population, and (3) reducing the per capita cost of health care (IHI, n.d.) This set of goals is often referred to as better care, better health, and better value and was the framework for the National Expert Commission’s inquiry and its final report, A Nursing Call To Action: The Health Of Our Nation, The Future Of Our Health System (2012). The Commission set out to discover the most efficient, effective, and sustainable ways to meet the changing and pressing health needs of Canadians in the twenty-first century. According to the Commission,

Registered nurses are deeply engaged in system transformation because they care about human health and about delivering responsible health care. But more than caring, it is the professional and social responsibility of nurses to take a strong leadership stand on behalf of Canadians. (p. 1)

Policy- and decision-makers, spurred on by the Triple Aim framework, have recognized that a large-scale transformation of the health system is required to meet the desire to achieve sustainable and high-quality health care for Canadians.

Transformation of the Canadian Health Care System (Major Foci)

Concerns over the financial sustainability of the health care system, as well Canada’s declining health care system performance among Commonwealth countries and growing need for health care services, have prompted governments to begin to transform the system through various funding, structural, and programming policies. Seven key elements of the transformation are set out below.

Primary health care. The paradigm of care is beginning to shift to one premised on primary health care and the social determinants of health. In 1978, the WHO adopted the primary health care approach as the conceptual basis for effective health care delivery. The five principles of primary health care are:

  1. accessibility,
  2. public participation,
  3. health promotion,
  4. appropriate technology, and
  5. intersectoral cooperation.

Community. Efforts are underway to gradually shift health care services from the hospital setting to the community, with care being provided closer to home.

Delivery of health services. The nature of health care delivery is also changing. Canada’s current social policies, with a focus on marginalized populations and the recommendations of the Truth and Reconciliation Commission, require increased inclusivity, which will have an impact on the delivery of care.

Interprofessional practice. Nurses are increasingly practising within, and leading, interprofessional teams.

Establishment of professional boundaries. Participation in interprofessional teams requires nurses and nurse leaders to practise within their professional boundaries and to clearly define such boundaries to other professionals. Canadian nurses’ professional boundaries are explicitly described within their provincial legislation for registered nurses (see, for example, The Registered Nurses Act, 1988), standards and competencies documents (see, for example, SRNA, 2013). Registered nurses are also “accountable to the Standards of Practice and nursing values outlined in the Code of Ethics” (SRNA, 2018).

Chronic disease management. Chronic disease management has become a priority given the rising rates of chronic disease and an aging population. Seniors experienced rising rates of cancer, diabetes, and high blood pressure between 2003 and 2009 (CIHI, 2011). Studies have shown that high-cost users of health care represent only a small proportion of the population but consume a large proportion of health care funding. For example, “approximately 1.5% of Ontario’s population, represented by the top 5% highest cost-incurring users of Ontario’s hospital and home care services, account for 61% of hospital and home care costs” (Rais et al., 2013). Predictably seniors account for the majority of high-cost users and health care costs.

Technology. Technology, used by both health care providers and the general population, is altering the way in which people and their health care providers interact within the system. It also enables the provision of big data analytics to support evidence-informed decision making.

 

From the Field

Big data provides new opportunities to store and index previously unusable, siloed, and unstructured data for use by health care stakeholders. Analytics creates new business value by transforming previously unusable data into new predictive insights and actionable knowledge.

For more information on big data, see the Canada Health Infoway white paper titled “Big Data Analytics in Health.”

 

Essential Learning Activity 12.2.1

For more information on primary health care, watch this video titled “The Five Elements of Primary Health Care” (2:45), then answer the following question:

  1. What are the five elements of primary health care?

For additional examples of primary health care, watch two more videos and answer the questions that follow.

“Hand in Hand: Interdisciplinary Teams in Community Health Centres” (13:45)

  1. What is at the centre of interdisciplinary care?
  2. What is the health promoter’s role?
  3. How can you ensure that communication occurs within an interdisciplinary team?

“Teams Manage Chronic Disease in Canada” (5:00)

  1. Why is Ross a “lucky man”?

12.3 Leading and Managing in Today’s Health Care Environment

To lead effectively in this constantly evolving environment requires visionary, contemporary, and energetic nurse managers. “Exerting good management skills is part of being a good leader—and leadership skills are necessary for good management” (CNA, 2009a, p.2). While nurse managers must develop strong organizational and management skills, effective leadership skills are needed to navigate today’s challenging work environments confronted with human, fiscal, time, and other resource constraints. Nursing leadership is

about innovative and visionary administrators from the first level to the most senior nurse executives—leaders who understand and hold themselves accountable for creating vibrant, exciting practice settings in which nurses can deliver safe, accessible, timely and high-quality care for the Canadians they serve. (CNA, 2009a, p.1)

Various resources exist to define and shape nursing leadership. The Registered Nurses’ Association of Ontario (2013) has developed a best practice guideline on how to develop and sustain nursing leadership. Further, Huston (2008) suggests eight skills that will be essential nurse leader competencies for 2020.

Huston’s eight essential nurse leader competencies for 2020 include:

  1. A global perspective or mindset regarding health care and professional nursing issues;
  2. Technology skills, which facilitate mobility and portability of relationships, interactions, and operational processes;
  3. Expert decision-making skills rooted in empirical science;
  4. The ability to create organizational cultures that permeate quality health care and patient and worker safety;
  5. The ability to understand and appropriately intervene in political processes;
  6. Highly developed collaborative and team building skills;
  7. The ability to balance authenticity and performance expectations; and
  8. The ability to envision and proactively adapt to a health care system characterized by rapid change and chaos.

Various leadership theories and approaches have emerged over the years, in response to various contexts and societal and generational values. Leadership has become less hierarchical, less focused on tasks and more on relationships with collaborative frameworks for leadership evolving over the years (see Chapter 1). Nurse leaders, including nurse managers, must actively demonstrate the same professional, evidence-informed, innovative, collaborative, compassionate behaviour they expect of their staff nurses. This begins with clarifying their personal, professional, and organizational values. Leaders must find their own voice, then clearly and distinctively give voice to their values. Professional values can be drawn from the CNA Code of Ethics (2017a), which is applicable to nurse leaders in all domains (see Chapter 10). Nurses, including nurse managers, can find themselves in ethical distress as they try to manage and lead within an environment of constant change and resource constraint. Demonstrating ethical leadership is critical to their role as professional nurses. The next two sections outline the nurse leader’s ethical responsibilities in safe nurse staffing and in medical assistance in dying (MAID).

Safe Nurse Staffing

One of the key functions of a nurse manager is to manage resources, including budgets and personnel. Appropriate, evidence-informed, safe nurse staffing is a key responsibility of nurse managers, one that can often result in moral distress. Safe nurse staffing is critical to patient, provider, organizational, and system outcomes (Berry & Curry, 2012). The CNA and the Canadian Federation of Nurses Unions (CFNU) have developed an online, evidence-based safe nurse staffing toolkit made up of four modules. It is designed to provide nurse managers—or any nurse who has the responsibility and authority for staffing—with the knowledge, tools, and resources required to fulfill that responsibility in a variety of settings.

 

Figure 12.3.1 Safe Nurse Staffing—Nurses with Critically Ill Patient

[n.d.], “Hospital Staff Tending to Patient,” photo courtesy of the Saskatchewan Health Authority (formerly Regina Qu’Appelle Health Region) collection number 2003.8-1578, is licensed under a Creative Commons Attribution 4.0 International License.

The CNA/CFNU approach to safe nurse staffing calls for attention to be given to the following:

  • real-time assessment of patient needs;
  • nursing care delivery models;
  • staff mix decisions;
  • workload measurement;
  • quality practice environments; and
  • retention and recruitment.

 

From the Field

Ethical (or moral) distress arises in situations where nurses know or believe they know the right thing to do but, for various reasons (including fear or circumstances beyond their control), do not or cannot take the right action or prevent a particular harm. When values and commitments are compromised in this way, nurses’ identity and integrity as moral agents are affected and they feel moral distress.

See the following sites for key tools and resources related to evidence-informed staffing:

CNA’s Position Statement on Clinical Nurse Specialist

CNA/CFNU’s Evidence-based Safe Nurse Staffing Toolkit

RNAO’s report titled “Developing and Sustaining Safe, Effective Staffing and Workload Practices”

CNA’s Position Statement on Interprofessional Collaboration

CNA’s Position Statement on Patient Safety

The RN/RPN Utilization Toolkit (part of the HHR Demonstration Project in Ontario)

CNA’s report titled “Staff Mix Decision-making Framework for Quality Nursing Care”

CNA’s Position Statement on Taking Action on Nurse Fatigue

CNA’s Position Statement on the Nurse Practitioner

CNA’s Certification Program webpage

Medical Assistance in Dying

June 2016 saw amendments to the Criminal Code that made it possible for eligible persons to receive medical assistance in dying (MAID) in Canada. Canada’s nurses have a significant role in providing high-quality, person-centred end-of-life care, which includes palliative care and natural death and, in some jurisdictions, MAID. This is a key area of nursing practice in which nurses and nurse managers will draw on their personal and professional values and ethics. Nurse managers may be responsible for the operational aspects such as policy development, coordination, and management of the delivery of MAID on their unit or work setting. They may also serve as an ethical resource for their staff nurses as they choose whether or not to participate in MAID. The Canadian Nurses Association has released a National Nursing Framework on MAID that includes seven core values and responsibilities derived from the CNA Code of Ethics; these values and responsibilities are meant to be used as an initial lens through which all ethical guidance and decisions for MAID are viewed.

The framework serves many purposes including, but not limited to, the following:

  • to reinforce sound ethical nursing practice;
  • to outline the role of nurses (i.e., nurse practitioners as compared to registered nurses, licensed practical nurses, and registered psychiatric nurses) in MAID and to support nurses in their practice as they work with clients receiving MAID, as well as their families and interprofessional health care teams (in alignment with regulatory direction in relevant jurisdictions); and
  • to be a resource that supports nurse regulators, clinical nurse leaders, administrators, employers, and interprofessional health care teams in developing policies, guidelines, processes, and services that use the knowledge and skills of nurses appropriately to provide or aid in MAID.

In 2016, the Saskatchewan Registered Nurses’ Association issued a Guideline for RN Involvement in Medical Assistance in Dying, which outlines the different roles of RNs and RN(NP)s who are involved in MAID.

 

Research Note

Makaroff, K., Storch, J., Pauly, B., & Newton, L. (2014). Searching for ethical leadership in nursing. Nursing Ethics, 21(6), 642–658.

Purpose

The aim of the study was to investigate how frontline nurses and formal nurse leaders (FNLs) envision ethical nursing leadership.

Discussion

The researchers used a meta-ethnography methodology to guide their analysis and synthesis of four studies conducted with 601 participants in Canada (from 1999 to 2008) that explored the notion of ethical nursing leadership. The intent was to determine what frontline nurses in practice expect of their formal nurse leaders regarding ethical leadership, and importantly, how formal nurse leaders perceive ethical leadership. Two main themes are reflected in the four studies. First, ethical nursing leadership must be responsive to practitioners and to the contextual system in which they and FNLs work. Second, ethical nursing leadership requires receiving and providing support to increase the capacity to practise and discuss ethics in the day-to-day context. This work draws attention to the important, and somewhat neglected, need for FNLs to have organizational support in order to enact ethical leadership.

Application to leadership practice

Frontline nurses do not necessarily perceive FNL as visible, responsible, and supportive. This highlights a gap between perceptions and actions that requires more attention. FNLs may face challenges in their ability to enact ethical nursing leadership. Ethical leadership is an important aspect of creating an ethical climate in which both nurse and patient outcomes are enhanced. Yet FNLs may find themselves caught in the tension between enacting ethical obligations of the profession and working within the priorities and needs of their health care organizations and governments. Chief among these challenges is navigating the current health care environment in which values related to quality of care may be of second priority to business and market-oriented values of efficiency and cost effectiveness. Organizational resources such as vision, mission, values, and codes of ethics can be utilized by FNLs to enact the responsibilities and competencies associated with ethical nursing leadership. There is a need to focus on and develop the ethical competencies of FNLs as part of organizational leadership. A key rationale for strengthening ethical nursing leadership is to support ethical nursing practice as part of excellence in patient care.

 

The Institute for Healthcare Improvement (2017) has identified four main responsibilities of leaders to achieve safe, reliable, and effective operational excellence. These four responsibilities correlate with newer, empowering leadership styles such as transformational and authentic. One might add that ensuring value alignment also requires the application of professional values such as those found in the CNA Code of Ethics.

Guarding the learning system. Fully engaging in the work of self-reflection that leads to transparency; understanding and applying improvement science, reliability science, and continuous learning; and inspiring that work throughout the organization.

Creating psychological safety. Making sure that anyone in the organization, including patients and families, can comfortably voice concerns, suggestions, and ideas for change.

Fostering trust. Creating an environment of non-negotiable respect, ensuring that people feel their opinions are valued, and any negative or abusive behaviour is swiftly addressed.

Ensuring value alignment. Applying organizational values to every decision made, whether in service of safety, effectiveness, patient-centredness, timeliness, efficiency, or equity.

 

From the Field

Review the following CNA ethics-related resources for nurse managers:

Ethical Distress in Health Care Environments

Ethical Issues Related to Appropriate Staff Mixes

Ethics, Relationships and Quality Practice Environments

E-Learning Modules on CNA Code of Ethics (E-learning Modules, accessible to CNA members)

National Nursing Framework on Medical Assistance in Dying in Canada

12.4 Leading and Promoting Environmental Health

Visionary nurse leaders are also responsible for strengthening the presence of the determinants of population health, both internal and external to their health care organizations. The 2017 CNA Code of Ethics guides nurses in providing leadership through individual and community health interventions directed at eliminating environmental threats and improving our health worldwide. As expressed in a 2009 joint position statement put out by the CNA and the Canadian Medical Association, “the physical environment is an important determinant of health” (CNA, 2009b). Each of us has a responsibility for the environment at an individual, community, national, and international level. Health care providers can offer leadership in advocating for environmentally responsible practices and policies. Leadership and advocacy include actions such as:

  • “assessing and communicating risks of environmental hazards to individuals, families and communities;
  • advocating for policies that protect health by preventing exposure to those hazards and promoting sustainability; and
  • producing nursing science, including interdisciplinary research, related to environmental health issues.” (CNA 2009c, p. 1)

Nurses are encouraged to provide leadership in environmental health throughout all areas of nursing practice.

12.5 Leadership Development

Leadership development can take many forms including self-reflection, networking, education, training, and coaching. Many universities, including the DeGroote School of Business at McMaster University, offer health care leadership development courses and programs. The Kouzes and Posner leadership model is the basis for many leadership development programs, including that offered by the Dorothy Wylie Health Leaders Institute offered in collaboration with the CNA. Established in 2001, this unique Canadian leadership program was originally designed to strengthen nursing leadership, but has since evolved to include health care leaders from all disciplines across the country. More than 75 per cent of Institute alumni said their experience had a positive or profound impact on their personal life and career with attendance at the Institute described as a catalyst for change (Purdy, 2016).

Nurse managers have various resources available to them, including the opportunity to network, connect, collaborate with, and learn from their peers and colleagues. Networking resources include:

  • the Academy of Canadian Executive Nurses, which represents the voice of nursing leadership in Canada, offering a forum for discussion and sharing of strategies and opportunities for coalitions and partnerships; and
  • the Canadian College of Health Leaders, which is a national, member-driven, non-profit association dedicated to ensuring that the country’s health care system benefits from capable, competent, and effective leadership.

Summary

In this chapter, the responsibilities of a nurse manager and leader are examined and identified through various lenses. A nurse manager is responsible for the day-to-day operations of a workplace in addition to providing inspiration and direction to other nurses and health care professionals. Nurses, including nurse managers, may find themselves in workplace moral and ethical distress. The CNA Code of Ethics is a valuable resource to support nurse managers in demonstrating ethical leadership in situations related to safe nurse staffing, medical assistance in dying (MAID), and environmental health. Numerous resources and networking opportunities exist across Canada to support nursing leadership development. Nurse leaders— in particular nurse managers—play a key role in the immediate lives of nurses, as well as in the health care system and the health of Canadians.

Some key takeaways from this chapter include:

  • Know your own personal, professional, and organizational values.
  • The application of personal and professional values is particularly relevant in the practice of empowering, collaborative leadership styles, such as transformational leadership (see Kouzes and Posner, 2012) and authentic leadership.
  • Nursing leadership is “about innovative and visionary administrators…who understand and hold themselves accountable for creating vibrant, exciting practice settings in which nurses can deliver safe, accessible, timely and high-quality care for the Canadians they serve” (CNA, 2009a, p.1).
  • Nurse managers are in a key position to influence the professional practice of staff nurses through the creation of professional practice environments.
  • While nurse managers must develop strong organizational and management skills, effective leadership skills are needed to navigate today’s challenging work environments confronted with human, fiscal, time, and other resource constraints.

After completing this chapter, you should now be able to:

  1. Recognize the role of nurse leaders, in particular, nurse managers.
  2. Integrate the role of the professional nurse into the role of the nurse leader or manager.
  3. Illustrate the importance of examining personal, professional, and organizational values in nursing practice.
  4. Describe how the CNA’s Code of Ethics can be used in your nursing practice to deal with environmental threats.

 

Exercises

  1. Linda is a nurse manager on a critical care unit. It has been brought to her attention that it is common practice for the nurses working on the night shift to sleep in the visitors’ lounge. Linda is planning to discuss this with the nursing staff. What elements of the CNA Code of Ethics could Linda apply to inform her discussion with the nurses?
  2. Define a clinical or management issue that requires action. Assume that you have six weeks to make a difference. Create a high-level plan that demonstrates effective leadership.
  3. How is data, information, and research to inform management decision making?
  4. As a nurse manager, you have a small group of staff nurses with a keen interest in diabetes care who offer to revise the diabetic foot care policies and procedures. What actions might you take to empower these nurses?
  5. A diabetic client, living on a ranch in rural Saskatchewan, has a leg ulcer that appears to be infected. The local physician has advised her to wash the ulcer with Sunlight soap every day to dry out the exudate. You have just made a home visit to the client and you know that this treatment is not best practice for wound care. What are your next steps? Describe how your next steps fall within the professional boundaries of authorized registered nursing practice.

References

Berry, L., & Curry, P. (2012). Nursing workload and patient care. Ottawa: Canadian Federation of Nurses Unions. Retrieved from https://nursesunions.ca/wp-content/uploads/2017/07/cfnu_workload_printed_version_pdf.pdf

Canadian Institute for Health Information [CIHI]. (2016). Regulated nurses, 2015. Ottawa: Author. Retrieved from https://secure.cihi.ca/free_products/Nursing_Report_2015_en.pdf

Canadian Institute for Health Information [CIHI]. (2011). Seniors and the health care system: What is the impact of multiple chronic conditions? Ottawa: Author. Retrieved from https://secure.cihi.ca/free_products/air-chronic_disease_aib_en.pdf

Canadian Nurses Association [CNA]. (2017a). Code of ethics for registered nurses. Ottawa: Author. Retrieved from https://www.cna-aiic.ca/~/media/cna/page-content/pdf-en/code-of-ethics-2017-edition-secure-interactive.pdf?la=en

Canadian Nurses Association [CNA]. (2017b). National nursing framework on medical assistance in dying in Canada [Position statement]. Retrieved from https://www.cna-aiic.ca/~/media/cna/page-content/pdf-en/cna-national-nursing-framework-on-maid.pdf

Canadian Nurses Association [CNA]. (2009a). Nursing leadership [Position statement]. Retrieved from https://www.cna-aiic.ca/~/media/cna/page-content/pdf-en/nursing-leadership_position-statement.pdf?la=en

Canadian Nurses Association [CNA]. (2009b). Nurses and environmental health [Position statement]. Retrieved from https://www.cna-aiic.ca/~/media/cna/page-content/pdf-en/nurses-and-environmental-health-position-statement.pdf

CNA and Canadian Medical Association. (2009). Environmentally responsible activity in the health sector [Joint position statement]. Retrieved from https://www.cna-aiic.ca/~/media/cna/page-content/pdf-en/jps99_environmental_e.pdf?la=en

Government of Saskatchewan. (1988). The Registered Nurses Act, 1988. Retrieved from http://www.publications.gov.sk.ca/freelaw/documents/English/Statutes/Statutes/R12-2.pdf

Huston, C. (2008). Preparing nurse leaders for 2020. Journal of Nursing Management, 16, 905–911.

Institute for Healthcare Improvement [IHI]. (2017). IHI Triple Aim initiative. Retrieved from http://www.ihi.org/Engage/initiatives/TripleAim/Pages/default.aspx

Kouzes, J., & Posner, B. (2012). The leadership challenge (5th ed.). San Francisco: Jossey-Bass.

Makaroff, K., Storch, J., Pauly, B., & Newton, L. (2014). Searching for ethical leadership in nursing. Nursing Ethics, 21(6), 642-658.

National Expert Commission. (2012). A nursing call to action: The health of our nation, the future of our health system. Ottawa: Canadian Nurses Association.

Nightingale, F. (1860). Notes on nursing: What it is, and what it is not. New York: D. Appleton and Company. Retrieved from http://digital.library.upenn.edu/women/nightingale/nursing/nursing.html

Ontario Hospital Association [OHA]. (2011). Leading Practices for Addressing Clinical Manager Span of Control in Ontario. Retrieved from https://www.scribd.com/document/231791329/Span-of-Control-Final

Purdy, N. (2016). Impact of a leadership development institute on professional lives and careers. Nursing Leadership, 29(2), 10–30.

Rais, S., Nazerian, A., Ardal, S., Chechulin, Y., Bains, N., & Malikov, K. (2013). High-cost users of Ontario’s healthcare services. Healthcare Policy, 9(1), 44–51.

Registered Nurses’ Association of Ontario [RNAO]. (2013). Developing and sustaining nursing leadership (2nd ed.). Toronto: Author.

Saskatchewan Registered Nurses’ Association [SRNA]. (2018). What is a registered nurse? Retrieved from https://www.srna.org/about-us/what-is-an-rn/

Saskatchewan Registered Nurses’ Association [SRNA]. (2013). Standards and foundation competencies for the practice of registered nurses. Regina, SK: Author. Retrieved from https://srna.org/wp-content/uploads/2017/09/Standards_and_Foundation_2013_06_10_Web.pdf

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Leadership and Influencing Change in Nursing Copyright © 2018 by Joan Wagner is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted.

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