NURSING LEADERS find themselves on

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1 Nurs Admin Q Vol. 32, No. 2, pp Copyright c 2008 Wolters Kluwer Health Lippincott Williams & Wilkins Illuminating the Inner Leadership Journey by Engaging Intention and Mindfulness as Guided by Caring Theory Teresa Britt Pipe, PhD, RN Sustained, high-performance nursing leadership can be effectively guided by caring theory. While much of leadership performance is manifested by external behaviors, highly effective leaders are also grounded by internal work of self-reflection and growth. This article focuses primarily on the inward journey of leadership as guided by Jean Watson s Theory of Human Caring. Key elements of the theory are interpreted within the context of the emerging, urgent, high-stakes challenges of the current healthcare environment. The links between self-nurturance and caring-healing leadership of others are explored. Key words: leadership, self-nurture, Theory of Human Caring NURSING LEADERS find themselves on a quest for creative and effective approaches to address the perfect storm of nursing shortages of staff and faculty, growing demand and complexity of care needed by an older and sicker population, fiscal pressures, and socio-political-environmental issues that require rapid and ready responsiveness. Among others, Harrison, 1 Neil, 2 and Watson 3,4 have outlined other pressing challenges to the ethic of caring in nursing, including the issue of a dispirited nursing workforce. They have suggested possible ways of meeting the emerging issues and pointed out that theory can help guide, direct, and inspire nursing leadership in organized and systematic ways that are congruent with the disciplinary theory and science of nursing. Jean Watson s Theory of Human Caring 5,6 can be used to inform and organize leadership approaches that are From the Mayo Clinic Hospital, Phoenix, Ariz. Corresponding author: Teresa Britt Pipe, PhD, RN, Mayo Clinic Hospital, 5777 E Mayo Blvd, Phoenix, AZ ( pipe.teri@mayo.edu). intentional, effective, and uphold human dignity among those served. Leadership, for the purposes of this article, is broadly defined as behavior and ways of being that have a positive, enduring influence on those whose lives are impacted by one s presence. Part of the work of nursing leadership is to bring health and healing to individual colleagues, clinical nurses, groups, and organizations by virtue of exerting a positive and lasting influence. Self-reflection, nurture, and renewal are key strategies toward this goal. A primary focus of this article is the inward journey of leadership as guided by the Theory of Human Caring. 5 7 While much of leadership performance is manifested externally in actions and behaviors, effective highperforming leadership is rooted in the inner work of self-reflection and growth. WHY USE A THEORETICAL APPROACH? Nurse leaders are typically faced with multiple and changing priorities and operate within short time frames. The question naturally arises about why nursing theory would 117

2 118 NURSING ADMINISTRATION QUARTERLY/APRIL JUNE 2008 be relevant or useful when addressing the rapid-fire and often-chaotic challenges currently emerging in healthcare. The following simple illustration may be useful in answering this question. Imagine a car at night, departing from a well-lit parking lot such as a super shopping center or mall. The driver leaves the parking lot and enters a busy street with multiple streetlights. Soon the driver notices that several cars in the oncoming lane are flashing their headlights as they pass. Suddenly, the realization hits that the driver has forgotten to turn on the headlights and so immediately remedies the situation by doing so. Now, the dashboard is illuminated making the instrumentation panel easily readable, so that the driver can have instant feedback about the car s speed, direction, and other navigational capacities. Likewise, the road in front of the car is now much more easily seen. Communication with other vehicles is enhanced because oncoming traffic can readily see the car s approach. While driving without headlights on is physically possible, driving with them on is a safer, more efficient, and easier way to travel and ultimately reach the destination. Nursing theory can similarly illuminate nursing leadership practice. Using this illustration, engaging nursing theory is like turning on the headlights. Nursing leadership, like driving, is possible without the use of theory. However, using theory can help illuminate the internal workings of the mind and spirit, assisting leaders to see the dashboard consisting of personal thoughts, insights, and professional values. This dynamic feedback can be used to guide outward activities and adjust the course, momentum, and energy exerted on leadership initiatives. Similarly, using theory can help communicate with others by providing a common language structure, shared vision, and relationships between concepts. Others can see where you are coming from when theory is used to direct activities and make them more effective, systematic, orderly, and predictable. Theory can also, like headlights, help reach the destination or outcome safely and efficiently. ENGAGING THEORY FOR REFLECTIVE LEADERSHIP PRACTICE: AN INTERPRETATION OF JEAN WATSON S THEORY OF HUMAN CARING Many individual nurse leaders as well as healthcare systems are turning to theoretical models as a way to meet the current tensions with optimism, encouragement, and a unifying vision for how healthcare can be shaped in a way that is scientific and caring. Watson 3,4 highlights Nyberg s 8 application of the science of human caring in nursing administration and suggests the following updated and expanded responsibilities of nurse leaders and administrators 3,4 : understanding and communicating caring as a philosophy and ethic for organizational processes, structures, and relationships; developing skills of caring behaviors, caring presence in formal-informal relationships with individuals and groups; being alert and responsive to situations for modeling, creating, and articulating theoretical-philosophical ethics of caring with staff and colleagues; providing leadership in implementing and evaluating experimentaldemonstration models of caring-healing theory guided practices; promoting and supporting research on caring and healing/health outcomes; exploring relationships between and among data which document connections between caring theory guided practice models, nurse retention, patientnurse satisfaction, healing outcomes, and costs; and serving as stewards of caring-economicscosts by incorporating caring as a valuable economic resource and as the foundational ethical variable in cost-benefit ratios. In addition to these external leadership initiatives, it may also be beneficial to revisit the foundational ideas presented in the Theory of Human Caring 5,6 with the lens of internal leadership practice. An aspect of this theory that

3 Illuminating the Inner Leadership Journey 119 makes it particularly appealing to the current workforce challenges is that it encompasses a focus on nurses and nursing as well as on the care of patients. Likewise, the tenets of the theory also support self-nurturing for the leader as well as the one being cared for. The major elements are the caritas processes, transpersonal caring, and the caring moment. 5,6 Each of the elements will be presented along with interpretive statements regarding possible application to leadership practice, with a concentrated emphasis on the inner work of the leader. The following are 10 caritas processes from the Theory of Human Caring as interpreted for use in nursing administration and leadership. The one being cared for in these instances may include other colleagues, individuals, or groups being led, the one being mentored, or the student. The caritas processes can be applied to the selfcare practices of the leader as he or she turns loving-kindness and healing efforts inward in preparation for leadership. Caritas originated from the Greek word meaning to cherish, to appreciate, to give special attention, if not loving, attention to; it connotes something that is very fine, that indeed is precious. 5,6 Caritas characterizes the approach that leaders can choose to take, extending an intentional, positive regard for self and other as an essential part of cultivating a mindful, intentional leadership practice. Self-acceptance and cherishing are also important attitudes to cultivate within the spirit of caritas. CARITAS PROCESSES Practice of loving-kindness and equanimity within context of a caring consciousness. 5,6 The word practice is a reminder that the attitude of loving-kindness and equanimity is not something that can be accomplished quickly or permanently. This attitude is practiced not with the striving goal of achievement, but rather with the objective of continually becoming more conscious of how we approach ourselves and those we lead. The leadership role affords many opportunities each day to practice loving-kindness. Ideally, the attitude of loving-kindness and compassion is extended to the self as well as to others. Taking a moment to engage this attitude before answering the phone, opening the office door, making the presentation, or replying to an will help build the strength and discipline of meeting individuals with consciousness of caring. Equanimity is the quality of being calm and even-tempered. It refers to an evenness of mind characterized by calm temper or firmness of mind: patience, composure, and a steadiness of the mind under stress. Cultivating equanimity during times of relative calm will help strengthen its application during times of increased stress and tension. The leader sets the emotional tone for the group or organization, and thus can consciously make the choice to transmit calm confidence. Being authentically present and enabling and sustaining the deep belief system and subjective life worldview of self and onebeing-cared-for. 5,6 Authenticity is a key attribute that is valued and expected of organizational leaders. Research suggests that honesty and authenticity are essential characteristics that followers identify as important for leaders to possess, regardless of the age/generation category of the follower. 8 To convey a genuine and sincere sense of self, leaders must take the time to conduct ongoing self-assessments and exploration. Selfknowledge is not only a vital leadership competency but also an important strategy toward gaining a true sense of authenticity. At times, reflective activities can seem selfish, unless the links among reflection, authenticity, and effective performance as a leader are well understood. Successful leaders develop strategies to cultivate greater understanding of one s self in the context of others, with the recognition that taking the time and effort to understand one s own perspective, values, strengths, and weaknesses will contribute greatly to achieving meaningful goals and fostering a heightened sense of interconnectedness with those who look to them for guidance and support. Reflective

4 120 NURSING ADMINISTRATION QUARTERLY/APRIL JUNE 2008 leadership practices that support authenticity may include keeping a journal of personal insights and growth opportunities, talking with trusted colleagues or mentors to glean information on performance, and cultivating opportunities for solitude and self-reflection. Authenticity requires that the leader know who he or she is and how he or she contributes to the one being cared for. While authenticity sounds very simple, it can be counterintuitive within the context of modern standardized healthcare practice to remember that each nurse or colleague brings something unique to the organization and unless the individual talents and gifts of the leader are known, they cannot be shared. Discovering one s unique sense of authenticity involves taking the time to reflect on how experiences, clinical learning, personal knowledge, culture, belief system, aspects of personality, and a vast array of other factors unique to each individual can be cultivated to help in the current leadership situation. Cultivation of one s own spiritual practices and transpersonal self, going beyond ego self. 5,6 This element of caring requires a delicate balance. Caring leadership involves tapping into the leader s own source of strength according to a personal belief system, while taking care not to assume the other person shares in these values. The leader who is able to recognize and benefit from his or her personal source(s) of strength can use this as an internal navigational guide for help monitoring and motivating outward leadership activities. Using the transpersonal self requires that the leader be able to sustain healthy personal boundaries and acknowledge yet be able to put aside private concerns, worries, and needs to care for the other. This part of the approach involves supporting the other person in their spiritual beliefs and source(s) of strength and meaning, although they may differ from the leader s own beliefs. Going beyond the ego self means acknowledging the uniqueness of each individual, and being able to rise above self-interest to consider the various perspectives of others. To temper the sacrifice of leadership and to promote resilience and high performance, the effective leader cultivates practices that actively renew and replenish, preferably throughout the day and integrated with the flow of activities that typify a life of leadership. Resonant leadership has been described as living in a state of full conscious awareness of one s whole self, other people, and the context in which we live and work. 9 Resonant leadership is supported by ongoing, frequent, and feasible practice of renewing behaviors, such as mindfulness, deep breathing, listening to music, whatever the individual leader finds most effective and reasonable to incorporate into the moment-to-moment life. Developing and sustaining a helpingtrusting authentic relationship. 5,6 The leader has the choice of framing the leadership interaction as a professional healing-caring relationship. Within this framework, the leader cultivates a caring consciousness as integral to the healing-leading process. Developing the professional relationship takes time, intention, and patience. Proper boundaries are established according to the organizational culture. The leader who is authentically, professionally present with followers sets an example for how staff members are expected to interact with patients and others. When followers have a high level of trust with the leader, they are more likely to share meaningful information and feedback that can be critical to the performance of the organization. For example, if a nurse has an idea for a clinical process innovation, he or she is much more likely to share the idea with the leader if there is a high level of trust that the nurse s thoughts will be treated with respect and compassion rather than discounted. Being present to, and supportive of the expression of positive and negative feelings as a connection with deeper spirit of self and the one-being-cared-for. 5,6 Being present to and supportive of one s own positive and negative feelings as a leader is an important first step in being able to live this caritas process within a leadership role. Acknowledging and honoring the range of human emotions that

5 Illuminating the Inner Leadership Journey 121 occur within can help strengthen the leader s performance by providing insights and empathy for others while also helping develop healthy personal boundaries. By nurturing a healthy regard for the emotions of the self and others, the leader is better prepared to meet challenges with a balanced presence. The leader recognizes that within a trusting relationship, the colleague or group will feel more comfortable with sharing negative as well as positive expressions and may voice disagreements and deeper feelings than might not otherwise be exchanged. It is the leader s role to listen to what is said as well as to develop an understanding of what is left unstated, or reading between the lines. It is a good idea to confirm or validate verbally what the leader understands from the other s expression. Possible questions to ask include, How do you feel cared for and nurtured as a professional? What are the triggers that you are not feeling cared for? How do you replenish yourself? What are your rituals for letting go of work/obligations? Sometimes being present to a colleague only requires that the leader observes and describes the behavior as it is seen. For instance, a nurse on a critical care unit described it as particularly meaningful when the manager of the unit simply described the caring behaviors that were observed. Simply noticing and acknowledging caring behaviors can be a powerful nursing leadership intervention, especially if they are also linked explicitly and intentionally with patient outcomes. Creative use of self and all ways of knowing as part of the caring process; to engage in artistry of caring-healing practices. 5,6 By taking the time to dwell within, experiencing one s own thoughts, feelings, dreams, and visions places the leader in a position of strength with a strong grounding in personal and professional values. From here, strategies and actions can be directed and executed more effectively. To do this, high-performing leaders learn to make optimal use of time, space, and rituals needed to cultivate selfknowledge and focused energy. 9 It takes time to bring intentional, creative focus to leadership practice. Questions to consider include, When are you at your creative best? When do your inner critics come to haunt? What is the link you draw among selfcare, creativity and leadership? Sometimes, it is necessary to create rituals as part of focusing on being creative. For example, when confronted by an issue or problem that requires an innovative solution, a leader might play certain music, take a walk, seek solitude, or talk with an energetic colleague. Having the self-knowledge to put together the resources and environment that support creative thinking are part of the challenge. Leaders often use creativity in ways that help them connect with staff. For example, leaders may use stories about themselves or their creative pursuits to illustrate major points during discussions or presentations with staff. Creative use of self can help build trusting and healing relationships because it may help colleagues and clinical staff relate more closely with the leader s human experience. Engaging in genuine teaching-learning experience that attends to unity of being and meaning attempting to stay within other s frame of reference. 5,6 Teaching and learning can be inward activities, as the leader seeks to grow personally through self-evaluation, reflection, and deciding how to respond to feedback from trusted others. Self-learning involves choosing new competencies to explore, selecting new opportunities for expanding skills, and garnering the resources to take the next steps. In this sense, the leader becomes the teacher and learner within one s self to become a more effective teacher, role model, and mentor for others. Leaders are also constantly teaching others, both formally and informally. Formal presentations and communication strategies can be well thought out and structured intentionally. On the other hand, informal teaching is often impromptu and occurs by role modeling and sometimes unexpectedly. Therefore, it is beneficial for leaders to carefully consider their ways of being present in situations

6 122 NURSING ADMINISTRATION QUARTERLY/APRIL JUNE 2008 that wouldn t be traditionally thought of as educational. Leaders assess the learning needs and styles of their colleagues and clinical staff and tailor their educational approaches accordingly. By individualizing communication, the leader conveys a sense of respect and responsibility. Staying within the other s frame of reference requires tuning into the audience s verbal and non-verbal behaviors. As leaders teach, they are open to new learning within themselves. Teaching provides a vehicle for information to flow both ways and not only from leader to learner. Listening is a vital, yet underrecognized part of teaching and leadership. Listening is an essential competency that involves more than the ears and hearing. It allows exploration of deeper meanings and pathways for the most successful approaches. Listening can provide a way for innovative practices to be advanced and it may prevent irrelevant work. Listening conveys caring. Creating healing environment at all levels, physical as well as non-physical, subtle environment of energy and consciousness whereby wholeness, beauty and comfort, dignity and peace are potentiated. 5,6 Leaders can focus on creating a personal workspace that is supportive of the ability to think, create, converse in private, seek peaceful energy, and support self-nurturing strategies. The purpose is to find a way to manipulate the environment in an arrangement that supports focused intentional energy and creativity. The space should be welcoming and energizing, and the ways to accomplish this are very individualized depending on the style of the leader. Even the interpersonal space of the leader becomes a tool for effective caring behaviors if the leader conveys a sense of confident equanimity and compassion with his or her physical presence. The leader works with others in the organization to create the best environment, physical and nonphysical, for healing to occur. Leaders may encourage staff to identify ways by which the environment can be improved to support healing for patients and staff. Manipulation of the environment can range from basic to more complex. To the greatest extent possible, the physical environment should be well-lit, ventilated, clean, and ergonomically supportive. Beyond that, the leader can work to incorporate elements of beauty including sources of color, movement, texture, and form to enhance the healing environment. When possible, a view of the outdoors, a change in surroundings, paintings, flowers, plants, and music can also be incorporated. It is important to eliminate or reduce unnecessary noise, clutter, and other distractions from the environment. The nonphysical environment is also important. Creating and sustaining a culture of respect and healthy communication, conflict management, and innovation is part of directing the nonphysical environment. In the fast pace of healthcare environments, there is an emphasis on acting, doing, and reacting. This focus can be positive if the strategies and decisions are anchored on what the leader knows to be what is true and right according to the needs of the organization. However, sometimes leaders find themselves reacting too quickly, and in retrospect, the actions taken may have been misdirected or misappropriated. When this dissonance occurs, symptoms can include miscommunication, a need for backtracking, errors and leaders may find themselves off course and needing to readjust. Most importantly, in haste, relationships may have been harmed and there may be fear or frustration in the very people we were hoping to inspire. 9 Doing the work of leadership and being an inspirational force require that leaders cultivate a focused, clear mind and engage others in creating an environment conducive to intentional, wellreasoned action. Helping self and others to identify dissonant and supportive behaviors is a key leadership function. Assisting with basic needs, with an intentional caring consciousness, administering human care essentials which potentiate alignment of mindbodyspirit wholeness and unity of being in all aspects of care tending to both embodied spirit and evolving

7 Illuminating the Inner Leadership Journey 123 spiritual emergence. 5,6 Self-nurturing for leaders focuses on making sure that the mind, body, and spirit are well cared for and in the most optimal condition in preparation for the challenges of high-performance leadership. Hungry, tired, mentally and physically exhausted leaders are not typically in the best condition to make important decisions and exert positive, confident influence. It is well recognized that leadership roles are inherently stressful, so preparing the body with rest, exercise, food, and recreation is vital to performance, just like it would be with a highly competitive athlete. Leaders find tailored methods of creating and renewing a relaxed but focused energy, perhaps through exercise, meditation, enjoyment of the arts, or social gatherings. The basics are simple, but sometimes not easily accomplished. It may take ongoing experimentation to find the right combination of scheduling, organization and prioritization to make true self-nurturing a reality. In addition, patterns of need change over time and so the self-nurturing practices of the leader can be a dynamic process that is adjusted and refreshed periodically. Basic needs of employees include fundamental resources such as healthy food choices in the cafeteria, clean and ergonomically supportive workspaces, and a safe environment in which to work. The leader, working within the context of the caring-healing perspective, can align needs and resources to meet these requirements with an explicit focus on caring. In addition, more attention is currently being focused on the leader s role in bringing together resources that support a healing environment for healthcare professionals. This may mean arranging for classes on stress management, employee fitness centers, childcare facilities, or the availability of quiet places for meditation or contemplation. Opening and attending to spiritualmysterious, and existential dimensions of one s own life-death; soul care for self and the one being cared for. 5,6 Leaders may be rewarded by exploring the existential dimensions of life and work as part of rediscovering the personal sources of meaning that come from work and leadership. Pausing periodically to examine what things about work and life inspire and motivate the spirit can be energizing and can reinvigorate leadership practice. Nyberg described this as, we do believe our work has a meaning beyond the concrete here and now. 10(p357) Regularly identifying and reflecting on how to best bring about the legacy, one hopes to leave can be a very informative and restorative exercise for leaders. In healthcare, the essence of the work is often high-stakes, time-sensitive, and centers on the preservation of life, health, and human dignity. During times of conflict, confrontation, or critical clinical situations, employees sometimes have serious questions or concerns, perhaps even about their own personal or professional future and what the event means for them individually. This is an environment in which patients and families often confront issues of loss and mortality, even if the injury or illness is not considered life threatening. Leaders can help staff members with difficult situations by providing access to resources such as counseling or employee assistance and by supporting programs that help professionals deal with the suffering and pain they see on a daily basis. Acknowledging the emotional work of nursing roles is particularly important. TRANSPERSONAL CARING-HEALING RELATIONSHIPS Traditionally, transpersonal caring relationship connotes the sharing of authentic self among individuals and within groups in a reflective frame. 5,6 This focus can be extended to developing and enriching the relationship with the self. The leader can nurture a sense of self-discovery, and build on it by sustaining a trusting relationship with the self. Aspects of this relationship with self include being honest internally, honoring the commitments one makes to one s self, and finding new ways to grow, improve, enjoy, and give back. By nurturing a healthy

8 124 NURSING ADMINISTRATION QUARTERLY/APRIL JUNE 2008 relationship with the self, the leader can subsequently turn the focus outward more effectively and with sustained stamina over time. Caring leadership is founded on transpersonal caring relationship and built on moral commitment, intentionality, and caritas consciousness. All parties are changed within the relationship. It is a vehicle for healing through the auspices of the relationship. The leader recognizes and connects with the inner aspect of the other through presence, being centered in the caring moment, and through actions, words, intuition, body language, cognition, thoughts, senses, and other ways of interacting and connecting with others. 5,6 Leaders can help followers understand the connections between theory-illuminated practices and specific nursing outcomes. For example, the leader is in the translational role of helping explicate the important connections among caring behaviors, transpersonal caring relationships, and patient safety metrics such as fall prevention, pain management, and safe medication administration. Knowing the individual patient and identifying patterns of health, healing and disease can help nurses prevent problems from growing and can encourage patient advocacy behaviors that are linked with safe and effective care. THE CARING MOMENT The caring moment happens when the leader and the one being cared for come together with their unique life stories and enter into the human-to-human relationship in a given point in space and time. 5,6 The caring moment can also be the moment of internal awakening and insight the leader experiences through reflective practice. There is awareness that the moment in time is transient; there are choices and actions one makes about how to spend the time, occasion, or opportunities that transcend the moment itself. On a more global plane: We learn from one another how to be human by identifying ourselves with others, finding their dilemmas in ourselves. What we all learn from it is self-knowledge. The self we learn about... is every self. It is universal- the human self. We learn to recognize ourselves in others, (it) keeps alive our common humanity and avoids reducing self or other to the moral status of object. 6 CONCLUSION Leadership practice can be illuminated by caring theory. 11 Leaders can act as translational forces, enacting caring theories by living the self-nurturing practices that support intentional, mindful leadership attitudes and behaviors. Internalizing the approaches and energies of caring and compassion toward the self can help build and guide the leader s outward influence. Exhibiting the attitudes and behaviors of caring toward the self and then toward others becomes a natural expression of caring-healing, transformational leadership. 11 Recognizing and acknowledging caring behaviors in others also help build an environment and culture of caring. As Watson points out, From this leading from the inner voice, nurse leaders emerge as spiritual warriors, leaders who are grounded in their own sense of being and becoming; their own power with others; connected with and guided by that which is greater than self or system. 11(p4) REFERENCES 1. Harrison LL. Guest Editorial. Maintaining the ethic of caring in nursing [guest editorial]. J Adv Nurs. 1990;15: Neil RM. Caring for the human spirit in the workplace. In: Parker M, ed. Nursing Theories and Nursing Practice. Philadelphia: FA Davis; 2001: Watson J. Can an ethic of caring be maintained? J Adv Nurs. 2006;54: Watson J. Caring theory as an ethical guide to administrative and clinical practices. J Nurs Adm. 2006;8(1): Watson J. Postmodern Nursing and Beyond. Edinburgh, UK: Churchill Livingstone; 1999.

9 Illuminating the Inner Leadership Journey Watson J. for University of Colorado Health Sciences Center School of Nursing. Theory evolution Available at: content/evolution.asp. Accessed May 29, Watson J. A meta-reflection on reflective practice and caring theory. In: Johns C, Fleshwater D, eds. Transforming Nursing Through Reflective Practice. London: Blackwell Science; Wieck KL, Prydun M, Walsh T. What the emerging workforce wants in its leaders. J Nurs Scholarsh. 2002;34(3): Boyatzis R, McKee A. Resonant Leadership. Boston, Mass: Harvard Business School Press; Nyberg J. Caring in Nursing Administration. Boulder: University Press of Colorado; Watson J. Leading via caring-healing: the fourfold way toward transformative leadership. Nurs Adm Q. 2000;25(1):1 6.