ALR
Goodwills
ALR-Reading9.pdf
Commentary
Congruent leadership: values in action
DAVID STANLEY N u r s D , M S c H S , B A N g , D i p H E ( N u r s i n g ) , R N , R M , T F , G e r o n t i c C e r t
Senior Lecturer, Curtin University of Technology, School of Nursing and Midwifery, Perth, WA, Australia
Introduction
Clinical leadership is best understood if our knowledge
and insights of it are based on a theoretical foundation
or a paradigm specifically related to clinical leadership.
This paper discusses why current leadership theory,
particularly transformational leadership, is inadequate
for helping nurses understand or develop clinical
leadership capabilities. It also outlines the new theory of
�congruent leadership� that has developed from
significant and sound research undertaken in the clinical
setting, to offer a theory that can better support and
develop nurses� understanding of clinical leadership.
Background
Rafferty (1993, p. 25) undertook a review of nursing
leadership approaches for the then Kings Fund Centre
and recommended that, �more attention needed to be
paid to leadership training, management development
Correspondence
David Stanley
School of Nursing and Midwifery
GPO Box U1987
Perth
WA 6845
Australia
E-mail: [email protected]
S T A N L E Y D. (2008) Journal of Nursing Management 16, 519–524
Congruent leadership: values in action
Aim(s) To discuss the significance of an appropriate leadership theory in order to
develop an understanding of clinical leadership. Background Leadership theories developed from management and related para-
digms, particularly transformational leadership, may be ineffective in supporting
nurses to gain insights into clinical leadership or to develop and implement clinical
leadership skills. Instead, congruent leadership theory, based on a match between the
clinical leaders� actions and their values and beliefs about care and nursing, may offer
a more firm theoretical foundation on which clinical nurses can build an under-
standing of and capacity to implement clinical leadership or become clinical leaders.
Evaluation The information used is drawn from the contemporary literature and a
study conducted by the author.
Key issue(s) Leadership can be better understood when an appropriate theoretical
foundation is employed.
Conclusions With regard to clinical leadership, congruent leadership is proposed as
the most appropriate theory.
Implications for nursing management It is important to recognize that leadership
theories based on a management paradigm may not be appropriate for all clinical
applications. Education should be aimed specifically at clinical leaders, recognizing
that clinical leaders are followed not for their vision or creativity (even if they
demonstrate these), but because they translate their values and beliefs about care
into action.
Keywords: clinical leadership, congruent leadership, leadership theories, nursing
leadership
Accepted for publication: 22 January 2008
Journal of Nursing Management, 2008, 16, 519–524
DOI: 10.1111/j.1365-2834.2008.00895.x ª 2008 The Author. Journal compilation ª 2008 Blackwell Publishing Ltd 519
and clinical leadership�. For that reason, clinical nurse
leadership has slowly become more prominent as an
aspect of nursing leadership study.
This has coincided with more research and literature
about the theories and concepts of nursing leadership
and a great deal has been achieved. However, much of
the research and literature has supported the exploration
of leadership within what Antrobus and Kitson (1999, p.
751), call the, �academic, political and management do-
mains�. Numerous studies or articles (McKeown &
Thompson 1999, Antrobus & Kitson 1999, Rafferty
1993, Kitson 2001, Beech 2002, Firth 2002, Jasper
2002, Faugire & Woolnough 2003) have focused on
nursing leaders who hold senior levels within organiza-
tions, nursing divisions, wards and/or departments.
Although clinical leadership is often mentioned, it is
rarely the subject of research because of its low status
(Antrobus & Kitson 1999) when compared with the
academic, political and management domains. For this
reason, the uniqueness of clinical leadership has
remained largely unrecognized and under-valued.
Research specifically focusing on clinical leadership is
sparse and the term �clinical leadership� is used inter-
changeably and inappropriately, alongside or in con-
junction with the term �nursing management� or �nursing
leadership� (Lett 2002). This problem is compounded
because �nursing leadership� and �nursing management� are also commonly used as interchangeable concepts and
much of the literature related to nursing leadership was
developed to support nurses in management positions or
with management responsibilities. This has meant that
literature and research to support one concept (e.g.
nursing management) has been accepted as transferable
when seeking insights or understanding of the related
areas. However, it is argued that this is not the case and
clinical leadership and management are clearly different
concepts (Stanley 2006d).
Therefore, more needs to be done to outline what
clinical nurse leadership is and frame it so that clinical
nurses can recognize it in themselves and their col-
leagues, as they work towards developing their skills as
clinical nurse leaders.
Nursing actions, assessments, plans, interventions
and evaluations of care are best instituted and under-
stood if they are based on a theory that supports their
most effective deployment. These theories offer a core
philosophical foundation and a common basis for
understanding. In many cases nursing curriculums,
health care delivery systems and patterns of care are
developed in keeping with a particular philosophical
view or conceptual framework. Nursing theories,
such as Nightingale�s Environmental Theory, Orem�s
General Theory of Nursing, Roy�s Adaption Model,
Watson�s Human Caring Theory and many others
(Berman et al. 2008), have been developed to support
and help nurses understand the rationale behind a
particular approach to patient care. Nursing theories
therefore, help nurses contextualize their practice, giv-
ing it meaning and a foundation, or a base on which
they can build their care and develop therapeutic rela-
tionships with their clients or patients.
Likewise, clinical leadership is best explained,
understood and implemented if it is based on a theory
that also supports its most effective deployment. In re-
search undertaken on clinical leadership between 2001
and 2005 (Stanley 2006a,b,c) it became apparent that
conventional leadership theories failed to adequately
describe or offer a framework within which nurses
could recognize the attributes, characteristics and
qualities associated with clinical leadership.
To really understand clinical leadership and support
nurses to develop and implement clinical leadership
characteristics, what is required is the development of a
more suitable theory. Current nursing leadership devel-
opment is based on contemporary leadership theories
and frameworks, most of which have grown from the
management domain. These theories, frameworks and
models have developed from and are best suited to busi-
ness and management functions, but appear to be simply
superimposed on nursing and clinical nursing activities.
Research into the characteristics, theories and practice
underpinning clinical leadership (Stanley 2006a,b,c)
suggested that current leadership theories may not be the
most effective or appropriate models to employ.
Leadership theories
There are a number of prominent leadership theories
identified in relation to nursing leadership (and nursing
management). These include, transformational leader-
ship, transactional leadership, authentic leadership,
contingency theory, servant leadership and others, but
to a lesser degree. Of these, the most commonly sited as
a theory capable of supporting nurses� insights into
clinical leadership is transformational leadership.
Transformational leadership is a theory where the
interdependence of followers and leaders is linked. As
such, it has found favour in care-related and teaching
fields. According to Welford (2002, p. 9) �transforma-
tional leadership is arguably the most favourable lead-
ership theory for clinical nursing in the general medical
or surgical ward setting�. Thyer (2003, p. 73) also feels
it is �ideologically suited to nurses�; Sofarelli and Brown
(1998) indicate that it is a suitable leadership approach
D. Stanley
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for empowering nurses, while the NHS Confederation
(1999) indicated that transformational leadership is in
their view, best suited to modern leadership of the NHS.
Transformational leadership is strongly connected to
the process of addressing the needs of followers, so that
the process of interaction increases the motivation and
energy of others (Bass 1990).
Transformational leadership is seen as a process that
changes and transforms individuals (Northouse 2004).
It involves emotions, motives, ethics, long-term goals
and an exceptional form of influence that moves fol-
lowers to accomplish more than is usually expected of
them, incorporating both charismatic and visionary
leadership (Northouse 2004). It involves setting
directions, establishing a vision, developing people,
organizing and building relationships. According to
Bennis and Nanus (1985) its deployment requires vision,
effective communication, trust and self-knowledge.
For these reasons, transformational leadership has
gained favour in health-related literature because it is
related to the establishment of a vision and adaptation
to change.
Clinical leader characteristics
In an extensive study of clinical leaders� attributes and
characteristics (the features that identified them as
clinical leaders) between 2001 and 2005 (Stanley
2006a,b,c), it was found that characteristics generally
associated with transformational leadership (specifically
creativity and vision) were not prominent on the list of
characteristics that followers (i.e. nurses in a range of
clinical settings) or clinical leaders identified.
This omission from the list of clinical leaders� iden-
tifiable characteristics brings into question the suitabil-
ity of transformational leadership theory to explain or
support their role and function. It also brings into the
question the promotion of transformational leadership
(Finlay 1998, Bowles & Bowles 2000, Welford 2002,
Thyer 2003) as the best suited theory for understanding
and developing future clinical nurse leaders.
However, if clinical nurse leadership and clinical nurse
leaders are to be understood and supported, identifying
the attributes with which they are associated is vital. The
characteristics and attributes identified in this author�s study (Stanley 2006a,b,c), clearly indicated that clinical
nurse leaders appeared to be chosen because they display
the attributes and qualities shown in Figure 1.
Clinical leaders were identifiable and recognized by
their colleagues because of where they stood and how
they behaved when dealing with patients and
colleagues. When facing challenges in the clinical arena
they were recognizable because they displayed their
principles about the quality of care. They dealt with
patients in a �hands on� fashion, living out their values in
the actions of clinical care. They stood apart from
novice clinicians, poor decision-makers, staff who were
�hidebound� and managers who were tied up with other
functions and those who were less visible in the clinical
environment. Many were experts in their clinical field,
but they were identified and recognized not necessarily
because of their expert practice. When faced with
challenges and critical problems, their actions were
directed, and their leadership was defined, by the values
and beliefs they held about care, nursing and respect for
others.
The study results prompted a fresh look at clinical
leadership. It was imagined that clinical leaders would
fit the description of a transformational leader. That
they would be seen as enthusiastic, motivated, creative
and visionary. They would have elaborate visions of
where they wanted care to go and their colleagues,
inspired by the clinical leader�s descriptions of these
visions, were willing followers.
Nursing has looked for, and to, leaders with their eye
on the horizon; leaders who are academically, politically
and managerially aware; visionaries who can take the
profession forward (Rafferty 1993, Antrobus & Kitson
1999). However, the research sited here placed clinical
leaders at all levels of nursing. Individuals were often not
even aware that they were identified as clinical leaders
and they were nominated specifically because of their
passion for patient care and high quality nursing, not
their vision. They were seen as motivational, enthusi-
astic and strongly connected to the process of addressing
the needs of followers and, in this sense, reflected
elements of transformational leadership. However,
clinical leadership and clinical leaders appeared at odds
with the principle aspects of transformational leader-
ship, where the transformational leader possessed an
idealized influence, inspirational motivation and a vision
of some future state (Bass 1985, 1990). Therefore, a gap
appeared to exist between the aspects identified with
Approachable and open Seen to be displaying their values and beliefs (they lived out what they believed to be important to them. They know were they stand and hold fast to their guiding principles) Effective communicators Positive clinical role models Empowered / Decision makers Visible Clinically competent and clinically knowledgeable (usually within the specific area in which they work)
• •
• • •
• •
Figure 1 Characteristics of clinical leaders.
Congruent leadership
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transformational leadership and the reality and attri-
butes associated with clinical leaders.
Results from this Stanley�s (2006a,b,c) study, where
�doing� rather than �creating� was valued, indicated that
transformational leadership may, in fact, fail to fulfil its
promise as a suitable leadership theory for nurses. Being
�visionary� was not regarded as a quality or character-
istic strongly associated with clinical leadership, and as
a result of the grounded theory research approach
(Glaser & Strauss 1969, Glaser 1992) taken with the
study, congruent leadership was proposed as a new
framework that satisfied and demonstrated all the
qualities and characteristics recognized as attributable
to clinical leaders. It also met the need of clinical nurse
leaders to be seen and valued for the often invisible, but
vital contribution they make.
Congruent leadership
Congruent leadership can be seen when the activities,
actions and deeds of the leader are matched by and
driven by a leader�s values and beliefs about (in this case)
care and nursing. Congruent leaders may have a vision
and idea about where they want to go, but this is not
why they are followed. Congruent leadership is based on
the leader�s values, beliefs and principles. It is about
where the leader stands, not where they are going.
Congruent leaders are motivational, inspirational, or-
ganized, and effective communicators and relationship
builders. Congruent leaders are often found throughout
an organization�s structure and they are commonly not
in managerial positions.
For clinical leaders, who are at the bedside, based in
clinics, community care environments, and hospital
wards and units, congruent leadership may offer a
better theoretical framework to explain how and why
they function.
Transformational leadership appears to resonate with
nurses who occupy positions assigned as leadership or
management, where they have hierarchical power, titled
positions or fulfil a leadership role as an expectation of
their job description. Change, goals and targets are built
into the post.
However, congruent leaders appear to be guided by
passion, compassion and by qualities of heart. They
build enduring relationships with others, stand the test
of their principles and they are more concerned with
empowering others, than with their own power or their
own prestige. Congruent leadership explains why and
how nurses and other non-titled leaders at all levels can
function and be effective without formal influence. A
clinical leader summed this up saying:
�Honesty, loyalty, passion, integrity, those sort of
things are probably more important… years ago
when I was less experienced I would have said
knowledge would have been oh, right up there,
but because of the way I have changed, I don�t think that this is necessarily so any more… these
other qualities out-weigh them.�
The interviews with clinical leaders, and with nurses
talking about what they looked for in a clinical leader,
indicate that not all leadership is about changing
people�s vision of the future. Some leaders lead because
they demonstrate where their values lie and are fol-
lowed because others identify with them and stand with
them. This is reinforced by the following comments:
�I think you�ve got to have respect for that person
because of the way they nurse, you identify with
them, identify with the way they nurse and agree
with that.�
�I am not only able to empathize with patients and
their relatives, but with staff as well… trying to
think ‘‘What would they be going through?’’… It
makes my ability to communicate with them
much better.�
�I think people know that I am quite passionate
about what I do and I also like to support others
to be… erm… to achieve the best they can achieve
and very strongly centred on patient care and
good standards of care.�
Manley�s (2000a,b) study offers other insights in
accord with these assertions. Manley looked at her role
as a nurse consultant leading a small intensive care team.
Her study makes it clear that she led with her values first
and was successful as a clinical leader because her values
were demonstrated for others to see. Her values were
supported and matched by her actions and this congru-
ence formed the basis for her success as a clinical leader.
Manley (2000b, p. 34) recognized that her leadership
brought about �cultural change� because her values were
used to �highlight the contradiction between espoused
culture and culture in practice�. Respondents in Manley�s (2000b) research indicated that they were influenced
more by her actions than by her vision. One said, �the
enthusiasm of the consultant nurse incited enthusiasm in
myself�. Manley (2000b) supported practitioners to
become aware of their own values and beliefs and helped
in this process by allowing others to see and recognize
her own values and beliefs, and how they supported a
change in the culture of the ward.
D. Stanley
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ibrary on [05/04/2023]. See the T erm
s and C onditions (https://onlinelibrary.w
iley.com /term
s-and-conditions) on W iley O
nline L ibrary for rules of use; O
A articles are governed by the applicable C
reative C om
m ons L
icense
Discussion
If nursing is to develop effective nursing leaders, it needs
to do so without loosing the core values and principles
that guide nursing. Congruent leadership establishes a
foundation from which all good or effective nursing
leaders can start, because it grounds the leaders princi-
ples within the core values of the nursing profession and
ensures that the dominant cultural narrative of nursing is
one of patient-centred care, with nursing values and
care-centred attributes placed ahead of those associated
with the dominant groups of managers and physicians.
Transformational leaders, in an effort to achieve their
vision, may at times move from positions of influence
and power to positions of control, in an effort to achieve
their goals. Unwittingly, in doing so, they run the risk of
loosing their connection to their core values and guiding
principles, or at best become embroiled in a state of
conflict as their managerial (controlling) demands con-
flict with their professional, and often personal, desire to
remain focused on patient care.
Congruent leadership is not power neutral and the
power of congruent leadership comes from unifying
groups and individuals around common values and
beliefs. This is not a strategy as such, but the results
from the research (Stanley 2006a,b,c) appear to
demonstrate that nurses seek out or follow clinical
leaders who are more inclined to display or hold
values and beliefs that they themselves hold. Manley
too, found that as she displayed her values and beliefs
others began to share them, and the clinical area
united as colleagues began to identify with the com-
mon purpose of �providing patient centred care� (Manley 2000b, p. 38). One of the statements made
by a participant in Manley�s research supports this by
saying, �sometimes I feel like an evangelist trying to
spread the word to other people in other areas� (Manley 2000b, p. 37).
In relation to transformational leadership, power and
influence arise from being able to articulate a vision
that is accepted and acted upon by the majority of the
followers. The leader is held in high regard because
they are trusted and because their own self-belief is
evident. Change is the goal and as the new vision is
worked towards the leader is able to take the followers
forward. In relation to congruent leadership, the
leader�s power and influence is derived from being able
to articulate and display his/her values, beliefs and
principles. Followers and others recognize or align
themselves with these same values or beliefs. This
supports and promotes these values and beliefs,
increases the leader�s credibility and worth, and
promotes the significance of �this� leaders values and
beliefs over any others. Change, although often not the
intention, results when new values and beliefs are dis-
played, promoted and then adopted.
Understanding and promoting clinical leadership
depends on grounding nurses� insights in a theory that
nurses can identify with and relate to. It is argued here
that clinical leaders employ congruent leadership as it is
based on their ability to live out their values and beliefs
in their actions, on being approachable and open,
because they are effective communicators, positive
clinical role models, empowered decision makers,
visible in clinical practice and are seen as clinically
competent and clinically knowledgeable.
Conclusion
Theories are vital if common understanding is to
prevail. They act like foundations on which
understanding, explanation and implementation are
built and in the case of clinical leadership, it has been
suggested that contemporary theories of leadership, in
particular transformational leadership theory, fail to
offer a foundation capable of supporting and building
nurses� understanding of clinical leadership.
It is proposed instead that the successful development
of clinical leadership rests on the development of the
theory of congruent leadership, that is based on leaders
who respond to challenges and critical problems with
actions and activities in accordance with (congruent
with) their values and beliefs.
Implications for nursing management
• It is important to recognize that leadership/manage-
ment theories developed for management and busi-
ness may not be a �best fit� for clinical nursing practice
and clinical leadership.
• More attention should be paid to how to promote
leadership education aimed specifically at clinical
leaders at all levels of an organization and make the
educational content specific to the learners/practitio-
ners (i.e. include congruent leadership).
• It is vital to recognize that bedside leaders (in clinical
practice) are followed not for their vision or creativity
(even if they demonstrate these), but because they
translate their values and beliefs about care, nursing
and respect into action. They can be the heart of an
organization, ward or unit and they need their
managers� support and understanding to remain
focused on their values.
Congruent leadership
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iley.com /term
s-and-conditions) on W iley O
nline L ibrary for rules of use; O
A articles are governed by the applicable C
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