TRANFORMATIONAL LEADERSHIP: MAKING INFORMED CHANGE
This continuing nursing education activity was approved by Montana Nurses Association, an accredited approver by the American Nurse Credentialing Center’s Commission on Accreditation.
There is no conflict of interest from anyone in position to control content of the learning activity.
In order to receive an award letter (certificate), learners must read the article in its entirety, answer any critical thinking problems/essay questions on their own, complete the Continuing Nursing Education Contact Hour Request Form, and pay the required contact hour fee.
Expiration date: 11/6/2020
LEARNING OUTCOMES REPRESENTING SUCCESSFUL COMPLETION (GOALS)
1. Introduce the concept of Transformational Leadership
2. Differentiate between leadership and management
3. Identify components and challenges of the change process
4. Identify the qualities and expectations of leadership
5. Present the concept “It All Depends”
Key Words for Application
5. Nurse Residency Program
6. Nature vs. Nurture
7. Autocratic vs. democratic vs. Laisse-Faire
8. Problem Conquering
15. It All Depends
Why Be Concerned Regarding Change?
Change, as such, occurs everywhere, to everybody and everything, every day, and in every situation! This forever-changing happening is one of the thermodynamic laws of the universe called ENTROPY. Even though there is sometimes anxiety, fear, and/or frustration in the ever-changing need for a new learning process that must accompany these natural occurrences, we must be watchful to the need for this evolution and have the knowledge to make informed change.
Why Do Employees Appear to Resist Change?
Job performance predictability for employees is often comforting. Therefore, it is natural for employees to:
1. Question why the change is necessary
2. Question what impact the change will make on their job role
3. Question the amount of change required
4. Question the personal support of administrators to make the change
5. Question the loss of their job due to the change
These questions often bring new job change resistance. Being aware of employee possible resistance means that increased communication with employees must occur when employees are experiencing a change.
Your role as an administrator includes the following:
1. Be empathetic regarding the stated (or non-verbal) evidence of fears
2. Be there for employees as they integrate change into their work life
3. Be vigilant and patient with employees as to their acceptance and evolution of behaviors that will bring about a needed change
Using Transformational Leadership Concepts to Encourage Change
No matter how the facility/organization carries out a nursing quality control program for the purpose to analyze and carry-out change, the process will result in what is known as a transformation. This change process is suitably named in theory as Transformational Leadership. The “leadership” portion of the title indicates the change process occurs as a democratic or group process.
Transformational Leadership Theory provides a theoretical change process (different in title and emphasis from other theories of leadership) allowing the change transformation to attain the highest level of nursing practice and, therefore, support the facility/organization in maintaining quality care standards, including the requirements of accreditation.
Basic Rules of Transformational Change
The basic rules of a successful change process require the following:
1. Get it right the first time
2. Accept the fact that there will be resistance
3. If there is resistance, identify the root of the resistance
4. Identify resistant leaders or managers
5. Identify supportive front-line leaders or managers
Your approach has to do with the size of the organization, extent/degree of the change process, and the support of the leaders/managers of the area in which the change is expected. You, as an administrator, have at least two choices of approach to start the change process. The two choices (according to the situation) is to “sell” the change process to the front-line administrators (managers, senior leaders, middle managers, and front-line supervisors) first for the purpose of support or have an entire group process to identify needed changes/problems.
If the facility/organization is of substantial size, the problem identification, resolution, and support for change and minimizing resistance is usually best achieved by first “selling” the change to front-line administrators usually known by title or job description as managers, senior leaders, middle managers, and front supervisors. (Do not first try to use project managers, human resources, or organizational development specialists.) The reason is that the front-line administrators are closest to the “frontlines” that will reflect the needed change, know the related problem(s), reason for the change, and understand that their support is required and commitment is expected to instigate successful change. If there is resistance at this level of administration, the resistance to change must be resolved before the facility/organization continues with full incorporation of the intended change.
If the facility/organization is small by your definition, the problem identification, resolution, and support can often occur through a total group participative activity using the process stated in this document (under another section) as “Problem-Conquering”. However, and depending on the situation, informing and accepting the initial feedback from managers, senior leaders, middle managers, and front supervisors as a preliminary effort of introducing change is considered, usually, to result in the most successful change process.
By the way--there probably is no better way to determine the job suitability of front-line administrators than to experience their personal response to supporting the need for a change! Expected positive involvement and support should be a part of every front-line administrator’s job description.
Selecting Transformational Leadership and/or Transformational Management
There remains a reality and predictive health care need for occasional transformational change. It could mean assisting a nurse(s) to transition their learning, skills, and behaviors in a direction for augmentation of current skills and knowledge or introducing a completely new set of nursing knowledge, skills, and behaviors. Overtime, this recognition of the need for a broad spectrum of multifaceted nursing abilities/skills have required and/or encouraged some cross-training as a necessary component of change for the survival of quality and economics of a health care system’s survival! Cross-training helps to accommodate entropy. There is often, also, a need for change in order to learn new information and skill or to meet a nurse’s personal employment needs. This means there is a need for a teaching, mentoring, coaching, or a preceptor to be sure that the cross-training is correct and timely. All change processes require support in at least one of these support systems to effectively enable nurses to add an area of nursing expertise to current nursing knowledge, skill(s), attitude. and/or behaviors.
A mentor, coach, or preceptor, by title, is a counselor, teacher, or advisor. To be such a person requires that there is the ability to recognize and appreciate existing skills as well as identify deficits between current nursing employee talents, availability of nurses to provide care, willingness of nurses to learn, and the administrative nursing expectations of the facility/organization.
Some health care facilities/organizations have a Nurse Residency Program which, as a part of this supportive change program, include as a part of the program a mentoring, coaching, or an assigned preceptor. A Nurse Residency Program is usually committed to providing a comprehensive knowledge base and/or skill. It is often used as an in-facility/organization introductory educational program for new nursing graduates, nurses returning to work after being away from the nursing profession for a significant period of time, or any nurse transferring to a nursing position requiring a different set of nursing leadership, management, or technical skills. The residency program is a safe opportunity for nurses to experience new and existing nursing practice and protocols. It is intended to be a predetermined facility/organizational program designed for nursing success as well as increasing a nurse’s ability and requirement to set personal professional goals and self-assessment toward personal attainment of these goals. The management or leadership requirement as a part of this program for support and change is a result of a professional and administrative agreement that appropriately meets the needs of all concerned.
The willingness and attitude of new or returning nurses to actively participate in this program enlightens administration as to the nurse’s extent of commitment to personal and professional growth and the extent of a positive attitude regarding new learning processes.
If someone is to be the mentor, coach, or a preceptor for the purpose of teaching the needed change, is there an acceptable basic process of decision-making that supports acceptable positive outcomes? Absolutely! For each change process required, there is a decision-making choice of using:
1. a democratic change process in which employees are actively involved in the change process (known as “leadership”) (or)
2. an autocratic change process in which employees are not actively involved in the change process and, instead, are told what to do (known as “management”) (or)
3. a more undefined and personally creative process of “laissez-faire” in which employees are given little to no involvement or direction regarding the change process. (known as a do-it-yourself or self-help model)
There are times when a nurse administrator must determine which role to perform—manager or leader, as each has a role to play in the change process related to nursing practice. Management and/or leadership behavior --- ISN’T IT SOOOO TRUE: YOU KNOW LEADERSHIP AND/OR MANAGEMENT WHEN YOU SEE IT, AND EVERY FACILITY/ORGANIZATION REQUIRES BOTH!
TRANSFORMATIONAL MANAGER TRANSFORMATIONAL LEADER
Role : Controlling, eliminating, detailing problems VS. Leading, Directing, Changing
Direction : Maintaining direction, Doing things right VS. Supporting direction, Doing right things
Risk : Minimizing (e.g. Risk Management) VS. Willing to take appropriate risks
Action : Reacting to problems VS. Proactive to prevent & solve problems
View : Today’s concerns VS. Tomorrow’s outcomes
Appeals : Head appealing (intellectual) VS. Heart appealing (Comforting, Caring)
Response : Subordinate related (You versus me) VS. Follower related (Togetherness)
The chosen method(s) of transformational leadership behavior(s) (democratic or autocratic) will depend on the existing situation, the ability of the nurse required to make the change, the needs of the health care facility, and other pertinent considerations.
Management Skills --- An Authoritarian Approach
Management involves generating efficiency and meeting financial or non-financial objectives. Managers are concerned with directing, telling, and controlling others to reach goals. Even though management and leadership, by definition and behavior are different, many leaders must perform both leadership and management roles. That dual role is not good or bad, it just says that the person doing the directing, telling, and controlling knows the difference and can separate the two behaviors to work in his/her advantage as well as those he/she serves. Let us remember, too, that people receiving direction are different—some need to be told what to do (managed) and some need to be allowed to help in providing direction of other less enthusiastic and productive persons.
Leadership Skills---A Democratic Approach
Excellent leaders do not present themselves in flocks—they present themselves one at a time by exhibiting charismatic caring abilities for other employees. They motivate others to tackle tough problems through employee participation in the pursuit of improvement and productivity. Employee involvement, active discussions, and aligning people toward a higher direction of performance occurs under the direction of a true leader.
Leaders are sometimes known as “risk-takers” who make the work-place better through creative ideas and activities. They are concerned with achievement through consultative methods with employees to determine facility/organizational success. Often, a leader is seen as brilliant in the use of his/her imagination in the effort to meet goals.
Many people question whether this unique leadership ability through effective leadership of others is a product of either nature or nurture. That is, some believe the qualities of a good leader are in place and recognized naturally in a person’s early twenties (nature) and others believe it is learned behavior (nurture). Whatever it is or whatever you believe, a great leader with leadership talent is a gift to every facility/organization and, consequently, a gift to every patient/resident within a health-care facility.
Dacher Keltner, Ph.D. at University of California, Berkeley, says that the right to leadership power comes from others who allow a certain person (leader) to have and use a given type of power. This is a democratic process that gives permission to a leader by followers to direct others while showing empathy and kindness toward others. This quality of empathy and kindness allows a person to reach out to others, listen to others, relate effectively to others, and have others share their concerns.
Keltner reminds leaders that research shows that without a constant personal effort and encouragement by others to continue to empathize and relate to others, the leader, over time, often loses leadership power. Overtime there is lost ability to recognize the emotions and needs of others; therefore, the leader that was initially empathetic and kind to others often becomes increasingly self-serving. The leader will, then, be less generous and will empathize less with others. Without the empathetic and kind skills, democratic leadership responsibilities, he says, decrease resulting in several obvious changes in leadership behavior, such as:
1. A decrease in effective personal leadership behaviors
2. An increase in promiscuity evidenced by individuals brought together in a casual, irregular, mixed-up, inappropriate, or jumbled manner
3. A lessening in their concern for others
4. Less sharing, empathy, and caring regarding the individuals he/she is assigned or allowed to lead
By leaders and their constituents being aware of the researched findings of leadership “progressive failure propensity”, education regarding this propensity and forceful insistence of a leader’s democratic behaviors or return to empathic and kind behaviors can be enforced and required by others.
The requirement of empathetic and kind behaviors can and should be a part of job descriptions, evaluated at regular intervals, and reprimanded or rewarded as the situation warrants. Therefore, choose leaders who have a natural tendency to empathize and show kindness toward others. The democratic leadership power to involve, empathize, and show kindness to others is the definition and hallmark of true leadership!
Lord Acton (1834-1902) made this profound and remembered statement ---“POWER CORRUPTS, AND ABSOLUTE POWER CORRUPTS ABSOLUTELY!” Then, John Steinbeck (1902-1968) countered that comment by saying that “POWER DOES NOT CORRUPT, FEAR CORRUPTS!—PERHAPS A FEAR OF THE LOSS OF POWER.” According to Robert Caro (born 1935 and a famous American Journalist of U.S. political figures)---"POWER ALWAYS REVEALS!” (In case you need help determining two “revelations”, consider the willingness and ability to use effective leadership skills that produce positive outcomes!)
Think of Rudy Giuliani and his known preparedness and effective use of others before, during, and after the bombing of the 1993 World Trade Center and the many other great leaders such as, Alan Mulally (Ford Company), and Abraham Lincoln during the Civil War. If we could identify just one thing that a few great leaders did and their thinking to produce their leadership success, we would “have it made by recognizing the involvement of others.” The truth is, there is not just one “thing” that made these leaders great; however, they were personally prepared FOR ANYTHING AND EVERYTHING, they effectively and appropriately used the resources around them (particularly people), and were flexible in meeting the current needs of the masses. They responded to the presented situation(s) in a true leadership form and involved the people around them to get the job done. Get the message?---The help and involvement of others, in most cases, produces success. Even Michelangelo had at least 16 others to help him paint the Sistine Chapel.
A democratic process allows group democracy to exist. It is based on the premise that everyone in the group under a leader’s direction has equal rights and they are allowed to participate creatively in decision-making.
Thinking of ways to allow and encourage group democratic processes in leadership requires some creativity! It must be contemplated, planned, deliberate, and INTENTIONALLY COHESIVE---and often quietly and carefully contemplated in order to encourage group involvement and democratic participation. Not only is group participation important, the actual feeling by each participant as a cohesive part of the whole is important.
If you are expected to lead (not manage, by definition) a group of people, there are probably specific and usual ways that are already expected and ongoing of the group/people you lead. Perhaps you meet at a certain time on a certain day, follow an agenda received on a certain day, sit at the same spot at every meeting, and listen to the same person reiterate the same expected categories of information. Hold on! You can do BETTER! Interrupting the USUAL gets and keeps group attention. However, every “better” meeting starts with a cohesive, supportive, or message of appreciation.
OK—so every situation is different! The following creative leadership suggestions are just—thinking out of the box! So—maybe:
1. Have a meeting in a different place that requires mingling socially.
2. Teach another co-worker how to conduct the meeting and the expected process. Let that person conduct some or all of the meeting. (good way to identify abilities of employees).
3. Do something to show and encourage group cohesiveness (i.e. sing a song that everyone knows, say together the allegiance to the flag, have someone repeat the shared mission and goal of the facility/organization, hold hands and say something together, distribute the same handout or gift to everyone, have officers or administrators sit among the other employees, wear name tags with the same name of the organization followed by their name, ----whatever! The message is “We are all in this together!”
4. Let people express their concerns, desires, fears, likes, dislikes, etc. related to the purpose of the meeting. DO NOT INTERRUPT a person’s verbal contribution (within reason). Always recognize verbally the first person who gave “birth” to any original positive contribution (not, necessarily, who elaborated on it) and thank them in front of the entire group for their positive contribution.
5. Have a given amount of time per verbal contribution. A time clock with a ring/buzzer per each person’s verbal contribution allows input from any/all participants. Some groups pass a baton to the person who now “has the floor.”
6. Award/reward participants that are fully recognized by the entire group to be deserving of the recognition.
7. Provide name plates around the table requiring facility/organizational administrative staff to set between/with other non-administrative employees.
8. Offer a collective toast by the raising of glasses to a common goal or accomplishment.
9. Have a mentorship program for new employees to encourage the sharing/learning of specific information or skills.
10. Use creative problem-solving group activities of your own choosing.
This group process is important to support the democratic process of the group. As you can tell, the purpose is to provide a sense of shared comradeship, cohesiveness, and participation for the common good of the facility/organization.
Leadership Through Group Problem-Conquering
One thing about human nature is that we all know when something “works” and when something does “not work” and, consequently, what needs to change. However, the ole adage of “not throwing the baby out with the bathwater” (sort of speak) applies! So—we must start with WHAT WORKS SO MAYBE WE CAN KEEP WHAT WORKS!
The process of determining “what works” comes from the people who “work.” First, we assess the good (leave out the “bad” for now) to start employee involvement in a change process. Maybe, this means exploring what makes an involved employee’s job “great” or “good” and what do you love about your job? Nevertheless, it sets a positive tone of administrative caring that says—“Let’s recognize (together) all the good we do and build on this to make it even better and more rewarding!
To determine the need for change requires bringing together as many employees of choosing in the same room who do similar jobs—nurses, perhaps, or administrative personnel as a starting point. Fill the room with enthusiasm and light talk about the wonderful philosophy, goals, and attainments of the facility/organization to that point in time. People love to hear about their success and how they do/are contributing to the success of their facility/organization. Read the philosophy and goals of the facility/organization out loud to the entire group. You could even serve refreshments and maybe give selected nurses awards/rewards for their special positive contributions to the philosophy and goals of the facility/organization. Get the picture—everyone in the room has now been reminded of the expected path toward success. There should be a positive feeling about their role toward supporting a successful health care facility/organization.
Now that you have everyone’s attention—take an opposite approach and have the entire same group in the room identify what the facility/organization needs to do to improve and become even better. List all of these verbal contributions on a board or flip chart. Take note that the main problems of concern are, usually, stated first. Once the list has been completed regarding all the “things” that they consider problems, ask the group to vote for the two least problematic concerns they have identified. Continue the voting and removing the least problems from the list until only two or three problems remain.
The two or three problems left (after the voting and removing from the list the least problematic concerns) are known as the MAJOR PROBLEMS. The purpose of the process is to reduce the number of stated problems to just a few.
Once just a few identified major problems remain as an outcome of voting, proceed to another board/chart and use this same group to identify how they see themselves, individually or as a group, resolving each major problem.
Now—use the input from this same group on how they, individually, (employees of the facility/organization) plan to assist in the resolution of the major problems. Try to incorporate, encourage, and document personal comments of their intended involvement to solve the major problems. In other words, establish a PLAN.
Write the plan on the board. If a person(s) is (are) accepting responsibility for helping to solve a specific major problem(s), write that person’s name on the board indicating what he/she will be doing to help resolve each major problem. This personal commitment by individuals in a group setting increases accountability. Set up another meeting time to discuss and evaluate progress and possible outcomes of the existing plan.
SOMETHING VERY INTERESTING USUALLY HAPPENS WHEN THE MAJOR PROBLEMS ARE IDENTIFIED AND RESOLVED. IN REVIEWING THE INITIAL/PREVIOUS ALL-ENCOMPASSING LONG LIST OF PROBLEMS, IT CAN BE NOTED THAT ALL OR MOST OF THE PROBLEMS ON THE BEGINNING LONG LIST OF PROBLEMS WILL BE RESOLVED AFTER RESOLVING THE IDENTIFIED MAJOR PROBLEMS.
Choosing to be Autocratic or Democratic— IT ALL DEPENDS!
Contingency Leadership Theory provided the elusive theory of IT ALL DEPENDS. With this freedom comes leadership or management decisions that are determined by the concept of IT ALL DEPENDS. The concept of IT ALL DEPENDS says that choices of leadership and/or management behavior can be a mixed-bag of administrative behaviors—and IT ALL DEPENDS. It reminds administrators that administrative decisions and responses cannot be predictable, but, must arise from the current needs of health care situations and health care economics. We, therefore, enhance the accuracy of administrative decisions if we accept that our decisions regarding the need to instigate a change fluctuate with the need at the time. The determination for the need for change requires watching, listening, and responding appropriately and timely, as is needed, to the unpredictable changing needs of patients and nurses.
We often attribute a facility’s/organization’s success or failure to the decisions of top leader(s) or manager(s)---usually known as the CEO. If you ask yourself why they were successful or why they failed---well, IT ALL DEPENDS! The Contingency Leadership Theory (recognized by several theorists) endorses that decisions are contingent on internal and external forces; therefore, administrative success is not dependent on one factor, but a result of considering the entire dynamics of a situation and making the appropriate and correct decision!
The attributes for success are related to knowing when to make quick decisions (in the case of emergencies), when to teach staff how to lead, and when to incorporate others in the problem-solving and supportive roles of decision-making. To the novice, it can be seen as a confusing role as the leader changes from what is historically perceived as demonstrating democratic administrative behaviors (usually conversing, listening to others, and involving others in decision-making) to more autocratic behaviors (usually telling and controlling others) in a more management style. Conversely, it can be just as confusing to some observers as the manager changes to a leadership style. The goal is to get the job done!
Democratic processes of groups/councils/boards are often used by leaders/directors for a well-known process of group assessment, goal setting, planning, implementation, and evaluation. Through their gathering of information as an outcome of this group process they, too, make recommendations and suggestions related to the concept of IT ALL DEPENDS. However, and even though democratic solutions and processes are allowed and encouraged, the final acceptance and enforcing of recommendations and suggestions will always remain with the leader/board director. What shall we call that?—how about, THE BUCK STOPS THERE (with the leader/board director).
For us, as nurses practicing in a humanistic and caring profession, we should understand that every leadership position brings new challenges and the ongoing need for different and varying leadership behaviors—and, often times, an emergency demands management directions—immediately! This requires an administrator to be prepared for just about anything—birth, death, nursing differences and personal needs, accreditation expectations, disasters, scheduling, meetings, different geographical areas to care for different patient needs and desires, and psychological and physical needs of everybody—need I go on?! This is why effective flexible nursing administrative behaviors (leadership or management) occur (and are often “unpredictable”) because administrative behavior is determined by the concept of, IT ALL DEPENDS!
Conversely, another widely-read business consultant says that this is a time (today) of chaos with numerous variables that can cause easily the demise of a business. Therefore, this business consultant says that true leadership is mainly an autocratic behavior (not democratic). With this philosophy there is no mention of being democratic or autocratic—just autocratic---and those decisions have nothing to do with IT ALL DEPENDS—just the fact that he/she wants THIS DONE NOW! Therefore, as you can tell, well-known authors of leadership do have varied opinions of the ideal leadership behavior.
Recognizing Talent for Accommodating Change
Is the drive to be successful a talent or a genuine desire to succeed?! Some nurses just seem to have a talent for achieving a high level of success in certain behaviors and areas of nursing. It takes time for an administrator to determine specific talent and the energy a nurse is willing to commit to be successful by using their talent. Watch, listen, and look at results of humanistic and/or technical nursing abilities and outcomes. The talent evidence is there (or not there) for the person you originally considered for a specific job. Talent to any extent to perform any behavioral or technical skill means that the person with the talent should be teaching others how to perform this behavior or skill. Remember—teaching is an independent function of nursing; consequently, that means nurses should teach each other!
Once you see the evidence of expended efforts as to success (or no success), it will identify if a change should occur—maybe again. Evaluating outcomes of verbal and non-verbal behavior(s), also, tells a story. So, tune into what your senses are determining! A change in something might be in order at any time and in your best interest!
Accurate and effective communication with a nurse prior to requesting a change in expected job behavior is important. Always initially respond to the talent you, as an administrator, have noted. Then, communication the change in position or job expectations related to the talent. Listen to the nurse, carefully, to determine his/her willingness to make the change. If the change is mutually agreed upon, change the job description to reflect the new requirements/responsibilities and the intended goal related to the change. Give the nursing employee a copy of the job description. Make it clear that this new job description will now be the basis of future job evaluations.
Keeping Records to Substantiate Change
Keep private records regarding changes related to administrative goals. Identify the person, by name, in your records for a specific job change for the purpose to reach goal(s) and record the reason for your decision(s). Watch behaviors of this person. Chart positive and negative responses you, as the administrator, see and hear about from others. Use your documentation to support your administrative choices, new job descriptions, commendations, job changes, advancements, promotions, demotions, etc. Date each entry and personally sign each entry. This method provides objectivity for any change and can be very helpful in legal situations. Use your records to substantiate your administrative choices.
“True Leader” Different Perspectives
Many interesting qualities about the so-called “leader” have been discussed and found in literature. Different from a leader (by definition) incorporating democratic group processes, some see the “true leader” as dynamic, forceful, controlling, demanding, etc. However, Jim Collins (re-known business writer) found that truly great leaders (more often than not) demonstrate humility and modesty. We cannot ignore the fact, also, that some theorists believe leaders are born (Nature), not made (Nurture) and the qualities of leadership are often first identified in teenagers and young adults—years before they acquire a leadership role.
Leadership is lifting a person’s vision to high sights, the raising of a person’s performance to a higher standard, the building of a personality beyond its normal limitations.
Critical Thinking Questions
1. Who, by title and experience, would be the most likely employees to be resistant to change?
2. Under what circumstance(s) would you, as an administrator, choose to use management rather than leadership skills?
3. What current happening in your facility/organization has caused a need for management behaviors?
4. What employee(s) in your facility/organization would you first encourage to support a change and why?
5. What is the last situation in which you used leadership?
6. What information should you keep in your records to support a change process?
7. What two employees (at least) have a talent for their current nursing position?
8. When you make many decisions during the day, what concept determines whether you use management or leadership?
9. What author in his statement of POWER has meaning to you, and why?
10. What group behaviors do you plan to use (or continue to use) that promote group cohesiveness?
11. What happens when the group identifies and resolves Major Problems from a list of all their concerns or problems?
12. What are the personal talents that represent leadership and/or management abilities.
References (Suggested Reading)
Donaldson, L. (2001).
The Contingency Theory of Organizations
Drucker, P. (1999).
Management Challenge for the 21St Century
Keltner, D. (2016).
The Power Paradox
Western Schools (2018-2019).
Leadership and management strategies
Smith, M. (2011).
Are you a transformational leader?
Nursing Management, V. 42, Issue 9, pp. 44-50
Taylor, C. (2017). Entropy: a factor for change