The goals of nursing leadership are as follows:

One way nurses achieve leadership goals is by participating in a Healthy Communities (CDC, 2010) initiative at the local level. Working with others to develop policies for smoke-free public spaces is an example of promoting healthy living and working environments. Another example is collaborating with consumers and professionals from other disciplines to evaluate root causes of medication errors in home-bound elders and design a process improvement strategy to reduce errors.

The goals of nursing management are as follows:

An example of how nurses achieve management goals occurs when they develop plans for broad-based immunization clinics, such as smallpox vaccination clinics. Doing this in advance of confirmed bioterrorism is a way of preparing to meet an emerging community health need that achieves goals of protecting the public’s health and helping personnel work effectively and efficiently. Table 40-1 shows examples of ways population-focused nurse leaders and managers facilitate primary, secondary, and tertiary preventive services.

Organizational and systems theories explain issues at a broader agency or community level. These theories focus on the best ways to organize work, on how to obtain the resources necessary to accomplish agency goals, on organizational level change, on power dynamics, and understanding systems. Systems theories help explain the dynamics of rapid, interconnected change and the emergence of patterns of activity (Holden, 2005).

Good leadership skills are essential for nurse leaders and are among the key competencies for generalist public/community health nurses recommended by the Quad Council of Public Health Nursing Organizations (2009) and for “entry level public health professionals” by the Council on Linkages Between Academia and Public Health Nursing Practice (2010, p 1).

The transformational leader is able to transform, or change, the situation to one that differs from the status quo (Bass and Bass, 2008). Transformational leaders are sometimes found in learning organizations, or agencies that create cultures that support ongoing learning, experimentation, and creation of new knowledge (Roussel, Swansburg, and Swansburg, 2006). Transformational leadership is essential to promoting a culture of safety and positive work environments for others (Committee on the Work Environment for Nurses and Patient Safety, 2004).

Systems theories and systems thinking emphasize the interdependence of multiple parties. Nurses often recognize interdependence of units within an agency but may be less aware of agency interdependence. Economists analyze how distribution of resources affects policies, which players in a system will be influenced by policies, and how they will be influenced. These are called distribution effects. For example, if the federal government reduces money for health and social services, the clients of those services may be negatively affected. Employees of service agencies are also affected because agencies are likely to downsize to manage the reduced funding. Consequently, employees may either lose their jobs or experience wage cuts. Others likely to be affected include voluntary agencies and religious groups who might be expected to provide more services.

Roy’s adaptation model of nursing has been extended to include nursing management (Roy, 2002). Roy argues that agencies are composed of interdependent systems. The role of nurse managers is to help the agency adapt to changing circumstances in the most effective way possible. Roy’s model is particularly helpful for explaining and predicting how nurse managers and consultants can help agencies adapt to change. Nurse leaders should analyze how well interdependent units function to achieve agency goals. Furthermore, nurse leaders function as change agents because they foster agency adaptation. Complex adaptive systems theory accounts for the unpredictability of the behavior of people and organizations (Holden, 2005). The combination of unpredictability and interdependence leads to disequilibrium and potentially to adaptation and growth. Communities exemplify complex adaptive systems. Understanding the importance of relationships and tension in the midst of change led one group to design a primary care team-based approach to reflection as a way to improve care (Stroebel et al, 2005). Nurse leaders must understand the analytical, political, and communication skills needed to work effectively in these systems.

Clinical microsystems are the systems, people, information, and behaviors that take place at the point of client care (Nelson et al, 2008). Evidence-based clinical improvements can be implemented quickly in a clinical microsystem that has sufficient data about the practice, information systems that support clinical decision making, and a well-functioning team. For example, nurses working in a mobile health unit are part of a clinical microsystem. The team can make rapid changes in responses to quality problems if team members work well together and the mobile health clinic has an information system that makes it possible to track population health outcomes and clinical practice patterns.

The goal of consultation is to help others empower themselves to take more responsibility, feel more secure, deal with their feelings and with others in interactions, and use flexible and creative problem-solving skills (Sabatino, 2009). The functions of a consultant differ from those of a manager because consultation is typically a temporary and voluntary relationship between a professional helper and a client. The similarities between consultants and leaders are in their emphases on empowerment and helping others develop. Consulting relationships are based on cooperation and respect between consultants and clients, who share equally in problem solving (Argyris, 1997).

The nurse’s job responsibilities may include internal and external consultation. Internal consultants are members of the organization who work in a temporary capacity to help the client create or sustain change (Lacey and Tompkins, 2007). For example, a nurse may be employed to consult with other nurses in the agency about client care problems or, as an employee of the health department, may serve as a consultant to a local community retirement center about the public health care needs of its residents. If the nurse is an internal consultant, the nurse is employed on a full-time salaried basis by a community agency in which the consultation takes place. If the nurse is an external consultant, the nurse is employed temporarily on a contractual basis by the client. The client of the external nurse consultant may be a colleague, another health provider, or a community group or agency. Consulting may occur informally when a staff nurse asks a colleague for advice or help in solving a problem. The nature of the consultation relationship, whether it is internal or external, should not change the goal of consultation.

Several models of consultation have been developed. Although nurses often consult with individuals about their own health care, or with another nurse or health professional about the needs of an individual client, this section emphasizes population-based consultation. At this level, the nurse focuses on the needs of a group, organization, or community. The client in this case is an organization or group. Content models emphasize the role of consultant as the expert who provides specific answers to problems or issues identified by the client. This approach has the advantage of being relatively quick and often responsive to client requests, but it does not help engage the client in problem solving and learning how to address similar issues in the future (Schein, 2009). This chapter focuses on Edgar Schein’s model of process consultation because it is consistent with the nursing process and with nursing values of empowering clients and collaboratively working as partners with clients. The process model consultation focuses on the process of problem solving and collaboration between consultant and the client. The major goal of the process model is to help the client assess both the problem and the kind of help needed to solve it (Schein, 2009). Process consultation includes assessing the underlying agency culture that influences the problem and its solution (Schein, 2010). Both consultant and client participate in the problem-solving steps that lead to changes or to actions for problem solution.

Although consultants should emphasize process consultation, they should be willing to share their expert knowledge when appropriate. Because process consultation is collaborative, Schein (2009) recommends that consultants be willing to offer opinions and advice at all stages of the consultation process. Thus, although the major emphasis should be on process consultation, consultants may find it effective to integrate both context and process.

In the process model, the consultant is a resource person whose primary goal is to provide the client with choices for decision making. Process consultation includes the same steps as the nursing process: establishing a nurse–client relationship based on trust to assess the problem, planning and implementing actions, and evaluating the outcomes of nursing interventions. Nursing interventions may be described as direct client care or as consultation activities, depending on the goal of the intervention.

Consultation may occur before a problem occurs or after a problem exists. For example, a parent–teacher council developing a school-based family center contacts the nurse to assist with options for future nursing and health care for the students and their families. The board wishes to be proactive and plan for the needs of high-risk students and families. The administrator of a minimum-security prison has found that inmates are missing work for minor health problems and that health costs are skyrocketing. The nurse is asked to help explore solutions to the problem. Prison administration is reacting to an existing problem requiring immediate intervention.

The client is identified by determining who in the situation has the problem and needs to change. The following vignette illustrates this point:

Barry Henderson, RN, has been asked by the pastor of his congregation to consult with the parish council regarding the potential establishment of a health ministry. Barry decides that the consultation contract needs to include representatives of the parish council and parishioners themselves to find effective answers to the question. He realizes that time would be wasted and resistance to change would still be present if the focus were on only one group at a time. If he met separately with the parish council, they may decide such a program should include only one set of services. The parishioners either may want a different set of services or may desire to have services and programming organized in a very different manner. For example, the parish council may be especially interested in blood pressure screening, whereas the parishioners may be interested in wellness classes to keep the congregation healthy and in home visiting for those who are ill. After spending much energy meeting with both groups separately, Barry believes that by being a messenger between the two groups rather than a facilitator for problem solving, the consultant role has been diluted. On the other hand, by meeting with both groups together, Barry could serve as a resource, helping them explore all viewpoints and alternatives for developing the new program. In this case, both the parish council and the parishioners are Barry’s clients.

The consultation relationship is based on expectations. The consultant has expectations concerning time, money, resources, and the participation of the client in the process. Clients have expectations about what they will gain from the consultation relationship. Discussing the terms of a consultation contract makes expectations explicit, lessens the likelihood of violations of contract terms, and reduces the risk of additional demands being made on either party. Areas to include in the written consultation contract are as follows:

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