Tiziana Rivera, the winner of the 2013 Nursing Leadership Award at the November HealthAchieve conference, is chief nursing executive and chief practice officer at Mackenzie Health. As such, she provides strategic leadership for the development and implementation of a shared vision for professional practice, nursing and all disciplines to promote innovative care and the development of care delivery models that will improve quality of care and population health.

Prior to assuming her position at Mackenzie Health, Rivera provided strategic leadership for the Seniors' Health Program at Trillium Health Centre, where her role focused on the development of seniors' health services across the continuum of care. She has published numerous articles in refereed journals, conducted several research studies and presented her papers provincially, nationally and internationally. Rivera has a clinical appointment at the University of Toronto Faculty of Nursing, a faculty adviser position at Ryerson and an adjunct faculty position at the School of Health Sciences, York University and at the School of Health Sciences, Humber Institute of Technology and Advanced Learning.

In the following Q and A, Rivera shares her thoughts on leadership in nursing and perspectives on several critical issues.

How would you describe your leadership style?

I would describe it as transformational. My style is adapted to the particular demands of the situation, the needs of the people involved and the challenges at hand. In my practice, I am intentional and purposeful in creating opportunities for inter-professional collaboration and co-creating a vision for practice in a client-centred care environment. In establishing a way of being with others, clarity, transparency, respect and integrity underpin my communication and practice. I believe emotional intelligence is critical and intersects with my leadership style. This means understanding and being aware of one's emotions and the emotions of others in order to manage oneself effectively and form high-quality relationships. In my practice, I actively seek and establish settings that foster innovation and creativity to explore new ways of doing things through cross-departmental and cross-sectorial partnerships.

What have you found to be the most important attributes for leadership in nursing? Why?

The key attributes I have found to be the most important for leadership in nursing include tenacity in being a voice for high-quality care, commitment to collaboration, relentlessness in articulate communication, passion as a mentor, courage as a risk-taker, confidence as a role model and enthusiastic creativity as a visionary. In the clinical and administrative leadership roles I have had, giving voice to the patient's experience must happen in an articulate way across various audiences. These attributes have helped me to develop a deeper understanding of the complexities of building a caring, safe, sustainable and quality-focused environment. This must happen in tandem with developing breadth and depth in our collective understanding of "what it will take" to advance care, both locally and from a broad health system perspective. I recognize the gifts that are energy, enthusiasm and the ability to see possibilities through the eyes of the nurses I have had the privilege to mentor. These gifts have fostered positive, synergistic relationships and have informed my vision and the opportunities for moving beyond established boundaries. Being a risk-taker is an essential element for nurse leaders to nurture and develop. We continuously ask nurses and other disciplines at the point of care to be courageous, to bring forward issues, to give voice to areas of safety and concern; this aspect of leadership must be visible, especially at the senior levels of an organization. I am inspired when I see my role models deal with difficult, long-standing issues in an expert, evidenced-informed and professional manner. I aspire to embody and reflect all these leadership attributes in my actions and behaviours in order to be a catalyst for change in healthcare.

How has your style evolved over the years of your career?

My leadership style has evolved in direct proportion to my level of maturity as a professional in developing self-awareness and bringing consciousness and transparency to my values and the actions and behaviours that align with them. The word "leader" was attributed to me early on, but only through deep reflection on my personal and professional experiences have I grown to appreciate what it actually means, the responsibility it holds and the impact it can have. The impact of my leadership has been strengthened through my increased comfort with ambiguity, knowing it is better to ask the right questions than to know the answers, and trusting, supporting and enabling the achievement of excellence through others. The ability to bring change through articulating confidence in others and supporting continued professional development of individuals and teams has been the greatest evolution of my practice. This has been enabled through the various roles and responsibilities I have had. I see the development of my leadership style as a creative process influenced and shaped by many factors and becoming fully actualized through reflection, dialogue, openness, continuous learning and feedback.

What or who have been your most important influences? Why?

I had the opportunity to have my mother as a strong female role model growing up. As an immigrant to Canada, she had few marketable skills, no family support, no social services, nor the ability to communicate in English. Although these posed difficult challenges, she explored the opportunities that lay within and around her. She built on her strengths despite her circumstances, she rose above what was presented to her and saw beyond it, she envisioned what could be, not what was, and that drove her actions. With few resources, she sought to develop the skills required for the changing environment in which she found herself and her family with a focused determination, compassion, caring and moral fortitude. She had deep spiritual roots and held human caring and respect as her core values. This was foundational to my personal growth and as I chose my career path and professional roles.

The second most important influence in my career has been the practice environments in which I have had the opportunity to work. Engaging in formal learning and achieving academic credentials and certifications provide you with tools, knowledge and skills to practise. Seeking, working and actively contributing to one's full potential is a key to finding the right fit within an environment where one can continue to grow, learn and influence healthcare at all levels. I have been fortunate to work in progressive organizations with incredible inter-professional leaders who value nursing, practice and leveraging the collective voice for achieving health system transformation.

What is the most satisfying aspect of your role as a nurse leader? What has been the most disappointing?

The most satisfying aspect of my role as a nurse leader is co-creating opportunities and environments where nurses and other professionals begin to embody the art of what is possible and then actively engage in making it happen. The ability to work with others to influence and sustain systemic change at the broader level, and the ability to be creative in approaching long-standing issues, is immensely gratifying. On a recent trip to Florence, Italy, I visited and read about Michelangelo's David and how it was sculpted from a flawed, discarded and unusable piece of marble. Michelangelo saw the stone and the masterpiece that lay within. His role was to release it. As nurse leaders, recognizing potential in others, removing barriers, releasing, unleashing, seeing what others cannot see is a skill that requires discipline and a consistent application to practice. Seeing old problems in a different way and galvanizing others through dialogue is profoundly satisfying.

What has been the most disappointing is the slow pace of systemic change, the resources available and the difficulties in creating alignment at all levels. Deep positive change requires connecting with users of the healthcare system, those responsible for its administration and direct care providers, who are all keenly aware of what is needed for a better healthcare delivery system. What is lacking is political will to realize the alignment that will advance us beyond protected silos to a legacy model for the ages.

What role do you see for nurse leaders in advancing transformation of the healthcare system over the next five years?

Advancing transformation of the healthcare system will require nurse leaders to focus on the patient's voice, to give meaning to the lived experience of navigating and receiving healthcare services. Understanding this perspective as the "alpha" will be imperative. The journey towards achieving transformation from a consumer perspective will require engaging physician leaders towards interprofessional collaboration in designing, implementing and evaluating deep system transformation for a quality-based and effective healthcare system. The outcomes of such collaboration among health professionals can be seen in reduced lengths of stay, better health outcomes for patients, decreased healthcare costs, staff satisfaction and teamwork.

Collectively, it will be imperative that we use the levers of health system funding reform to create a practice platform that can advance much-needed change in how care is designed and delivered from an evidenced-based practice perspective. Innovation and research must continue to identify and develop improvements to care that are then translated efficiently and effectively into the practice environment. As nurse leaders, it is essential that we step out of our risk-averse culture and develop political acumen and awareness to facilitate the formation of evidence-based policy affecting quality of care and health service delivery. Last but certainly not least among the potential levers for transformation is the investment in people. Great things can be accomplished when skilled, knowledgeable and valued professionals come together in an environment where the vision is clear and possibilities thrive.

What was the best piece of advice you were ever given in your career? Why?

That great leadership is dynamic and that dynamic, responsive and agile leaders are effective in any environment.

The meaning of this statement continues to reveal itself daily, in situations I observe and with which I am intimately involved. Being dynamic, responsive and agile has meant that leadership requires one to be resilient and relentless in one's ability to engage, collaborate and advance systemic reform. Leadership is easy when things are going well; when they're not, it requires incredible endurance, resiliency and agility. It is sometimes through the most difficult of times that the best of times emerge, and being surrounded by individuals with depth of character, integrity and ethics brings out the best in situations and in you as a professional.

Patients, families, nurses and our inter-professional colleagues seek to be engaged in an unending pursuit to find new, innovative and creative ways to provide care. Broken, inefficient and fragmented care is played out at the bedside and more globally at a system level. Leadership requires being relentless: engineer practice changes, bracket your mental models (and in some cases, break them down), create models of care that challenge traditional approaches, place patient safety and voice at the forefront of care, and create environments where practice is questioned, inter-professional practice is celebrated and the patient experience is elevated.

We must be resilient and relentless, but our work must be driven by evidence-based principles, practices and performance expectations. This combination brings a level of rigour that validates the effectiveness and efficacy of clinical practice. Share the impact of your work, the successes and the failures. Visualize your failures, because they will happen, but be prepared to learn from them. Learn, perfect, refine and bring the best practice forward for the patients and families we have the privilege to serve.