Around the time that I was asked to write this column, the January 2003 issue of Canadian Nurse arrived in my mailbox. In the column "Nurse to Know," Barbara Sibbald introduced us to Michelle Inder-Milley, a 25-year-old nurse from Newfoundland. Inder-Milley has a clear sense that nursing leadership lies within the purview of every nurse and that leadership is about making a difference. She talks about leadership potential that emerges from overcoming limitations, using one's full potential and having a vision and passion for nursing. Her view is that nurses must be leaders for the sake of themselves, their patients and the profession.

Leadership in nursing easily brings to mind images of nurse managers, executive nurses and nurses in academia. In these roles, leadership is formalized and integrated into the qualifications, expectations and professional development of the incumbents. If you look a little harder, it is not difficult to find examples of informal leadership in nursing when you consider nurses who go beyond their regular duties to organize educational events, participate in professional associations or volunteer in health-related community events.

But Inder-Milley challenges me to think about how leadership in nursing practice is expressed at the very front line, where nurses in staff positions (without formal leadership roles) interact with patients and families. What are the leadership behaviours and attributes that we expect, recognize and seek to develop at this level? What is it that enables one young nurse to be clear and articulate about leadership, when so many others in the profession express discouragement and defeat?

Across a wide range of literature there is no tidy, concise definition of leadership, but there is agreement that leadership means influencing human behaviour and moving people toward a common goal. There is consensus that leadership is less about controlling and more about guiding; it is less about the individual and more about interpersonal relationships. There is concurrence that leadership styles vary, that leaders can be followers and followers can be leaders, and that leadership is not limited to formal managerial roles. The personal attributes of leaders are well described and include such characteristics as having a sense of vision, self-confidence and expert communication skills. Most importantly, the literature strongly implies that leadership can be nurtured and developed.

So how do these general beliefs about leadership play out in nursing practice at the front line? In nursing practice, leadership is evident in the knowledge and skill that front-line nurses bring to their patients. The nurse who skillfully starts an intravenous line, while teaching and comforting the patient and family and simultaneously preceptoring a student, models nursing care that inspires confidence. The complex interaction of her nursing knowledge, technical skill and personal approach lead the patient, family and student to see that she is competent, can be trusted and has their best interests at heart.

Leadership is also evident in the efforts that nurses make to influence their work environments. Think about the nurse who desires better working conditions for her nursing unit. She wants the right equipment in working order, supplies that are available without a scavenger hunt, and policies and procedures that are current and realistic. She wants enough qualified staff to meet the needs of her patients and access to support from a clinical educator or clinical specialist. In documenting her concerns, identifying how deficiencies negatively affect patient care and suggesting alternatives to traditional practice, she is attempting to bring positive change to her practice environment.

Conceptual Framework

The conceptual framework for the Dorothy M. Wylie Nursing Leadership Institute depicts four intersecting areas of competence that leaders must have: use of self, competencies of leadership, issues of professional nursing and the business of healthcare. If you apply the framework to the examples cited above, you can see how nurses use themselves (skills, knowledge, personal attributes), their professional obligations (competence, standards, advocacy for safe practice environments) and competencies of leadership (modelling, showing the way, challenging) in the context of specific healthcare environments to advocate for and deliver healthcare services that include patient care and student education.

I have the view that leadership is present in the commonplace acts that front-line nurse repeat every day in countless variations and settings, and I suspect Inder-Milley would agree that these examples constitute nursing leadership. But perhaps you think I am stretching the point - seeing leadership just because I want to see it. You may view the nurse starting the IV and precepting the student as just doing her job. Perhaps you perceive the nurse who wants workplace improvements as complaining and troublesome. You might consider these examples to be nothing more than basic performance expectations outside the realm of leadership.

The reason I think these actions constitute leadership is that our response influences what happens next. The nurse in the first example could simply be complimented for her high level of nursing skill and preceptorship abilities and encouraged to keep up the good work. Or, she could be guided to expand her interest in student preceptorship and contribute to building strong links between the nursing education program and her service organization. With support, her technical skills could be shaped into opportunities to develop practice standards and set direction for IV therapy that will benefit all her colleagues.

Consider that the nurse in the second example may express her significant concerns about equipment and staffing problems in a way that causes others to feel defensive. She could be placated or reprimanded, or she could be directed to take her considerable energy and ideas for improvement and assist the manager to develop a proper business case for change.

The response of leaders in formal roles will determine if and how the leadership exhibited by front-line nurses gets recognized, shaped and supported. In turn, this recognition gives formal leaders an opportunity to use their leadership skills for the direct development of other nurses, which is potentially highly rewarding. Ralph Nader has been quoted as saying that the function of leadership is to produce more leaders. The people who manage Michelle Inder-Milley and every other front-line nurse have a delightful challenge on their hands.

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