The need for effective and innovative leadership in our healthcare system is unprecedented and fuelled by the pressures for change in light of the current economic downturn, a large aging population, imminent retirements of current leaders, decreasing interest in formal management roles, stressful work environments, and patient safety concerns. A significant body of knowledge has been generated around leadership, job satisfaction and retention practices that can promote healthier work environments. However, there is a gap in the application of the best leadership practices to create the sustainable changes our system requires.

The paper by Gottlieb and colleagues (2012) speaks to a strengths-based leadership approach that they believe is necessary to support an already changing and new healthcare system founded on different values than our "old system." Although the authors are not entirely explicit about the values that drive this new system or this leadership approach, their articulation of eight strengths-based leadership principles provides a vision for current and future nursing leadership. Their paper contains important messages about the role of empowering leadership practices directed towards developing nurses' health and strengths, paying attention to multiple points of view but also searching for "common ground," making continuous learning in the workplace a priority and promoting collaborative partnerships.

My goals in this commentary are to review some of the evidence supporting this positive strengths-based leadership approach, argue for a shift in work and patient outcomes, and briefly highlight evidence for a similar positive leadership approach.

Nursing Leadership and Outcomes

A review of studies (n=53) examining the effect of nursing leadership styles on nurse outcomes found that leadership styles that were relational in nature (i.e., compared to a more task-oriented style) were associated with positive outcomes for nurses, including greater job satisfaction and organizational commitment; reduced turnover, absenteeism and emotional exhaustion; and more positive work environments in terms of empowerment, work team climates, innovation and nurse–physician relationships and research use (Cummings et al. 2010). In addition, a review of studies (n=7) examining the relationship between nursing leadership and patient outcomes provided evidence of significant associations between positive leadership behaviours, styles or practices and increased patient satisfaction, reduced adverse patient events and reduced patient complications (Wong and Cummings 2007).

While further studies of a longitudinal nature, examining interventions in a variety of settings, are needed to advance knowledge of the complex contextual and multivariate influences among leadership and patient outcomes, we do have evidence that positive and relational leadership styles are linked to both positive nurse and patient outcomes. Although relational leadership is not specifically strengths-based leadership, "relational" refers to a perspective on leadership that emphasizes the leader's ability to create positive relationships within the organization. The strengths-based perspective is congruent with the notion of relational leadership.

Reframing Outcomes

Gottlieb and colleagues (2012) suggest that we need a shift to more strengths-based outcomes in the clinical world, which would entail a stronger focus on indicators associated with "the human spirit and the whole person" rather than the current emphasis on outcomes associated with problems, disease, deficits and complications. The positive psychology movement of the late 1990s reflected a similar shift away from deficit-based approaches to psychological concerns and towards more resource- and strengths-based orientations. More recently, the same paradigm shift was reflected in the development of positive organizational scholarship (POS), which is the study and application of positively oriented human resource strengths and psychological capacities that can be measured and developed for performance improvement in today's systems (Luthans 2002). As opposed to identifying problems, improving underperformance, and addressing weaknesses and obstacles, POS examines successful performance that exceeds the norm and embodies an orientation towards strengths and developing collective efficacy in organizations.

If we were to utilize a POS or strengths-based framework, it is interesting to consider what additional outcomes – besides quality of life or subjective well-being – might be included as organizational performance measures from the patient's perspective, such as return to work, return to self-care activities, perceived health or functional status. The Health Outcomes for Better Information and Care (HOBIC) project (Doran et al. 2006), recently reported in this journal, focuses on identifying nursing-sensitive clinical outcomes that include examples incorporating a positive approach to assessing the effectiveness of nursing care.

The switch to a more positive emphasis is important in nurse or employee outcomes by moving from dependence on turnover, absenteeism or work injuries data to measures of physical and emotional health and well-being, retention, the balance between job demands and resources, and thriving at work. Gretchen Spreitzer, a well-known POS researcher, suggests that the concept of "thriving at work" is central to sustainable organizations because thriving employees experience vitality and learning on the job, thereby increasing job performance while also preventing burnout and improving health (Spreitzer et al. 2012). Furthermore, research shows that organizations can increase employee thriving at work by enabling decision-making discretion, providing information about the organization and its goals, facilitating performance feedback, minimizing incivility and creating a climate of trust and respect for individuals (Spretizer et al. 2012). These features are remarkably similar to the work conditions of Kanter's (1993) concept of structural empowerment: opportunity, information, resources and support. Nurse empowerment has been linked to many job-related and organizational outcomes, such as job satisfaction, trust, respect and organizational commitment (Laschinger and Finegan 2005; Laschinger et al. 2000, 2009; Manojlovich and Laschinger 2007).

One has to wonder, when we have established evidence for the positive role of empowerment in healthcare work settings, why it is still an issue. The biggest challenge for establishing empowering workplaces may reside in the role of effective leadership. Nurse leaders create the conditions for nurses' work by shaping the quality of support, information and resources available in work areas (Laschinger et al. 2009; Shirey 2006). In particular, when nurses perceive their leaders as authentic, open and truthful, and involve them in decision-making, nurses respond positively to their work, reporting higher work engagement and greater trust in management (Wong et al. 2009, 2010).

Positive Leadership Orientation

The positive orientation to leadership embedded in the strengths-based approach of Gottlieb and colleagues is certainly echoed in other leadership models, such as transformational, servant and more recently, authentic leadership (Avolio and Gardner 2005). Authentic leadership was founded on the tenets of positive psychology and aimed at understanding positive human processes and organizational dynamics that make life meaningful. Avolio and Luthans (2006) have reported that to a large extent, prior leadership development work was based on a deficit-reduction model strategy, in which one discovered what was wrong with a leader and then worked to correct deficits in terms of focusing on the leader's development rather than on building on his or her personal resources to grow and develop. Authentic leadership theory suggests that leaders who are more authentic draw upon their life experiences, psychological capacities (i.e., hope, optimism, resilience and self-efficacy), a sound moral perspective and a supportive organizational climate to produce greater self-awareness and self-regulated positive behaviours. This, in turn, fosters both the leader's and the followers' authenticity and development, resulting in well-being and genuine, sustained performance (Avolio and Gardner 2005; Gardner et al. 2011).

An increased awareness of the relative importance of positive psychological strengths and capacities such as hope, optimism, confidence and resiliency in this model supports a leadership approach focused on strengths and the development of wellness rather than weaknesses and vulnerabilities. Similarly, the discipline of nursing has for many years focused on health promotion, well-being and client capabilities rather than disabilities (Gottlieb et al. 2012). It is time for the same positive and action-oriented approach to changing and sustaining the work environment. Consistent with the strengths-based approach, the authentic leadership model prominently incorporates hope, trust, positive emotions, and optimism as mechanisms by which authentic leaders influence nurses' attitudes, such as work engagement and commitment. Some studies have confirmed a positive relationship between nurses' psychological capital (self-efficacy, hope and optimism) and their organizational commitment, intent to stay in their jobs (Luthans and Jensen 2005) and job performance (Sun et al. 2011).

The concept of supporting and developing the positive capacities that already exist in the nursing workplace may provide critical leverage towards lasting change. When leaders focus on strengths and promote work environments that feature honest information sharing and a climate of trust and respect, individuals are more likely to be positively engaged in exploration and experimentation, as well as thoughtful relating with others, and thus experience a sense of thriving at work. Thanks to Gottlieb and colleagues, who have clearly connected positive leadership to a strengths-based model of nursing care, we have another important opportunity to close the gap between the reality of today's healthcare and a positive future based on strengths and possibilities.

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