Role of the Registered Nurse in Improving Care to People with Stroke - Essay Example

Role of the registered nurse, with specific reference to leadership theories and change management in improving care given to people with stroke Introduction Stroke is a form of illness where normal functioning of the brain is affected due to disturbances in blood supply. The World Health Organization defines stroke as a clinical condition comprising of “rapidly developing clinical signs of focal (at times global) disturbance of cerebral function, lasting more than 24 hours or leading to death with no apparent cause other than that of vascular origin” (Hatano, 1976, 541). There are two prevalent forms of stroke: ischaemic, where a clot causes blocking or narrowing of blood vessels, leading to lack of adequate blood supply and subsequent brain death from low oxygen; and haemorrhagic that is caused by ruptured blood vessels resulting in bleeding inside the brain and subsequent brain damage (Mant, Wade, and Winner, 2004). Stroke might produce debilitating and long-term effects on patients and their families, and sometimes these effects become permanent. Evidence shows that nearly one-third of the people with stroke suffer from long-term disabilities that include physical disabilities, depression, aphasia, and other mental disorders. In the UK, stroke costs the national economy and the NHS almost £7 billion annually, wherein £2.8 billion goes in direct expenses to the NHS, £2.4 billion is spent in informal care (as for example, home nursing costs that are borne by the families) and £1.8 billion lost to disability and productivity (National Audit Office, 2005). Stroke related figures in the UK fare poorly globally, despite the expensive medical services offered, primarily owing to long stays in hospitals that are unnecessary, and high percentages of avoidable deaths and disabilities. Therefore, it is evident that stroke has a significant impact on the national economy, and individual lives in the UK. Annually there are almost 110,000 reported cases of stroke in the UK, and this clinical condition is considered the third largest cause of death in the country. According to various surveys, almost 11% of all deaths in the UK result from stroke; 20–30 % individuals with stroke survive for less than a month; 25 % of strokes happen to individuals less than 65 years of age; more than 9,00,000 people in the UK have already suffered from stroke; and almost 3,00,000 people in the UK suffer moderate to severe disabilities due to stroke; while stroke is considered as single largest contributor to adult disability in the UK (National Audit Office, 2005). In the last two decades, various scientific researchers have proven that contrary to the traditional notion that stroke occurs primarily due to aging and results in disability or death, this clinical condition like any other vascular disease is treatable and preventable. There are greater options available for more effective prevention (both primary and secondary) strategies, effective identification of people that are more vulnerable, and interventions that are successful right after the onset of stroke symptoms. Current researches suggest that after stroke, chances of recovery can be improved through special therapies and social support. Therefore, it is essential to frame an effective heath care system in the UK, to provide optimal care for the stroke patients in a cost effective manner. In this context, many researchers have emphasised the importance of effective leadership in nursing, since nurses have 24 hours access to the patients and their families (Tomey, 2009). This essay reviews the role of the registered nurse, with specific reference to leadership attributes and theories, and change management, in improving care provided to patients with stroke. Discussion Key leadership theories, roles and strategies in nursing stroke patients In all organisations, professionals use their knowledge and expertise to perform as leaders. Generally, leadership is associated only with corporate administrators, political heads, and army generals, since these leaders hold top ranking positions and are therefore highly visible. However, leaders are required at all levels within an organisation and leadership is a basic proficiency required in all health caregivers. Leadership development is an essential component in preparing health professionals for providing optimal care. Since nurses remain in close contact, they play a critical role in the lives of their patients and their families. Therefore, if the nurses are trained as effective leaders, they can use their expertise and knowledge to manage and address their patients’ daily care needs. While  there are  many  issues that challenge  leadership in nursing  in the  recent times  (such as, new technology, financial  constraints,  education, team activities,  and cultural  diversity ),  it must be kept in mind that leadership cannot be viewed as optional for the nurses. Leadership must exist in all facets of the healthcare system for achieving high standards and effecting changes in patient care (AACN, 2004). Leadership is generally viewed as a ‘process of influence,’ where a leader influences his/her followers to achieve a specific goal. In this context, Yukl defined the term leadership as “the process of influencing others to understand and agree about what needs to be done and how to do it, and the process of facilitating individual and collective efforts to accomplish shared objectives” (2006, 8). Here leadership is referred to as a process that goes beyond the ability to merely direct task completion or achieve specific results, and it takes into consideration the use of motivation by effective leaders to train their followers and lead them to achieve the desired results. Thus, according to Yukl, influence plays a major role in leadership, and leaders can influence others by engaging, motivating or enlivening them to participate. Therefore, it is a reciprocal relationship where the process involves interactions between the leader and his/her followers. Leadership can take place between the leader and his/her group, the leader and his/her follower, or between the leader and the society, the community or any organization. It can thus be suggested that leadership as a process significantly varies from the traditional leadership theory that projects leader as an individual in authority, exerting power and control over subordinates. Modern theories believe that any organisation has more leaders, besides those holding positions of authority, and every individual has the potential to function as a leader, as for example, nurses can function as leaders while influencing others towards achieving their desired goal (Yukl, 2006). Researches show that there are certain basic qualities shared by all successful leaders (Yukl, 2006). The first quality denotes a guiding vision, wherein effective leaders focus on a professional vision that gives a guidance toward achieving the desired goal. Since a nurse leader’s activities are aimed at achieving a desired goal or future (healing a stroke patient), it is logical that nurses train and upgrade their knowledge and skill levels keeping in mind the latest trends in stroke patient care. The second quality seen in successful leaders is passion, which is the ability to motivate and direct people toward a desired goal. In nurse leaders dealing with stroke patients, passion must be an integral part, which relates to helping the patients in fast and easy recovery while motivating them to live life to the fullest. The third one is integrity, which that founded on maturity, honesty, and self-knowledge, acquired through self-development and experience. Nurses show leadership by displaying skills and knowledge while performing their duties. Nurses also exhibit leadership by demonstrating cultural values enforced through personal beliefs, and professional and personal values as they serve their patients, while the values may be closely interlinked with ethical dilemmas (Dahnke, 2009). The American Association of Critical-Care Nurses stated that nursing leadership is a key element in achieving the desired patient outcomes, and requires efficiency in the core competencies of strategic vision, risk management, innovation, self-knowledge, motivation, and effective communication (AACN, 2004). In the context of stroke care management nursing leadership would involve preventing further clinical complication associated with respiratory problems that often arise due to pneumonia or smoking, dehydration, cerebral edema, hyperglycemia, hypertension, fever, malnourishment, coronary artery disease, thromboembolism and infection, since they all work towards deteriorating patient outcome (Mathers, Boerma, and Ma Fat, 2009). To provide optimal care, nurses must aim at coordinating multidisciplinary team activities. Standing orders from the attending physician or clinical pathways help in team guidance while dealing with stroke patients and coordinating therapies and diagnostic tests. Clinical pathways help in proper coordination of medical care of stroke patients, less hospital charges, discharge planning, alleviate rate of readmission, decrease hospital stay, and helps in improving overall quality and patient outcome (Kwan, and Sandercock, 2009). Stroke management can be divided into two basic phases. The first phase, also known as the emergency, comprises of the first 24 hours after the stroke. This phase includes the pre-hospital care and ED care procedures. The focus during this phase is on distinguishing the stroke symptoms assessing risks of severity or long-term complications, while deciding on the treatment available. The second phase includes acute care that starts from end of day 1 and continues until 72 hours after stroke. Here the focus is finding the cause of stroke, avoiding clinical complications, preparing for discharge, and preparing the patient and his/her family for entering rehabilitation programs and learning long-term prevention modalities. The care management of stroke patients often involve treating patients in a dedicated stroke unit, since researches show that specialised care helps in improved patient outcome. Rehabilitation after stroke is a continuous process that starts few days after the onset and ends only when there are no further positive results. Majority of the stroke patients that survive the first month require special rehabilitation programs and effective rehabilitation is obtained only when there is a coordinated team approach (Desmond, Remien, Moroney, Stern, Sano, and Williams, 2003). Regular team meetings, along with meetings with the patient, families and caregivers are necessary to facilitate informed decision-making. Ethical issues related to end-of-life care in acute cases must be handled with expertise, keeping in mind the decision of the patient, family members along with legal provisions. For a majority of the stroke patients, improvements in bodily function result from ischaemic penumbra recovery, neuroplasticity, removal of cerebral oedema, and compensatory procedures that must necessarily be learnt. Rehabilitation programs must adopt a multidisciplinary approach that is more focused on particular therapies, such as, speech therapies (since majority of the stroke patients suffer from speech disabilities), instead of emphasising on individual parts of the treatment procedure. After a patient completes a rehabilitation program, care management involves greater involvement of the general practitioner, wherein they assist patients with after effects of stroke that often include depression. GPs act as counsellors and deal with matters that may involve interpersonal issues, sexual relationships, recreational and vocational activities, driving abilities and other issues that assist a stroke patient in re-entering a normal life (Desmond, Remien, Moroney, Stern, Sano, and Williams, 2003). Table 1: Given below are some examples of nurses demonstrating leadership skills while caring for stroke patients: Leadership qualities Examples of nurses’ activities dealing with stroke patients 1. Relates to people and relationships Nurses demonstrate this quality while influencing stroke patient outcome, by developing close relationships with the patients and their families (Wong and Cummings, 2007). 2. Contextual leadership Nurses demonstrate this by adjusting and changing their working styles to address specific stroke patient situations (that may vary from acute cases requiring end-of-life care, to patients entering rehabilitation programs, to ones that are ready to leave the rehabilitation program and start psychological treatment under a GP) and performing as a team (Spence Laschinger, Finegan, and Wilk, 2009) 3. Effective meaning/communication management This quality is demonstrated when nurses effectively monitor and translate what is being communicated (verbally and nonverbally) by the stroke patients, and work towards achieving the desired goals (Murphy, 2005). 4. Effective decision making Nurses demonstrate this quality when they make evidence-based and logical decisions when dealing with stroke patients. While nurses must practice a certain degree of autonomous decision-making while handling emergencies, they must also perform as a team with other caregivers and service users to achieve the best patient outcome (Wong and Cummings, 2007). 5. A political process This quality is evidenced when nurses take part in nursing organizations and different political processes in their countries (Bishop, 2010). Leadership can be divided into two basic types: formal leadership, when the leader has authority or is sanctioned to play a role that signifies influence, as for example a clinical nurse specialist; informal leadership, where leadership qualities transcend borders of formal leadership and function by influencing others as a group member rather than a group head (Foti and Hauenstein, 2007). In order to understand leadership, a brief review must be made of the major leadership theories based on three varying approaches: behavioural, contingency, and contemporary. In behavioural approach, experts have categorised three leadership styles. These are autocratic, democratic, and laissez-faire leadership styles (Foti and Hauenstein, 2007). Autocratic leadership approach involves the leader assuming power over all decision-making processes and controlling his/her subordinates. Democratic leadership is more participatory in nature wherein authority is delegated to various team members. To exert influence, the leader must make use of his/her expertise, skill and the power base created from developing interpersonal relationships with the team members. The third approach, laissez-faire leadership, is permissive and passive in style, where the leader suspends decision-making. A comparative study of the three approaches revealed that most of the high-performing groups had autocratic leaders; however, hostile feelings were rampant in such conditions, making close supervision necessary. On the other hand, a democratic approach fostered positive feelings and performance levels were high, irrespective of whether the leader was present or absent. The laissez-faire approach was associated with dissatisfied employees and low productivity (Bono and Ilies, 2006). The second approach to leadership is the contingency theory that takes into consideration other external factors related to the environment that affects outcomes, besides the leader’s behaviour. The basic principle in this approach is that different leadership behavioural patterns will be successful in different situations. Contingency theory includes the situational theory of Hersey and Blanchard and Fielder’s contingency theory. Fielder’s theory of effective leadership stated that the leadership behavioural pattern is based on the interaction of the leader’s personality and the requirements of a specific situation, which in turn depend on the closeness of the leader-member relationship, leader’s power position, and the nature of the task structure (Foti, and Hauenstein, 2007). Hersey and Blanchard’s situational theory is more focused on the behavioural patterns of the followers in relation to successful leadership behaviour, and changes in leadership patterns based on the maturity level of the followers. The third approach to leadership is the contemporary approach that addresses leadership characteristics essential for developing learning organizations. This approach includes the transformational leadership theory, charismatic theory, and servant leadership. A charismatic leader possesses certain inspirational characteristics that foster an emotional relationship with the followers (Jackson, 2007). Servant leadership on the other hand focuses on placing importance on the needs of others above everything else, and encompasses healing, empathy, listening skills, vision and community development (Jackson, 2007). Transformational leadership can be defined as a process where leaders and followers push each other to achieve higher moral and motivational levels (Kotlyar, and Karakowsky, 2007). Transformational leaders promote growth, innovation and change within an organisation, and motivate others using personal values, while at the same time provides a vision that takes into consideration others’ values and beliefs, thus allowing all team members to contribute equally. The two core factors of transformational leadership, motivation and empowerment, helps the team members to look beyond self-interest, and commitment towards action and creating a vision, that promote changes. Among the various leadership theories, transformational leadership is the most suitable for nursing patients in long-term care, such as, stroke. Change management and nursing leadership while dealing with stroke patients According to a NHS survey, lack of awareness on stroke (symptoms, causes, effects and treatments) is a major factor when dealing with stroke patients. In 2006, a national survey observed that while almost 89% patients with stroke expressed satisfaction with the care received, nearly 50% were unhappy with the information received while the rest wished they were allowed to be more involved in their own treatment (Healthcare Commission, 2006). Since a fast response to stroke alleviates mortality and disability rates while cutting down on the expenses incurred, it is necessary to frame an emergency response within nursing management where all associated staff with direct public contact (including social care staff, receptionists, allied health practitioners and NHS Direct call handlers) has the expertise and skill to recognise stroke symptoms without even seeing the patient. Bringing in such levels of skill, knowledge and expertise, entails educating the hospital staff and other caregivers, and implementing change management through effective nursing leadership. While dealing with stroke patients nursing leadership must ensure the use of core competences of its entire staff, including those working in non-specialist areas. Leaders must ensure effective functioning of service development roles, while using both the caregivers and their patients to play motivational roles. They must provide high-quality training and information to help social care workers and non-specialist staff to gain expertise in dealing more effectively with stroke. The nurse leadership will have to work closely with primary care givers, higher education bodies and deaneries, to promote innovations at workplace. As already seen optimal care management can be provided in case of stroke patients when there is a coordinated team approach. To achieve this, transformational leadership can be used to provide motivation and empowerment of each team member by providing adequate training that would help them to gain the right expertise and skill when dealing with stroke patients, right from the onset of symptoms, to completion of rehabilitation programs. Since nurses play a primary role in all stages of care management of a stroke patient, they are often responsible for managing and coordinating care during the continuum. There are two major aspects in care management of stroke patients, which must be handled through expert leadership. The first aspect deals with the treatment during pre-hospital phase, which takes within a few hours of the onset of stroke and is most crucial for a patient’s survival and subsequent recovery, while second major aspect deals with the rehabilitation phase when the patient undergoes various therapies and psychological treatment, in order to live a normal life. These two aspects make it necessary for a nurse leader to improve his/her personal knowledge and expertise on stroke specific symptoms, while motivating others (paramedics and EMTs) to go for additional stroke specific education, in order to provide optimal care especially during the pre-hospital stage. While undertaking stroke education program, the nurse leader should take note of all local policies, laws and regulations that govern all acceptable practices for EMTs and paramedics in that state in order to avoid ethical and legal wrangles. As for example, some communities do not allow the commonly accepted acute stroke care procedures, such as, starting an intravenous line or using the finger-stick glucose levels, while other communities, support higher standards that make it necessary for the paramedics and EMTs to have specific assessment knowledge in order to respond faster (National Institutes of Health, 2003). As a part of the continuing education, nurse leadership must see that all EMS personnel are provided with right information about care management of acute stroke cases and the applicable treatment facilities within a community, while they must also be made to acquire the skill of rightly assessing a stroke in order to collect basic physiological data about the patient and subsequently transfer all gathered data regarding the patient’s condition to hospital. The second stage that deals with rehabilitation programs will be successful only if the nurse leadership strongly coordinates the medical team, stroke patient and other caregivers in a manner that allows for cooperation while defining interdisciplinary goals. Regular family and team meetings are necessary and the leader plays a major role in achieving cohesion by selecting a ‘key person’ from the caregiving team, who interacts with the family leading to familiarity and greater comfort. The medical team generally consists of a GP, a physiotherapist (dealing with limb movements), occupational therapists helping the patient to adjust to his daily routine, speech therapist helping in improved speech and communication, nurses with specifically skilled in dealing with bowl and bladder irregularities, neuropsychologists for treating cognitive defects, and social workers that help in social networking and community living. Here the role of the GP is paramount. Many stroke patients later have to deal with decreased mobility and lack of independence that often lead to frustration, anger, and feelings of depression (Desmond, Remien, Moroney, Stern, Sano, and Williams, 2003). Immobility also results in significant weight gain that may have an adverse effect on osteoporosis and diabetes. Therefore, the GP must deal with these, while at the same time taking care of secondary prevention, and advocating a healthy lifestyle. Thus, care management for a nurse leader involves not only improving the medical workers’ skill and knowledge levels by providing additional and specialised education on stroke, but also coordinating the activities of the entire team in order to achieve high patient outcome, reduce mortality rates, and increase the overall cost-effectiveness. There are various ways of achieving the desired changes within health care. However, a planned change that is directional, collaborative and calculated, under the guidance of an effective leadership must be adopted to bring about maximum improvements (Roussel 2006; Schifalacqua, Costello, and Denma, 2009). According to the Nursing and Midwifery Council (2008), nurses must essentially provide care as per the best available processes and evidences that suggest a constant requirement to change and update, keeping in sync with modern medical findings. However, it is not easy implementing change management, and Szabla (2007), in his researches revealed that nearly two thirds of all change management projects face failure. The factors that initiate changes within the health care include sharp increase in treatment costs (treatment of stroke in an expensive affair in the UK as already mentioned earlier), less number of workers, professional obligations, ethical dilemmas, legal considerations, amongst many more (Burritt 2005). Additionally there are other restraining factors, such as, inappropriate leadership, mismanaged action plans, lack of motivation amongst workers, and a lack of clarity in communication (O’Neal and Manley, 2007). In his researches, Price (2008) revealed that that the UK nurses felt held down by modern ‘corporate-like policies,’ while they felt health care management tended to change via ‘revolution’ instead of slowly evolving. In face of these challenges, it can be suggested that transformational leadership (with a democratic approach) is most suitable in nurse leadership while implementing change management, since it functions by motivating workers to create a future vision and implement gradually evolving changes. It is also important, for the nurse leaders to identify a suitable change theory that would help to frame an effective change management while dealing with stroke patients, yet remain cost effective (Pearson, Vaughan, and Fitzgerald, 2005). The most appropriate of change management theories was framed by Lewin where he categorised three phases for an effective change management: Unfreezing when there is a need to change; Moving when the change starts; and Refreezing, when there is balance once more after the change takes place (Hayes, 2013). In another theory, quite similar to Lewin’s, was Lippitt’s theory, which can be applied in care management for stroke patients (Tomey, 2009). It includes four elements closely interlinked: Assessment: this is the initial phase where the concerned nurse assesses the stroke patient’s details, such as, the medical history, biography, social details and other clinical observations; Planning: after the assessment, the nurse discusses with the patient, the family and the medical team to determine how to correctly address the patient’s needs; Implementation: here the nurse carries out and records the care management program discussed with the stroke patient, patient’s family and medical team during the planning stage; Evaluation: Evaluation is a constant process and is linked to the first phase (Assessment). This makes way for periodic assessment of patient requirement, which can be of future use during the time of readmission or further rehabilitation therapies (Pearson, Vaughan, and Fitzgerald, 2005). Conclusion From the above review, it can be suggested that nurses dealing with patients in long-term care, such as stroke, must have the ability to integrate nursing skills with leadership capabilities. The nurse leader must necessarily remain at pace with the healthcare environment that keeps changing constantly due to socio-political, economic and legal reasons. As a nursing leader, one must ensure the visions and goals of the organisation becomes a reality, and this can be achieved by remaining updated on the current social, political, legal, ethical, religious, and economic developments that might affect the health care system. One must assume responsibility and accountability while providing care for the patients; take strong decisions as the situation demands; possess updated knowledge on finance, computers, and business; while working together with the patient, the patient’s family and other associated caregivers. Besides these, the nurse leader must provide for public educational programs to spread awareness, while at the same time training the EMS team to assess, treat, and rapidly transport a stroke patient to a medical care facility. The nurse leadership must promote physician and community educational programs on stroke treatment to increase skill and knowledge levels, while coordinating team activities, in order to provide optimal care that is more cost effective. References Alberts, M., Hademenos, G., Latchaw, R., Jagoda, A., Marler, J., Mayberg, M., Starke, R., Todd, H., Viste, K., Girgus, M., Shephard, T., Emr, M., Shwayder, P., Walker, M., 2000. “Recommendations for the establishment of primary stroke centers: Brain Attack Coalition.” JAMA. 283, 3102–3109. American Association of Critical Care Nurses, 2004. AACN standards for establishing and sustaining healthy work environments: A journey to excellence. Accessed, January 26 2014, from www.aacn.org/WD/HWE/Docs/HWEStandards.pdf. Bishop, V., 2010. “Coalition in leadership, Politics The big picture and the big game.” Journal of Research in Nursing 15(4), 291–293. Bono, J., and Ilies, R., 2006. “Charisma, positive emotions and mood contagion”. The Leadership Quarterly 17(4), 317-334. Burritt, J., 2005. “Organisational turnaround: the role of the nurse executive.” Journal of Nursing Administration 35 (11), 482-489 Dahnke, M., 2009. “The role of the American Nurses Association Code in ethical decision making.” Holistic Nursing Practice 23(2), 112–119. Department of Health, 2007. National Stroke Strategy. London: Department of Health. Desmond, D., Remien, R., Moroney, T., Stern, Y., Sano, M., and Williams J., 2003. “Ischemic stroke and depression.” J Int Neuropsychol Soc. 9, 429 – 439. Foti, R., and Hauenstein, N., 2007. “Pattern and variable approaches in leadership emergence and effectiveness.” Journal of Applied Psychology 92, 347-355 Hatano, S., 1976. “Experience from a multicentre stroke register: a preliminary report.” Bulletin of the World Health Organization 54, 541–53. Healthcare Commission, 2006. Survey of patients 2006, Caring for people after they have had a stroke: A follow-up survey of patients. Accessed 27th January 2014, http://www.nhssurveys.org/Filestore/documents/Stroke_followup_report.pdf Jackson, D., 2007. “Servant Leadership in Nursing: A framework for developing sustainable research capacity in nursing,” Journal of the Royal College 15(1), 27–33. Kotlyar, I., and Karakowsky, L., 2007. “Falling Over Ourselves to Follow the Leader.” Journal of Leadership & Organizational Studies 14 (1), 38-49. Kwan, J., and Sandercock P., 2009. “In-hospital care pathways for stroke.” Cochrane Database of Systematic Reviews Issue 4. Art. No.: CD002924, 1-72. Mant, J., Wade, D., and Winner, S., 2004. “Health care needs assessment: stroke.” In, Stevens, A., Raftery, J., Mant, J., et al., (eds.) Health care needs assessment: the epidemiologically based needs assessment. Oxford: Radcliffe Medical Press. Mathers, C., Boerma, T., and Ma Fat, D., 2009. "Global and regional causes of death". British medical bulletin 92: 7–32. Murphy, L., 2005. “Transformational leadership: A cascading chain reaction.” Journal of Nursing Management 13, 128–136. National League for Nursing, 2010. Core values 2010. Accessed, January 26, 2014, from http://www.nln.org/aboutnln/corevalues.htm. National Audit Office, 2005. Reducing Brain Damage: Faster access to better stroke care. London: The Stationery Office. National Institutes of Health, 2003. Improving the Chain of Recovery for Acute Stroke in Your Community. Bethesda, Md: National Institute of Neurological Disorders and Stroke, NIH publication No. 03–5348. Nursing and Midwifery Council, 2008. The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. London: NMC. O’Neal, H., and Manley, K., 2007. Action planning: making change happen in clinical practice. Nursing Standard. 21 (35), 35-39. Pearson, A., Vaughan, B., and Fitzgerald M., 2005. Nursing Models for Practice. Oxford: Butterworth-Heinemann. Price, B., 2008. “Strategies to help nurses cope with change in the healthcare setting.” Nursing Standard 22 (48), 50-56. Roussel, L., 2006. Management and Leadership for Nurse Administrators. London: Jones and Bartlett. Schifalacqua, M., Costello, C., and Denma, W., 2009. “Roadmap for planned change, part 1: change leadership and project management.” Nurse Leader 7 (2), 26-29. Szabla, D., 2007. “A multidimensional view of resistance to organisational change: exploring cognitive, emotional and intentional responses to planned change across perceived change leadership strategies.” Human Resource Development Quarterly 18 (4), 525-558. Spence Laschinger, H., Finegan, J., and Wilk, P., 2009. “Context matters: The impact of unit leadership and empowerment on nurses’ organizational commitment.” The Journal of Nursing Administration 39(5), 228–235. Tomey, A., 2009. Guide to Nursing Management and Leadership. St Louis MO: Mosby Elsevier. Wong, C., and Cummings, G., 2007. “The relationship between nursing leadership and patient outcomes: a systematic review.” Journal of Nursing Management 15, 508–521. Yukl, G., 2006. Leadership in organizations. Upper Saddle River, NJ: Prentice-Hall. Read More