149 NURSING ECONOMIC$/May-June 2009/Vol. 27/No.

3
T
H E H E A LT H S E RV I C E S I N D U S T RY
is a rapidly changing envi-
ronment; subsequently,
innovative leadership char-
acteristics and roles are re q u i re d
for the nursing profession. Port e r-
OGrady and Malloch (2006)
noted that the impact on nursing
management and leadership is
just beginning to be defined in this
c o n t e m p o r a ry and unsettled
health care arena. Furt h e rm o re ,
changes resulting from enhanced
t e c h n o l o g y, proliferating inform a-
tion available on the Intern e t ,
i n c reasingly informed health care
consumers, ongoing constraints of
managed care, a worsening nurs-
ing shortage, and the ever evolv-
ing health care delivery systems
a re converging to create unpre c e-
dented challenges for nursing
leadership (Aiken, 2007; Ameri-
can College of Healthcare
Executives [ACHE], 2005; Arm i n g
Health Care Consumers, 2006;
Dendaas, 2004). Additionally,
The number and magnitude of
challenges facing healthcare or-
ganizations are unpre c e d e n t e d .
G rowing financial pre s s u res, ris-
ing public and payor expectations
and the increasing number of con-
solidations have placed hospitals,
health networks, managed care
plans and other healthcare org a n i-
zations under greater stre s s
(ACHE, 2005).
The Institute of Medicine
(IOM, 2004) published its re p o rt
Keeping Patients Safe: Tr a n s-
f o rming the Work Environment of
Nurses, noting a decline in chief
nurse executives, directors of
nursing, and nurse managers, and
subsequently recommended the
adoption of transformational lead-
ership and evidence-based man-
agement (EBM) to increase patient
safety and reduce errors in the
work environment. Echoing the
call for change, Sofarelli and
B rown (1998), Clegg (2000),
Valentine (2002), and DeGro o t
(2005) advocated transform a t i o n a l
leadership theory for nursing lead-
ers.
B u rns (1978) seminal theory
of transformational leadership
defined a process in which leader-
ship is transcendent, uplifting,
moral, and often charismatic. It
EX E C U T I V E SU M M A RY
In a time of chaotic and unpre-
d i c t a ble health care, it is vital fo r
nursing to employ a nu r s i n g
leadership theory that is specifi-
cally applicable to nurses and
will holistically, and comprehen-
s i vely address and support both
the science and art of this hon-
ored profe s s i o n .
The authors propose that
Nursing Leadership Know i n g
can address and impact the my r-
iad issues confronting managers
and administrators within the tur-
bulent health care industry, with
the ultimate goals of quality com-
p r e h e n s i ve patient care and
i m p r oved employee satisfa c t i o n .
T h ey believe that N u r s i n g
Leadership Know i n g, gr o u n d e d
in the realties of nursing ex p e ri-
e n c e, is a logical theoretical
extension that can be tra n s l a t e d
into nursing leadership pra c t i c e
A particular and specific fo c u s
on empirics and ev i d e n c e - b a s e d
p ractice will not attend to the
r o bust and mu l t i d i m e n s i o n a l
u n d e rpinnings of the lived ex p e-
rience that is so vital to nu r s i n g
as a caring profe s s i o n .
The ideal of nursing leadership
t h e o ryis not a single-fo c u s e d
s h a d ow of its history, but a ri c h ,
i n c l u s i ve, mu l t i - faceted netwo rk
of know i n g .
As such, Nursing Leadership
K n ow i n g p r ovides a fo rum fo r
leaders to enhance their pra c-
t i c e, as well as their relationship
with their employe e s, which ulti-
mately translates into optimal
care for the patients we serve.
Janet P. Jackson
Paul T. Clements
Jennifer B. Averill
Kathie Zimbro
Pa t t e rns of Knowing: P roposing
A Th e o ry for Nursing Leaders h i p
JANET P. JACKSON, MSN, RN, is Adjunct
Faculty, School of Nursing, Old Dominion
University, Norfolk, VA.
PAUL T. CLEMENTS, PhD, APRN, BC, is
an Assistant Clinical Pro f e s s o r, Dre x e l
University College of Nursing and Health
Professions, Philadelphia, PA.
JENNIFER B. AVERILL, PhD, MSN, RN, is
an Associate Pro f e s s o r, College of
Nursing, University of New Mexico,
Albuquerque, NM.
KATHIE ZIMBRO, PhD, RN, is Director,
Clinical and Business Intelligence,
Sentara Healthcare, Norfolk, VA.
NURSING ECONOMIC$/May-June 2009/Vol. 27/No. 3 150
o ffers broad direction, strong com-
mitment, and raises both leaders
and followers to principled levels of
judgment. Ivancevich, Konopaske,
and Matteson (2005), established
pioneers in the field of corporate
o rganizational management de-
scribed transformational leader-
ship theory as one that includes a
v i s i o n a ry leader who motivates
followers to work for intern a l
re w a rds of achievement and self-
actualization, rather than extern a l
re w a rds of transaction and securi-
t y. This is a comprehensive, gener-
al leadership theory that is
applied in many disciplines; how-
e v e r, the authors ask whether
t r a n s f o rmational leadership is
a p p ropriate for nursing leaders in
health care settings.
Nursing is a unique pro f e s s i o n
because of its synthesis of prac-
tice, multidimensional assess-
m e n t / i n t e rvention, interpersonal
communication, case manage-
ment, and re s o u rce-linking on
behalf of patients. Nursing prac-
tice revolves around tenets of car-
ing within an overarching altru i s-
tic framework. In fact, nursing is a
multi-faceted science and art with
a rich history steeped in the ro o t s
established by Florence Nightingale
that embodies caring for vulnera-
ble populations at the highest
level (Clements & Averill, 2006;
Gill, 2004). Nursing typically
attracts people who are alre a d y
motivated by internal re w a rds of
self-actualization and achieve-
ment; there f o re, the goals of trans-
f o rmational leadership may not be
e ffective for selected members of
the nursing profession. Nursing
has borrowed a leadership theory
f rom a non-nursing discipline that
may not embrace and motivate
nurses. In a time of chaotic and
u n p redictable health care, it is
vital for nursing to employ a nurs-
ing leadership theory that is
specifically applicable to nurses
and will holistically, and compre-
h e n s i v e l y, address and support
both the science and art of this
h o n o red profession. Underlying
this science and art is the knowl-
edge base from which nurses
develop their practice, including
their leadership principles.
Overview
Historical underpinnings. C a r p e r
(1978) identified the now familiar
four Fundamental Patterns of
Knowing in Nursing in her
acclaimed manuscript. The pat-
t e rns included empirics, esthetics
(aesthetics), personal knowledge,
and ethics, and she proposed that
they re p resented the complex
phenomenon of knowing that
nurses use when caring for their
patients. In an eff o rt to include the
contexts of care, White (1995)
added sociopolitical knowing as
the fifth pattern of knowledge.
Recognizing the need to maintain
openness to new knowledge and
ideas, Munhall (1993) postulated
the sixth pattern of knowing
which she titled unknowing, and
Heath (1998) further expanded the
p a t t e rn of unknowing to re p re s e n t
a dimension of all patterns. More
re c e n t l y, Chinn and Kramer (2008)
added emancipatory knowing to
engage the issues of equity, justice,
and transformation in all arenas of
practice, including nursing leader-
ship. When used in synchro n y,
the seven patterns of knowing
have a goodness of fit for nursing
leadership theory, part i c u l a r l y
because they were created by
nurses and for nurses. Specif-
i c a l l y, in the contemporary era of
health care :
...the infrastru c t u re charg e d
with managing human disease,
illness, and well-being is chal-
lenged beyond its limitsAs
members of the health care
c o m m u n i t y, professional nurses
seek a balance between fiscal
imperatives and social re s p o n-
s i b i l i t y, and the f o u n d a t i o n a l
knowledge base for the disci-
pline The patterns of know-
ing which, when applied in an
integrated manner, provide a
holistic way of deeply under-
standing the client, nursing
practice, and the nurse as an
individual. Additionally, the
p a t t e rns re p resent a pro f e s-
sional commitment to value
diverse approaches to the
questions and problems that
arise within the nursing disci-
pline (Clements & Av e r i l l ,
2006, p. 268).
For example, they dire c t l y
a d d ress goals and challenges for
nursing leaders in the re l e n t l e s s l y
evolving health care arena such as
the deepening nursing short a g e ,
job satisfaction issues, compre-
hensive patient care across set-
tings, and the politics of nursing
leadership.
T h e o retical assert i o n s . O r i g i-
n a l l y, Carper (1978) did not iden-
tify the four patterns of knowing
as theories; however, the potential
that each pattern of knowing may
be re g a rded as theory has re c e n t l y
become evident because they indi-
vidually and collectively re p re s e n t
ontological and epistemological
foundations of the discipline of
nursing (Fawcett, 2006; Fawcett,
Watson, Neumann, Wa l k e r, &
Fitzpatrick, 2001). Although s o c i o-
political knowing, unknowing,
and emancipatory knowing have
not been explicitly examined as
theories, they re p resent valuable
p a t t e rns of knowing for nursing
leaders; after all, sociopolitical
issues and background pro v i d e
rich contexts for what occurs in
the nursing profession, including
leadership and management.
A d d i t i o n a l l y, unknowing invites
the option of responsiveness to
new ways of thinking or re s o l v i n g
p roblems.
For example, the pre v i o u s l y
mentioned IOM re p o rt (2004)
identified a critical need for nurs-
ing leadership and leadership the-
o ry. The development of policies
and pro c e d u res from an appro p r i-
ate theory that specifically applies
to nursing and its knowledge base
will have sociopolitical implica-
tions, including questions of fair-
ness and integrity. Since nursing
holds the largest number of health
c a re professionals in its ranks, it
should inherently be an equal
member of the overall driving
151 NURSING ECONOMIC$/May-June 2009/Vol. 27/No. 3
f o rce in health care planning and
d e l i v e ry, including aware n e s s ,
recognition, and utilization of the
fifth pattern of knowing, sociopo-
litical knowing, which incorpo-
rates an understanding of society,
politics, justice, and culture
(Chinn & Kramer, 2008; White,
1 9 9 5 ) .
Another example of signifi-
cant importance includes the eco-
nomic implications of the nursing
s h o rtage that confronts and chal-
lenges nurse leaders, part i c u l a r l y
since the current nursing short-
age is a serious problem at all lev-
els of nursing (Valentine, 2002, p.
1). Nurse experts presented data
on the value of nurses and the eco-
nomics of the nursing shortage at a
c o n g ressional briefing on May 2,
2006 (Hnatiuk, 2006). It was noted
that the cost of replacing one
nurse is $42,000 to $64,000, and
an average facility with 400 beds
replaces 80 RNs per year. The
minimum cost is $3.36 million per
y e a r, per facility. One appro a c h
cited for hospitals to impro v e
quality and reduce costs is to
i n c rease nurse staffing. Studies
have demonstrated the re d u c t i o n
of adverse patient outcomes and
extra hospital days (Aiken, 2007),
and additionally, that incre a s e d
patient satisfaction will off s e t
i n c reased labor costs (Needleman,
B u e rhaus, Stewart, Zelevinsky, &
Matte, 2006). Recruitment and
retention are significant factors
with serious economic implica-
tions for facilities (Hnatiuk, 2006;
Milliken, Clements, & Ti l l m a n ,
2007). Furt h e r, the additional lack
of nurse leaders exacerbates the
nursing shortage (Andrews &
Dziegielewski, 2005; IOM, 2004).
We propose here that N u r s i n g
Leadership Knowing can addre s s
and impact the myriad issues con-
f ronting managers and administra-
tors within the turbulent health
c a re industry, with the ultimate
goals of quality compre h e n s i v e
patient care and impro v e d
employee satisfaction.
The Patterns
How do nursing leaders know
about leadership? An obvious
need exists for nursing leadership
founded on plausible theory to
amend and facilitate staff support
and communication. We pro p o s e
that Nursing Leadership Knowing,
g rounded in the realties of nursing
experience, is a logical theore t i c a l
extension that can be translated
into nursing leadership practice
(see Figure 1). Specific examples
of such application follow.
E m p i r i c s . The first pattern ,
re f e rred to as empiric leadership
k n o w i n g (empiric L.K.), is based
on the science of nursing and
Figure 1.
Nursing Leadership Knowing (N.L.K.) Model
Empiric
L.K.
Outcome-Based
EMB, EBL
Unknowing
L.K.
Openness
Nursing
Leadership
Knowing
Ethical
L.K.
Justice, Ethics
Personal
L.K.
Relationship
Sociopolitical
L.K.
Strategy, Culture
Aesthetic
L.K.
Art, Vision
Nursing
Staff
E m a n c i p a t o ry
L K .
Tr a n s fo r m i n g
Wo r k p l a c e
NURSING ECONOMIC$/May-June 2009/Vol. 27/No. 3 152
includes a body of empirical
knowledge that is re s e a rch based
and systematically org a n i z e d .
Empirical knowing is factual,
objective, and verifiable by out-
come measures (Carper, 1978;
Fawcett et al, 2001). The IOM
re p o rt (2004) recommended the
adoption of EBM, and was fol-
lowed by DeGroot (2005) who
indicated that evidence-based
leadership (EBL) is nursings new
mandate. EBM and EBL are simi-
l a r, but various philosophical and
operational definitions exist for
d i ff e rences between managers and
leaders. For example, Sofare l l i
and Brown (1998) explained that
managers have legitimate power
and control, enforce policy and
p ro c e d u res, and emphasize org a-
nizational goals over concern for
employees. To contrast this, they
say leaders use empowerment and
change, communicate a vision,
and have great concern for team
members. However, not all leaders
a re managers and not all managers
a re leaders (DeGroot, 2005). In the
changing health care enviro n m e n t
and increasing nursing short a g e ,
the profession of nursing needs
leaders.
One exemplar, the Patient
C a re Staffing Report (2002),
described the practices of Middle-
sex Hospital in Connecticut by
developing an annual re p o rt card
to keep staff engaged and pro m o t e
EBL. This re p o rt card pro v i d e d
objective evidence of pro g re s s
t o w a rds goals, demonstrated lead-
e r s h i p s accountability, and edu-
cated staff about practice. The four
dimensions covered in the re p o rt
c a rd included functional, fiscal,
clinical, and patient/nurse/physi-
cian satisfaction characteristics.
Evidence-based leadership also
uses evidence-based practice.
Fawcett et al. (2001) declared that
Evidence-based practice is in the
f o re f ront of many contemporary
discussions of nursing re s e a rc h
and nursing practice (p. 115).
S h i rey (2006) suggested that evi-
dence-based nursing practice is
the solution to sustaining quality
and access in health care .
Leadership that uses data collec-
tion, analysis, and evaluation of
evidence-based practices exempli-
fies EBL (Sullivan, Bre t s c h n e i d e r,
& McCausland, 2003). These
methods illustrate the pattern of
empiric leadership knowing; how-
e v e r, empiric leadership knowing
re p resents only one pattern of
knowing for nursing leaders and
should be used in unison with the
other patterns.
A e s t h e t i c s . Often evident in
non-verbal expressions, therapeu-
tic actions, and unconditional
p resence, empathy is the primary
mode or manner of the second pat-
t e rn of knowing which Carper
(1978) called aesthetics, or the art
of nursing. Although this pattern
initially pertained to nurses and
their empathy toward patients,
aesthetic leadership knowing ( a e s-
thetic L.K.) presumes leaders who
demonstrate empathy toward
their nursing personnel. This is a
critical aspect to engaging and
retaining nursing staff. Aesthetic
leadership knowing is subjective
and should focus on the perc e p-
tion of what is significant and
meaningful for each nurse while
simultaneously giving substantive
d i rection to nursing practice.
Leaders should meet with staff
individually to ask what is moti-
vating and re w a rding for each
nurse. Diff e rent nurses may find
significance in advanced training,
mentoring, flexible scheduling,
s h a red governance, or monetary
re w a rds. Roy (2000) argued that
nurse administrators should focus
on human potential and pro v i d e
o p p o rtunities to foster and nurt u re
human growth. If nurse leaders
discover what has meaning for
nursing professionals, they may
be able to effectively stimulate the
g rowth potential of each person
while simultaneously enhancing
job satisfaction (Milliken et al.,
2007).
Aesthetic leadership knowing
also emphasizes aesthetic mean-
ings and inspiration for develop-
ing and expressing the art of nurs-
ing (Fawcett et al., 2001).
C o n g ruent with this thinking,
Kouzes and Posner (2002), leaders
in the field of organizational lead-
ership theory, presented scientific
data to support their re c o m m e n-
dations. They posited that leader-
ship is also an art, one which is
often beyond empirical measure .
Nurse leaders can benefit fro m
development and creation of evi-
dence for the art of leadership.
Schmidt, Nelson, and Godfre y
(2003) described the art of nursing
to include degrees of clinical judg-
ment, mentorship ability, estab-
lished standards of perf o rm a n c e ,
successfully completed perf o rm-
ance evaluations, and cogent
scheduling of personnel. These
a re all forms of the art of leader-
ship that nurse leaders may share
with others by their examples and
mentorship.
T h e re are many areas where
nurse leaders experience, in a
practical manner and setting, the
o p p o rtunity to develop their aes-
thetic knowing, and arg u a b l y, the
a rt of leadership is also the gro w t h
of wisdom as evidenced by the fol-
lowing statement:
A true leader has the con-
fidence to stand alone, the
courage to make tough deci-
sions, and the compassion to
listen to the needs of oth-
ers[and] does not set out to
be a leader, but becomes one
by the quality of [her/his]
actions and the integrity of
[her/his] intent (unknown).
Personal knowing. P e r s o n a l
leadership knowing ( p e r s o n a l
L.K.) may be one of the most diff i-
cult patterns to master and teach
because it is an expression of self-
knowing in the context of the
interpersonal process (Carper,
1978; Chinn & Kramer, 2008). For
nurse leaders, this pattern may be
developed by means of opening
and centering the self to thinking
about how one is or can be authen-
tic, by listening to responses fro m
others, and by reflecting on those
thoughts and responses (Fawcett
et al., 2001, p. 116). Perra (2000)
153 NURSING ECONOMIC$/May-June 2009/Vol. 27/No. 3
a ff i rmed the need for nurse
executives to have clearly
defined professional and per-
sonal values, integrity, tru s t
and tru s t w o rthiness, courage,
and vision. She asserted that
attentive listening, follow
t h rough, sharing inform a t i o n
and personal experiences,
and providing tools/re s o u rc e s
for staff to be successful can
build a trusting relationship that
can last through adversity (p. 59).
In short, personal knowing entails
consistency between what one
knows and what she does. Laure n t
(2000) suggested the nurse leader
must release some control to the
employee and develop risk-taking
behaviors. Releasing control to the
employee is a positive re f l e c t i o n
of the interpersonal process since
it conveys trust in the part n e r s h i p ;
s p e c i f i c a l l y, leadership is a re l a-
tionship between those who
a s p i re to lead and those who
choose to follow (Kouzes &
P o s n e r, 2002, p. 20).
E t h i c s. According to the
ACHE (2005), Now, more than
e v e r, the healthcare org a n i z a t i o n
must be managed with consistent-
ly high professional and ethical
s t a n d a rds. This means that the
executive, acting with other
responsible parties, must foster
and support an environment con-
ducive not only to providing high-
q u a l i t y, cost-effective healthcare ,
but also seek to ensure individual
ethical behavior and practices.
The fourth pattern, e t h i c a l
leadership knowing (ethical L.K.),
is primarily guided by the
American Nurses Association
(2005a) Code of Ethics for Nurses
which clearly delineates ethical
nursing behaviors, expectations,
and leadership roles. This code
includes respect for human digni-
t y, right to self-determ i n a t i o n ,
relationships with colleagues,
acceptance of accountability and
re s p o n s i b i l i t y, self-respect, influ-
ence of environment on nurses,
advancement of the pro f e s s i o n ,
and assertion of values. Thro u g h
analysis and clarification of
s h a red values, nurse leaders can
bring attention to the ethics of
nursing practice, and increase the
p robability for congruence be-
tween nursings core values and
nursing conduct (Carper, 1978;
Chinn & Kramer, 2008). Ethical
leadership knowing also includes
a moral obligation to respect nurs-
ing staff and treat each person
with justice and compassion. To
enhance employee satisfaction in
f renzied health care settings, these
qualities should not be undere s t i-
mated. One nursing theory that
s u p p o rts such an ethical appro a c h
to organizational culture is Rays
(2006) Theory of Bure a u c r a t i c
Caring. Emerging from the opin-
ions and viewpoints of nurses in
practice, this model describes car-
ing as the major construct and
conscience of nursing, even at the
o rganizational level. Ray calls on
p rofessional nurse leaders to sup-
p o rt the values that underlie our
discipline, awaken our conscious-
ness to each other and to our
patients, and to help heal a health
c a re system that is on the verge of
collapse.
M u rray (2007), in his re c e n t
c o m m e n t a ry on creating and
maintaining ethical enviro n m e n t s
in nursing, provided the following
w o rds of both wisdom and warn-
ing for nurse leaders re g a rd i n g
their important role in upholding
workplace ethics:
S t rong leadership is
essential to producing and
sustaining an ethical enviro n-
ment. As individuals, each
nurse is subject to countless
influences When leaders
expect and consistently
demonstrated the highest pro-
fessional and personal stan-
d a rds of conduct and ethical
behaviors individuals can
realize their greatest p o t e n t i a l .
C o n v e r s e l y, when s t a n d a rd s
a re unclear and questionable
behaviors are tolerated... indi-
viduals may find themselves
questioning profoundly held
values. For this reason, lead-
ers must remain on guard con-
stantly to ensure an ethical
e n v i ronment. Once standard s
a re set, even the slightest
d i v e rgence can be tro u b l e-
some (p. 49).
Sociopolitical knowing. S o c i o -
political leadership knowing
(sociopolitical L.K.) is framed
within the context of the leader
and nurse, as well as the contexts
of nursing as a profession in socie-
ty and politics. Sociopolitical lead-
ership knowing includes an
understanding of impact factors on
the nursing profession. Examples
of such factors include the work
behavior culture that surro u n d s
nursing, the politics that govern it,
and the complex physical, fiscal,
and psychological enviro n m e n t s
of each health care institution.
Savage (2003) believed that the
fundamental challenge in nursing
is addressing the impact of cul-
t u re societal, org a n i z a t i o n a l ,
and professional that keeps
nursing executives tied to the tacti-
cal when their energies should be
d i rected to more long-term, strate-
gic outcomes (p. 1). She added
that organizational culture exert s
unspoken assumptions about
nursing leadership that pre v e n t s
nurses from becoming a powerf u l
f o rce. These assumptions include
the significant and ongoing gro w t h
of nursing in a paternalistic hierar-
chy and the historic nature of a
p redominantly female pro f e s s i o n .
Jennings and colleagues (2001)
a ff i rmed that nursing leadership is
shaped dramatically by politics
and policy, and that effective nurs-
ing leadership is an org a n i z a t i o n a l
vehicle in which nursing policy
and practice can be shaped and
changed. Trent (2003) pro p o s e d
that change in nursing practice
N
ursing is a holistic
profession; similarly,
nursing leadership should
also be holistic, dynamic,
inclusive, flexible, and
a d a p t a b l e .
NURSING ECONOMIC$/May-June 2009/Vol. 27/No. 3 154
reflects the values of society. Being
cognizant of these influences and
a d d ressing them are examples of
sociopolitical leadership knowing.
For example, nurse leaders need to
actively participate in their pro f e s-
sional organizations, become off i-
cers on governing boards, and cre-
ate policy for their institutions to
stay abreast of national and local
issues and trends in nursing.
Roy (2000) emphasized that it
is imperative for nurse administra-
tors to plan and predict the future
of nursing. Nurse leaders often
make decisions based on the
changing environment in a health
c a re system that is highly integrat-
ed, continuum-based, and multi-
faceted (Port e r- O G r a d y, 1999).
These re p resent overarc h i n g
sociopolitical issues, such as gen-
d e r, diversity, culture, and power
that must be examined and
engaged to enhance effective lead-
ership.
Unknowing. The sixth pattern
of knowing is paradoxically called
unknowing leadership ( u n k n o w-
ing L.K.). Munhall (1993)
described unknowing as a condi-
tion of openness and an under-
standing, which as Heath (1998)
f u rther commented, can con-
tribute toward remaining alert to
the changing perspective of the
situation. Unknowing invites
a w a reness and release of the par-
ticular biases, prejudices, pre c o n-
ceptions, stereotypes, and ass-
umptions that most people (in-
cluding nurse leaders) carry into
the daily life of the workplace.
Instead, a sense of possibility and
real acceptance between points of
v i e w, persons, disciplines, or cul-
t u res unfolds. The IOM (2004) re c-
ommended that health care org a n-
izations acquire nurse leaders for
all levels of management who will
facilitate input of dire c t - c a re
nursing staff into operational deci-
sion making and the design of
work processes and work flow (p.
8). Front-line personnel have
a w a reness and knowledge about
bedside nursing and patient care
that is valuable for nursing lead-
ers. Consistent with the unknow-
ing pattern, leaders should meet
with staff in an open, nonjudg-
mental atmosphere to elicit their
opinions and then act upon the
knowledge they are given. Leaders
who invite input from nursing
s t a ff are recognizing their
unknowing about the staffs per-
spective of the situation. Regard-
less of their education and train-
ing, nurse leaders need to re m a i n
open, receptive, and aware.
Unknowing leadership re q u i re s
h u m i l i t y, flexibility, adaptability,
change readiness, and the ability
to listen intently to others. Kouzes
and Posner (2002) emphasized
that leaders need to listen to mul-
tiple voices in the org a n i z a t i o n ,
w a rning that a closed-minded
leader will not develop trust with
the staff and will not be successful
in retaining staff for the org a n i z a-
tion. Ultimately, this pro b l e m
a ffects patient outcomes. When
nursing leaders recognize they do
not know all the answers, when
they are open to the input and
feedback from nursing staff, when
they listen to the concerns and
plan change accord i n g l y, they are
honoring the intent of the
unknowing dimension of leader-
ship. The insight re q u i red for
unknowing leadership is exempli-
fied by the anonymous words pre-
sented in Figure 2.
As nurse leaders maintain
their re c e p t i v i t y, it allows them to
continue in their personal and
p rofessional growth. If they
remain in an all-knowing state
of mind, the results can be stagna-
tion, complacency, and constrain-
ing judgment. Unknowing allows
both the leader and the nurse the
f reedom to shed new light on the
dawn of each day.
E m a n c i p a t o ry knowing. T h e
seventh and most recently estab-
lished pattern is emancipatory
knowing which is based on both a
traditional social idea and a devel-
oping dimension of nursing
knowledge (Chinn & Kramer,
2008). Building upon the aware-
ness and knowledge seeking of the
other patterns, e m a n c i p a t o rylead -
ership knowing ( e m a n c i p a t o ry
L.K.) moves nurse leaders to the
next step, which is actively chang-
ing the workplace enviro n m e n t
and impacting outcomes for both
patients and nurses. Key strategies
for this pattern involve grassro o t s
c reative development pro c e s s-
esin small groups (Chinn &
K r a m e r, p. 94), aimed at raising
a w a reness of unfair and perh a p s
unethical situations, collectively
reflecting on the meaning of such
things, and deciding to transform
the situation. As with the other
p a t t e rns, introducing and infusing
the emancipatory way of think-
ing/knowing may take months or
years. Nurse leaders with a vision
of the future in health care sys-
tems may find this pattern espe-
cially valuable in leveling the
o rganizational playing field; they
will need to develop eff e c t i v e ,
i n f o rmative measure s / s t r a t e g i e s
for tracking the effects of emanci-
p a t o ry changes.
E m a n c i p a t o ry leadership know-
ing provides flexibility for adapta-
tion to contemporary trends and
issues as they emerge. For exam-
ple, the decision to reduce hospi-
tal reimbursement for serv i c e s
related to hospital-acquired infec-
tions presents transform a t i v e
Figure 2.
Insights Required for Unknowing Leadership
Watch your thoughts, for they become words.
Choose your words, for they become actions.
Understand your actions, for they become habits.
Study your habits, for they become your character.
NOTE: Author unknown
155 NURSING ECONOMIC$/May-June 2009/Vol. 27/No. 3
o p p o rtunities for nurse leaders to
re d i rect their energies toward
l o n g - t e rm strategic outcomes.
With the emergence of methicillin-
resistant Staphylococcus aure a s
(MRSA), a compelling public
health problem in health care set-
tings, there are significant chal-
lenges to care and clinical prac-
tice. MRSA is one of the leading
causes of hospital-acquired infec-
tions. These unnecessary compli-
cations result in sicker patients
while threatening financial viabil-
ity of health care agencies. Change
technologies, such as Lean Six
Sigma and Positive Deviance,
o ffer nurse leaders a vehicle to
shape nursing policy and practice.
Lean Six Sigma is a systemat-
ic approach to improving pro c e s s
re l i a b i l i t y. Care is enhanced and
clinical practice improved by
identifying and eliminating opera-
tional barriers along with unwant-
ed variation within a process or
system dovetailed with integrating
the voice of the customer (Six
Sigma, 2005). Positive Deviance is
a social and behavioral change
p rocess where nurse leaders
engage front-line staff in impro v e-
ment eff o rts. Specifically:
Positive Deviance is a
development approach that is
based on the premise that
solutions to community pro b-
lems already exist within the
c o m m u n i t y. The positive de-
viance approach thus diff e r s
f rom traditional needs b a s e d
or problem-solving appro a c h-
es in that it does not focus pri-
marily on identification of
needs and the external inputs
n e c e s s a ry to meet those needs
or solve problems. Instead it
seeks to identify and optimize
existing re s o u rces and solu-
tions within the community to
solve community pro b l e m s
(Positive Deviance Initiative,
2001, para. 1).
Within this paradigm, there
a re individuals (or groups) within
o rganizations who function as
positive deviants. Congruent with
the foundational underpinnings of
the empancipatory patters of
knowing, grassroots cre a t i v e
development processesin small
g roups of positive deviants can
potentially implement better solu-
tions to intractable problems com-
p a red to their peers with access to
similar re s o u rces (Chinn &
K r a m e r, 2008, p. 94; Positive
Deviance Initiative, 2001).
Nurse leaders often need to
make decisions without the best
level of evidence. Failure to act is
not an option. Lean Six Sigma and
Positive Deviance embody eman-
c i p a t o ry leadership knowing to
minimize operational and cultural
b a rriers to care and clinical prac-
tice. Evidence is presented and
l e a rning fostered. Early adoption
of strategies to enhance care and
i m p rove clinical practice is
encouraged. Empowerment that
Positive Deviance can bring to
engaging front-line staff is a pow-
e rful adjunct tool for advancing
quality and safety initiatives.
Discussion
Nurses in leadership enviro n-
ments can benefit greatly by
embracing a theory to guide prac-
tice that, created by nurses for
nurses, additionally addresses the
gestalt or unified whole of the pro-
fession. The patterns of knowing
a re one such theoretical appro a c h
which can encompass the multi-
faceted domains of nursing and
nursing leadership (see Figure 1).
S p e c i f i c a l l y, Fawcett (2006) notes
that if nurses are to provide the
highest quality of care that comes
f rom practicing nursing as both
science and as art, employing the
p a t t e rns of knowing must be fos-
t e red, emphasizing the special
i m p o rtance of the patterns for get-
ting to really know the people
who seek our careduring nurse-
patient encounters (p. 276).
The extant health care litera-
t u re currently emphasizes EBM
and EBL, which re p resent the
empirical way of knowing; how-
e v e r, this is only one pattern of
leadership theory and inhere n t l y
excludes some of the more person-
al and aesthetic factors that addi-
tionally impact health and illness.
Carper (1978) stressed that each
p a t t e rn of knowing is not a com-
plete approach in itself, while
Chinn and Kramer (2004, 2008)
and Fawcett et al. (2001) furt h e r
emphasize the danger of re l y i n g
on one pattern too heavily or
e x c l u s i v e l y, which they call a pat-
t e rn gone wild. Curre n t l y, this
danger has become a reality with
o v e ruse of the empirical pattern of
knowing, professionally re f e rred
to as evidence-based practice and
outcome measures. Although this
p a t t e rn has value, a singular or
o v e rused focus on empiric leader-
ship knowing can lead to the min-
imization and/or exclusion of the
other patterns encompassing
vision, creative experience in
practice, interpersonal re l a t i o n-
ships, ethics, culture, context, and
change. Consequences of exclu-
s i o n a ry thinking apply equally to
any pattern. For instance, the
impact of the lived experience of
postoperative pain and its eff e c t
on length of hospital stay often
involves empirical scales. Al-
though pain scales may pro v i d e
empirical data on postoperative
re c o v e ry, clearly the use of the
other patterns can enhance assess-
ment and understanding of the
holistic re c o v e ry of the client, as
well as provide insight into the
empirical measures of pain man-
agement and length of stay.
C o n g ruent with the foundational
tenets of the patterns of knowing,
nursing leadership knowing must
utilize all the patterns in unison,
which contributes to pre v e n t i o n
of nursing leadership theory fro m
becoming wooden, insensitive,
and ineffective. In addition to
EBL, integrating the pattern s
includes assessing leadership
skills for empathy and vision (aes-
thetic L.K.), mutual respect and
authenticity (personal L.K.), ethics
and morality (ethical L.K.), p o l i t i-
cal strategy and diversity (sociopo-
litical L.K.), humility and flexibili-
ty (unknowing L.K.), emancipatory
and transformative actions (eman-
NURSING ECONOMIC$/May-June 2009/Vol. 27/No. 3 156
c i p a t o ryL.K.). Additional re s e a rc h
is needed to determine the impact
of the other patterns of knowing
on nursing leadership, including
how those patterns can contribute
to evidenced-based practice and
outcome measure s .
Nursing is a holistic pro f e s-
sion; similarly, nursing leadership
should also be holistic, dynamic,
inclusive, flexible, and adaptable.
EBL, in and of itself and used in
isolation, ignores the heart and
soul the overall lived human
experience of leadership. This
will not serve the leader, the staff
nurse, the patients, or the pro f e s-
sion of nursing. Nurse leaders
need to guide the nursing pro f e s-
sion into leadership theory that is
as comprehensive as the pro f e s-
sion. Foundational facets with
brief descriptors of Patterns of
Knowing as leadership theory and
related implications are pro v i d e d
in the Table 1.
Implications for Nursing
Leadership Practice
A review of the extant litera-
t u re shows a paucity of re s e a rc h
about applying the patterns of
knowing as leadership theory.
Schmidt and colleagues (2003)
applied Carpers patterns of know-
ing to develop a successful clini-
cal ladder program for Ta m p a
General Hospital. Staff interest in
the program exceeded pro j e c t i o n s
and career advancement was
established. This ladder pro g r a m
is believed to be the first one to
utilize Carpers work for pro g r a m
development; however, it does not
a d d ress nursing leadership. The
study provides insight for leader-
ship strategies that dovetail with
the foundational assertions of the
leadership knowing theory; spe-
c i f i c a l l y, they re p resent the multi-
dimensional leadership appro a c h-
es inherent to use of the first six
p a t t e rns in unison, simultaneous-
ly addressing the needs of both the
leader and the employee. Add-
itional contemporary studies,
identifying the facets of job satis-
faction for nurses and subsequent
responses sought by employees
f rom management, can be easily
incorporated into the patterns of
knowing (see Table 2). Of note,
most re s e a rch concerning primary
nursing and job satisfaction has
been based on the assumption that
all nurses as professionals find job
Figure 3.
Comparison of Nursing Leadership Knowing to Transformational Leadership
Empiric
L.K.
Outcome-Based
Unknowing
L.K.
Openness
Transformational
Leadership
Ethical
L.K.
Justice, Ethics
Personal
L.K.
Relationship
Sociopolitical
L.K.
Strategy, Culture
Aesthetic
L.K.
Art, Vision
Nursing
Staff
Nursing
Leadership
Knowing
E m a n c i p a t o ry
L K .
Tr a n s fo r m i n g
Wo r k p l a c e
157 NURSING ECONOMIC$/May-June 2009/Vol. 27/No. 3
satisfaction in intrinsic factors.
This assumption must be ques-
tioned in the contemporary era,
p a rticularly when considering
methods of leadership that pro-
mote job satisfaction, which in
t u rn can significantly enhance
unit efficiency and optimize
patient care (Malkin, 2008).
C u rrent national re c o m m e n-
dations from the IOM (2004)
include use of transform a t i o n a l
leadership theory and EBM.
H o rton-Deutsch and Mohr (2001)
a rticulated that nursing leadership
is fading, and that nursing has
morally and ethically failed its
patients (perhaps re p resentative of
the empirical pattern having
gone wild). People do not enter
a hospital with the hope of being
c a red for by EBM; rather, they
want care from nurses practicing
h o l i s t i c a l l y, perhaps using all the
p a t t e rns of knowing? If the curre n t
emphasis on solely using EBL (the
empirical pattern of knowing) and
t r a n s f o rmational theory is founda-
tional in nursing leadership
a p p roaches, it is suggested that
nursing leadership will continue
to fail its staff and patients by
using borrowed and, subse-
q u e n t l y, inadequate methods. A
comparison of Nursing Leadership
K n o w i n g to EBM/EBL (evidence-
based practice) and transform a-
tional leadership gives evidence
that although each approach has
value, they do not address the
uniqueness and totality of the
nursing profession (see Figure 3).
Tr a n s f o rmational theory may
be ineffective for individuals
i n h e rently motivated by intrinsic
re w a rds as it does not address the
science of nursing (see Figure 3).
F u rt h e rm o re, in a recent detailed
l i t e r a t u rereview of nursing man-
agement and leadership compe-
tencies, Jennings, Scalzi, Rodgers,
and Keane (2007) concluded that
inadequate distinction exists for
d i ff e rentiating the two sets of com-
petencies. The authors suggest
that the strength of using the pat-
t e rns of knowing as nursing lead-
ership theory is they include both
the visionary qualities of transfor-
mational leadership and objective
data of evidence-based practice,
and they incorporate the addition-
al patterns which are so vital to
holistic leadership. For example,
Scott and Caress (2005) indicated
new forms of leadership are
re q u i red to engage staff in deci-
sion making and promote clinical
e ff e c t i v e n e s s .
Conclusion
A particular and specific
focus on empirics and evidence-
based practice will not attend to
the robust and multidimensional
Table 1.
Patterns of Knowing in Nursing Leadership Theory: Description, Qualities, and Examples
Pattern of
Knowing
Nursing Leadership
Knowing Description and Qualities Examples
Empirics Empiric Leadership
Knowing
Evidence-based nursing
leadership
Factual, objective
Annual report card
Empiric research, outcome-based
practice, EBM
Aesthetics Aesthetic Leadership
Knowing
Art of nursing leadership
Empathetic, subjective,
visionary
What is significant for nursing
staff? Perceptive leadership
Personal Personal Leadership
Knowing
Relationship-based nursing
leadership
Listening, being authentic,
empowering
Mutual respect
Interpersonal relationship
between leader and staff. Validate
staff concerns. Maximize individ-
ual potential.
Ethics Ethical Leadership
Knowing
Ethical nursing leadership
Values, standards, morality
Code of ethics, professional
organizations, accountability,
justice
Sociopolitical Sociopolitical Leadership
Knowing
Politics of nursing leadership
Strategic, cultural, diversity,
gender-based
Laws, regulations, external and
internal health care environment
Unknowing Unknowing Leadership Openness in nursing leadership
Humility, awareness, flexibility
Leaders do not know all the
answers. Open-minded, adapt-
able leadership
Emancipatory Emancipatory Leadership
Knowing
Motivational nursing leadership
Consciousness raising
Transformative workplaces
Governance partnerships
Policy changes
NURSING ECONOMIC$/May-June 2009/Vol. 27/No. 3 158
underpinnings of the lived experi-
ence that is so vital to nursing as a
caring profession (Averill &
Clements, 2007). How do nurse
leaders, both novice and seasoned,
know about leadership? They exam-
ine and embrace a way of thinking,
or theory, that they believe re f l e c t s
their ideals. The ideal of nursing
leadership theory is not a single-
focused shadow of its history, but a
rich, inclusive, multi-faceted net-
work of knowing. As such, N u r s i n g
Leadership Knowing p rovides a
f o rum for leaders to enhance their
practice, as well as their re l a t i o n-
ship with their employees, which
ultimately translates into optimal
c a re for the patients we serve. $
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Approach Patterns of Leadership Knowing
Criteria for advancement should pos-
sess sufficient flexibility to account for
individual experiences.
Personal, Ethical, Aesthetic,
Sociopolitical, Emancipatory,
Unknowing
Increased control with scheduling. Personal, Unknowing
Individually meeting with employees to
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Personal, Aesthetic, Emancipatory,
Unknowing
Providing opportunities for shared
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Personal, Aesthetic, Emancipatory,
Unknowing
Support for educational activities (con-
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Personal, Empiric, Emancipatory,
Unknowing
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Personal; Aesthetic
Acknowledgment of work/family
roles/responsibilities.
Personal, Sociopolitical, Unknowing
Active examination of and intervention
with staff dynamics: facilitation of
proactive conflict resolution versus
reactive passive-aggressive problem
solving.
Personal, Ethical, Aesthetic,
Emancipatory, Unknowing
Sharing of plans and goals in a clear
and definitive manner
Aesthetic; Unknowing
Table 2.
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