CONTINUING EDUCATION

Leadership and Management

Roles: Challenges and Success
Strategies 1.0 www.aornjournal.org/content/cme

JOYCE A. COX, MBA, MSN, CNP, CNOR, CRNFA, OCN, CHPN

Continuing Education Contact Hours Approvals

indicates that continuing education (CE) contact hours are This program meets criteria for CNOR and CRNFA recerti-
available for this activity. Earn the CE contact hours by fication, as well as other CE requirements.
reading this article, reviewing the purpose/goal and objectives,
and completing the online Learner Evaluation at http:// AORN is provider-approved by the California Board of
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Event: #16531
Session: #0001
Conflict-of-Interest Disclosures
As a recipient of an honorarium from the Competency &
Fee: For current pricing, please go to: http://www.aornjournal
Credentialing Institute, Joyce A. Cox, MBA, MSN, CNP,
.org/content/cme.
CNOR, CRNFA, OCN, CHPN, has declared an affiliation
that could be perceived as posing a potential conflict of interest
The contact hours for this article expire August 31, 2019.
in the publication of this article.
Pricing is subject to change.
The behavioral objectives for this program were created by
Purpose/Goal Kristi Van Anderson, BSN, RN, CNOR, clinical editor, with
To provide the learner with knowledge of best practices related consultation from Susan Bakewell, MS, RN-BC, director,
to leadership and management roles and challenges facing the Perioperative Education. Ms Van Anderson and Ms Bakewell
modern nursing leader. have no declared affiliations that could be perceived as posing
potential conflicts of interest in the publication of this article.
Objectives
1. Describe the differences between leadership and management.
Sponsorship or Commercial Support
2. Identify different leadership styles.
No sponsorship or commercial support was received for this
3. Discuss ethical issues perioperative leaders and managers
article.
may encounter in health care.
4. Explain the challenges facing the modern nursing leader.
Disclaimer
Accreditation AORN recognizes these activities as CE for RNs. This
AORN is accredited as a provider of continuing nursing recognition does not imply that AORN or the American
education by the American Nurses Credentialing Center’s Nurses Credentialing Center approves or endorses products
Commission on Accreditation. mentioned in the activity.

http://dx.doi.org/10.1016/j.aorn.2016.06.008
ª AORN, Inc, 2016
154 j AORN Journal www.aornjournal.org
 PERIOPERATIVE
LEADERSHIP

Leadership and Management

Roles: Challenges and Success
Strategies 1.0 www.aornjournal.org/content/cme

JOYCE A. COX, MBA, MSN, CNP, CNOR, CRNFA, OCN, CHPN

D etermining the differences between management

and leadership is not as straightforward as it may
seem. Leaders are not always managers, and
managers are not always effective leaders. This column describes
the difference between leadership and management in a broad
is a “process whereby intentional influence is exerted over
other people to guide, structure, and facilitate activities and
relationships in a group or organization.”1(p2) Effective leaders
should be visionaries who are adaptable and have the ability to
inspire others toward a collective goal. Nurses can be informal
sense and how these roles apply to health care settings. It also leaders without holding official positions of authority.
explores examples of selected types of leadership, current issues, Perioperative settings often have team members with technical
ethics, challenges, skills, and roles of nursing leaders. It is expertise and innovative ideas but who do not fulfill a formal
important for senior nursing leadership to understand the leadership role.
difference between leading and managing to capitalize on the
Management, in its simplest terms, involves planning and
strengths of the individuals in each of these roles.
organizing staff members and resources to achieve objectives.
Nickels et al define management as “the process used to
DEFINING LEADERSHIP AND accomplish organizational goals through planning, organizing,
MANAGEMENT leading, and controlling people and other organizational
The definition of leadership may vary based on the context and resources.”2(p179) Typically, managers are responsible for
setting to which it is applied, but in a general sense, leadership accomplishing tasks through the employees who report to
http://dx.doi.org/10.1016/j.aorn.2016.06.008
ª AORN, Inc, 2016
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Cox August 2016, Vol. 104, No. 2

them. Effective managers should motivate subordinates to budget, and leaders set the direction for success. Organizing
achieve measureable short-term goals. According to Morgan,3 and staffing are management roles; leaders align people.
the modern manager must have five important qualities, Management is controlling, problem solving, and devising
including the ability to effective action; leadership is motivating and inspiring people
and following through with meaningful actions. Leadership

follow from the front, removing roadblocks to ensure relies on persuasion and influence instead of control.4
employee success; Although some scholars would argue that manager and

understand the overall technology of the landscape and how leadership roles are mutually exclusive, others believe the
it affects work; opposite. Managers can possess leadership characteristics,

lead by example starting at ground level using the same tools and leaders can display traits of managers.
as the employees;

embrace vulnerability by being open, transparent, and Nursing managers ensure patient safety daily as they supervise
courageous; and and collaborate with staff members. Nursing leaders who

believe in sharing information and collective intelligence.3 oversee managers (eg, chief nursing officers, nursing directors)
must meet organizational goals while providing their nursing
Managers should trust employees to be involved in the managers with tools for success of both the organization and
decision-making process instead of excluding them. Forming employees. Yukl distinguishes between leadership and man-
employee subcommittees and allowing employees to partici- agement values by stating that “managers value stability, order,
pate in the interview process of potential candidates are ex- and efficiency, and they are impersonal, risk-adverse, and
amples of staff empowerment. Employees who have a voice in focused on short-term results. Leaders value flexibility, inno-
decision making tend to accept and promote changes in their vation, and adaptation; they care about people as well as
work environment. economic outcomes, and they have a longer-term perspective
Management often has three levels: top, middle, and supervisory with regard to objectives and strategies.”1(p6)
management.2 Chief executive officers and company presidents
are examples of top management. Top management works SELECTED STYLES OF LEADERSHIP
closely with the board of directors in developing overall Not all leaders exhibit the same leadership traits. Leadership
strategic plans. Middle managers are responsible for ensuring style affects the entire unit, including employee morale, and
that tasks are accomplished through supervising, organizing, ultimately can affect the quality of patient care. Many leaders
and overseeing day-to-day activities. Supervisory managers identify with one of three common styles: authoritarian/
report to middle managers and help ensure that their autocratic, democratic/participative, or laissez-faire/free rein.
subordinates’ performance meets expectations.

Three main skill sets are needed in management: technical, Authoritarian/Autocratic

human relations, and conceptual skills. Supervisory managers These leaders make all strategic decisions without consulting
need the greatest amount of technical skills and the lowest their staff members and reinforce a punitive environment.
amount of conceptual skills because they are responsible Everyone has heard the saying “knowledge is power,” and
for daily operations and rely on their superiors to use their these leaders believe that withholding information from
conceptual skills in making decisions. Middle managers need employees maintains power over others. The authoritarian
the three skills in more equal amountsdthey must be tech- leadership style is generally not well received. This style can
nically skilled, possess human relations skills, and be able to contribute to conflict with employees and failure of team
conceptualize the overall objective of the organization. They building over time. However, there may be situations, such as
manage supervisors but rely on top management for guidance an emergency or crisis, or instances with new or untrained
in meeting strategic goals. Top managers need to have employees, in which an autocratic style is both necessary and
the largest amount of conceptual skills for formulating the effective. These situations are limited and are typically related
organization’s vision.2 to short-term problems.5

A COMPARISON OF ROLES Democratic/Participative

Managing is coping with complexity and establishing control Democratic leaders value relationships and involve team
and predictability, whereas leadership is coping with and members when establishing and identifying essential goals and
promoting change and adaptability. Managers plan and making decisions. A democratic leader’s subordinates will

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August 2016, Vol. 104, No. 2 Leadership and Management Roles

develop procedures and strategies to achieve the established an increase in interventional, invasive, and surgical procedures
goals, and the leader will provide them with performance that could possibly be medically managed. The media have
feedback. The democratic leader encourages accountability reported cases of fraudulent billing to the Centers for
and responsibility. A strength of this style is involvement of Medicare & Medicaid Services for performing unnecessary
team members in making some, but not all, decisions. By medical procedures.8 Congressional hearings recently have
allowing the team to make some decisions, the leader fosters been held regarding abrupt and precipitous increases in
an environment of trust and shows that team member opin- medication prices.9 Media coverage of ethical issues in health
ions are valuable.5 A drawback to this leadership style is the care has become common, which has raised awareness of
time needed to facilitate participation. For this reason, the ethical issues among health care leaders, who must be
democratic style is slower paced, but taking the time to especially cautious and moral in their practice.
involve team members in decisions can be rewarding for the
leader and staff members alike.
LEADERSHIP ISSUES
Perioperative professionals have long assumed that to manage
Laissez-faire/Free Rein an OR, one must be an experienced perioperative RN, or an
The laissez-faire leadership style works well with highly RN at a minimum. Nurses and other health care leaders who
motivated teams, because little supervision is provided. may be involved in the process of choosing an OR manager
Managers set objectives, and the employees are free to do also have assumed that a clinical background is needed in this
whatever is appropriate to accomplish those objectives.5 Some role. Historically, staff members have believed that a good
leaders allow working from home or flexible hours as long clinician or perioperative nurse inherently will be a good
as the objectives are met, which may increase employee manager. Some still believe these assumptions to be true
satisfaction. This type of leadership is not helpful to employees because there is no core curriculum that teaches the necessary
who need structure from their leaders. For instance, an skills to be a perioperative nurse manager, and there is little
inexperienced nurse may require more instruction and guidance research-based evidence on who is best suited to lead an OR.
and therefore may function better under a democratic leader. At many facilities, an advanced degree is not a requirement for
an OR management position. According to AORN’s 2015
ETHICS AND LEADERSHIP Salary and Compensation Survey, 53.7% of nurse managers
According to Nickels et al, ethics are the “standards of moral (N ¼ 717) hold a bachelor’s degree (in nursing or another
behavior; [behaviors] accepted by society as right versus field) and 19.3% of nurse managers hold a master’s degree (in
wrong.”2(p92) Ethics start at the top of the organization in the nursing, business, or another field).10 Perioperative nurse
behavior modeled by senior leaders, and high standards must managers often have no mentors and learn on the job.11
be set. The most effective leaders treat employees fairly, and Recently, education and professional development resources
they highly regard integrity.6 Employee expectations must be have become available through AORN and the Competency
made clear and enforced. Ethical issues are not uncommon & Credentialing Institute. This includes AORN’s Center for
in the OR environment, and nurse leaders may find a basic Nursing Leadership12 and the Certified Surgical Services
introduction to ethical concepts helpful. Manager certification program.13

Ethics and obligation are strongly aligned. Consistency,

commitment, dependability, and respect are obligations of Challenges
strong leaders. Leaders who are attuned to ethics fulfill an Working in an OR is challenging, and managing an OR is
individual duty or obligation to do what is morally right. even more so. Some OR managers are physicians, business-
Leadership roles can sometimes present situations that chal- minded (nonclinical) managers, or seasoned OR nurses.
lenge a person’s basic morals and values, and the general public Irregular work hours with increased regulations and other
has scrutinized ethical decision making by organizational demands, such as attending leadership meetings or furthering
leaders because of well-publicized ethical lapses. one’s education, do not make this position attractive to many
nurses. Nurses who value time with family and friends may
There are examples of ethical lapses in the American health care not be attracted to the high workload required to lead an OR.
system. In recent years, the problem of physicians performing Skilled, seasoned nurses who do not necessarily have mana-
unnecessary procedures has fallen under public scrutiny.7 The gerial experience are often placed in management and leader-
health care system’s reimbursement process lends itself to ship roles. In addition, the climate for health care leaders has
encourage providers to do more with and for less, prompting become more complicated, as Belasen et al4 observed:

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Cox August 2016, Vol. 104, No. 2

The [health care] industry has grown more complex with new et al4 provide suggestions on how a health care organization
challenges for organizations to collaborate, prove their rele- can plan for hiring a new chief executive officer, and some
vance, institute efficiencies, satisfy patients, embrace new of their advice is applicable to hiring a perioperative nurse
technologies and clinical advancements, manage relationships manager. When considering candidates for a perioperative
with a shifting array of stakeholders, demonstrate that their nurse manager position, hospital administration must
efforts translate into improved health for the people they evaluate the candidates against a short-term emergency time
care for, and submit all their work to the universe of frame and a medium or long-term time frame. The
public scrutinydand leaders must bring all challenges into administration will want the position filled quickly but must
alignment.4(p307) consider who will be the best fit for the position on a long-
term basis. New managers also require support through
Because of these challenges facing perioperative nurse leaders, coaching and mentoring. Hospital administrators can
it is not shocking that OR manager positions have high smooth the transition for the new manager by removing
turnover and many facilities throughout the United States unnecessary barriers to create a comfortable environment.4
have open OR manager positions.
Nursing leaders should mentor and meet with every
Skills employee at hire and at defined intervals to determine goals
Leaders in any position must exhibit leadership qualities such as and professional development opportunities. Leaders must
flexibility, interpersonal skills, and the ability to mentor and hire high-quality employees and should be available as
build trust.6 Transparency is necessary for accountability. All mentors to assist them in meeting their professional goals.
stakeholders must be knowledgeable of the company’s facts If employee goals are defined early and consistently, em-
and figures.2 New managers may need formal training in ployees who desire a leadership position will already be
finance and strategic management, and existing managers prepared and able to step up to fulfill a leadership role should
must recognize the need for ongoing professional development the need arise.
to stay current.11 The OR is a complex setting in which
efficiency and patient safety are paramount. Surgical services CONCLUSION
are a large part of the revenue generated in health care The challenges for those who aspire to leadership positions in
organizations, and perioperative nursing leaders are charged the perioperative setting are plentiful. A better understanding
with balancing the organization’s financial needs, not only in of the role of leaders and managers in this setting may be
the perioperative arena, but in the larger health care system.11 helpful to those who take on these challenging roles or those
who aspire to do so. This column has presented some of the
Perioperative managers must understand the roles of various
latest thoughts on leadership and management and also briefly
practitioners in the perioperative environment, including (but
touched on the topics of ethical leadership and succession
not limited to) surgeons, anesthesia professionals, advanced
planning. For those working in the perioperative field, there
practice nurses, physician assistants, medical students, surgical
are ample resources available to further knowledge in this area.
residents, anesthesia technicians, RNs, surgical technologists,
Additional reading and study in this area may fulfill a small
housekeeping staff members, orderlies, and patient care assis-

portion of the need for continuous professional development
tants. The manager must be knowledgeable of scope of prac-
for perioperative nursing leaders.
tice, laws, and rules governing each role, if applicable.
Perioperative managers must appreciate the dynamic OR
environment and be flexible and adaptable. Patient and staff
References
safety is paramount in this role, and managers must work
1. Yukl GA. Leadership in Organizations. 8th ed. Upper Saddle River,
collaboratively with many disciplines. They must lead with NJ: Pearson Education, Inc; 2013.
confidence and knowledge while also implementing evidence- 2. Nickels WG, McHugh JM, McHugh SM. Understanding Business.
based practice. 9th ed. New York, NY: McGraw-Hill Companies, Inc; 2010.
3. Morgan J. 5 must-have qualities of the modern manager. Forbes.
http://www.forbes.com/sites/jacobmorgan/2013/07/23/5-must-have
Succession Planning -qualities-of-the-modern-manager/#770a869860d5. Published July
Many health care facilities do not have a formal succession 23, 2013. Accessed February 25, 2016.
plan in place for when a long-time perioperative nurse man- 4. Belasen AT, Eisenberg B, Huppertz JW. Mastering Leadership:
ager leaves an organization, although many managers have an A Vital Resource for Healthcare Organizations. Burlington, MA:
assistant who could fulfill the interim manager role. Belasen Jones & Bartlett Learning, LLC; 2016.

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August 2016, Vol. 104, No. 2 Leadership and Management Roles

5. Frandsen B. Nursing leadership: management & leadership styles.

American Association of Nurse Assessment Coordination. https://
www.aanac.org/docs/white-papers/2013-nursing-leadership--- Joyce A. Cox, MBA, MSN,
management-leadership-styles.pdf?sfvrsn¼4. Accessed March CNP, CNOR, CRNFA, OCN,

print & web 4C=FPO

3, 2016. CHPN, is the director of
6. Robbins SP, Judge TA. Organizational Behavior. 14th ed. Upper strategic care and community
Saddle River, NJ: Prentice Hall; 2010. relations at FairHoPe Hospice
7. Eisler P, Hansen B. Doctors perform thousands of unnecessary and Palliative Care, Inc, and a
surgeries. USA Today. http://www.usatoday.com/story/news/nation/ nurse practitioner in general
2013/06/18/unnecessary-surgery-usa-today-investigation/2435009/. surgery at Fairfield Healthcare
Published June 20, 2013. Accessed February 25, 2016. Professionals, Lancaster, OH. As
8. Healthcare fraud. Healthcare Business & Technology. http://www a recipient of an honorarium from
.healthcarebusinesstech.com/healthcare-fraud/. Published 2014. the Competency & Credentialing
Accessed February 25, 2016. Institute, Ms Cox has declared an affiliation that could be
9. Rockoff JD. Rising drug costs to be in focus at congressional perceived as posing a potential conflict of interest in the
hearing. The Wall Street Journal. http://www.wsj.com/articles/rising publication of this article.
-drug-costs-to-be-in-focus-at-congressional-hearing-1449311407.
Published December 5, 2015. Accessed February 25, 2016.
10. Bacon DR, Stewart KA. Results of the 2015 AORN salary and
compensation survey. AORN J. 2015;102(6):561-574.
11. Stobinski JX. Operational management: session 1. Presented at:
Surgical Services Summit; December 9, 2015; Las Vegas, NV.
12. Center for Nursing Leadership. AORN, Inc. http://www.aorn.org/ This CE meets eligibility requirements to recertify the
center-for-nursing-leadership. Accessed March 3, 2016. Certified Surgical Services Manager (CSSM) credential,
13. Certificate Program for Surgical Services Management. and eligibility requirements to apply for the CSSM
Competency & Credentialing Institute. http://www.cc-institute.org/ exam. Learn more at cc-institute.org/CSSM.
certificate-programs/management. Accessed March 3, 2016.

www.aornjournal.org AORN Journal j 159

LEARNER EVALUATION

Continuing Education:
Leadership and Management
Roles: Challenges and Success
Strategies 1.0 www.aornjournal.org/content/cme

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7.

8.
Will you be able to use the information from this article
in your work setting?
1. Yes 2. No

Will you change your practice as a result of reading this

article? (If yes, answer question #8A. If no, answer
.aornjournal.org/content/cme. Rate the items as described below.
question #8B.)
PURPOSE/GOAL
To provide the learner with knowledge of best practices related 8A. How will you change your practice? (Select all that
to leadership and management roles and challenges facing the apply)
modern nursing leader. 1. I will provide education to my team regarding why
change is needed.
OBJECTIVES 2. I will work with management to change/implement
To what extent were the following objectives of this a policy and procedure.
continuing education program achieved? 3. I will plan an informational meeting with physicians
1. Describe the differences between leadership and man- to seek their input and acceptance of the need for
agement. change.
Low 1. 2. 3. 4. 5. High 4. I will implement change and evaluate the effect of
the change at regular intervals until the change is
2. Identify different leadership styles. incorporated as best practice.
Low 1. 2. 3. 4. 5. High 5. Other: __________________________________
3. Discuss ethical issues perioperative leaders and managers
8B. If you will not change your practice as a result of
may encounter in health care.
reading this article, why? (Select all that apply)
Low 1. 2. 3. 4. 5. High
1. The content of the article is not relevant to my
4. Explain the challenges facing the modern nursing leader. practice.
Low 1. 2. 3. 4. 5. High 2. I do not have enough time to teach others about the
purpose of the needed change.
CONTENT 3. I do not have management support to make a
5. To what extent did this article increase your knowledge change.
of the subject matter? 4. Other: __________________________________
Low 1. 2. 3. 4. 5. High
9. Our accrediting body requires that we verify the time
6. To what extent were your individual objectives met? you needed to complete the 1.0 continuing education
Low 1. 2. 3. 4. 5. High contact hour (60-minute) program: _______________

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