ment are needed to fully secure the advantages of these five management practices. Because HCOs vary in the extent to which they currently employ these practices, as well as in their available resources, collaborations with other HCOs can facilitate more widespread adoption of these practices.

This chapter takes a detailed look at the crucial role of transformational leadership and evidence-based management in accomplishing the changes required in nurses’ work environments to improve patient safety. We first discuss transformational leadership as the essential precursor to any change initiative. We then review in turn the five management practices enumerated above and describe their uneven application in nurses’ work environments. Next, we present several models for evidence-based management in nurses’ work environments. Finally, we examine how evidence-based management collaboratives can be used to stimulate the uptake of health care quality improvement practices. During the course of the discussion, we offer four recommendations (highlighted in bold print) for addressing the deficiencies in nurses’ work environments through enhanced leadership and management practices.


The central function of leadership is to achieve a collective purpose (Burns, 1978). Not surprisingly, leadership has been observed to be the essential precursor to achieving safety in a variety of industries (Carnino, undated), a critical factor in the success of major change initiatives (Baldridge National Quality Program, 2003; Davenport et al., 1998; Heifetz and Laurie, 2001), and key to an organization’s competitive cost position after a change initiative. In a study of hospital reengineering initiatives in U.S. acute care hospitals from 1996 to 1997, only the chief executive officer’s (CEO) involvement in core clinical changes had a statistically significant positive effect on the cost outcomes of reengineering (Walston et al., 2000). The exercise of leadership has also been associated with increased job satisfaction, productivity, and organizational commitment among nurses and other workers in HCOs (Fox et al., 1999; McNeese-Smith, 1995).

In his Pulitzer Prize–winning, seminal study on leadership, James Burns identifies the essential characteristics of leadership (as distinct from the wielding of power) and distinguishes “transactional” leadership from the more potent “transformational” leadership (Burns, 1978). He stresses that leadership, like the exercise of power, is based foremost on a relationship between the leader and follower(s). In contrast to power, however, leadership identifies and responds to—in fact, is inseparable from—the needs and goals of followers as well as those of the leader. Leadership is exercised by engaging and inducing followers to act to further certain goals and pur-

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