Reflections on a decade of authentic leadership research in health care

My recent retirement from academia and an invitation to write this editorial have afforded me the opportunity to reflect on my work in researching authentic leadership theory in nursing and health care. When I was completing my PhD more than a decade ago, I searched for a leadership perspective that aligned with my learning in a variety of previous practice and leadership roles. Basically, my leadership experiences contributed to a belief that authenticity is a key: being oneself is extremely important to personal health and well-being and to effectiveness as a leader. Discovering authentic leadership theory (Avolio, Gardner, Walumbwa, Luthans, & May, 2004), provided me a sense of personal meaning in the descriptions of leadership behaviours and processes that were proposed to influence staff outcomes. A doctoral student colleague, Edmund Walsh, agreed to assist me with the goal of presenting a summary of authentic leadership theory, the current state of evidence and some implications for contemporary leadership practice internationally. In one of my first published papers (Wong & Cummings, 2009), we shared a description of how authentic leadership might provide guidance for nurse leaders in creating healthier work climates. The emphasis on leader and staff development and leveraging the positive capacities in the workplace may offer significant guidance for creating positive changes in work environments. In our view, authentic leadership has shown potential to illuminate the ways in which authentic leaders and staff influence work outcomes. The careful attention to leader and staff self-awareness, ethical values, positive psychological resources and propositions that connect model constructs establish authentic leadership as both a contemporary leadership approach and a return to genuine and timeless leadership qualities and processes. The beginning of the twenty-first century was marked by several highly publicized corporate ethics breaches, leading to a strong desire for honesty and integrity in leadership. Founded on this discontent, desire for authenticity in leaders, and the tenets of positive organisational psychology, authentic leadership theory soon appeared in the business and management literature (Walumbwa, Avolio, Gardner, Wernsing, & Peterson, 2008). Defined as “a pattern of transparent and ethical leader behavior that encourages openness in sharing information needed to make decisions while accepting followers' inputs” (Avolio, Walumbwa, & Weber, 2009, p. 423), authentic leadership is comprised of the following four components: self-awareness, internalized moral perspective, relational transparency and balanced processing (Gardner, Avolio, Luthans, May, & Walumbwa, 2005; Walumbwa et al., 2008). Through self-reflection and acquiring feedback from others, authentic leaders are dedicated to achieving heightened self-awareness. Self-awareness refers not only to leaders possessing a thorough recognition of their strengths, weaknesses and values, but also involves obtaining and maintaining an accurate understanding of how they influence and are perceived by others. The actions of authentic leaders are grounded in their positive moral and ethical values. They act in congruence with these values even when faced with pressure to act differently, which is called internalized moral perspective. Authentic leaders understand the importance of fostering trusting relationships with their staff members. They develop such relationships, in part, through relational transparency, which encompasses communicating openly and honestly with their staff members and encouraging the reciprocation of this communication style. Finally, authentic leaders undertake balanced processing when making decisions, which involves soliciting and truly listening to and considering diverse opinions, including those which are incongruent with their personal beliefs. Armed with this input, authentic leaders make fair and objective decisions (Gardner et al., 2005; Walumbwa et al., 2008). In addition to these four components, Avolio et al. (2004) proposed that authentic leaders enhance the work attitudes and behaviours of staff through the processes of personal identification with the leader and social identification with the workgroup. The authentic leader's behaviour is grounded in their psychological resources of hope, optimism, trust and positive emotions to model and promote these qualities in others. When an authentic leader role models these behaviours, she/he enhances staff attitudes such as motivation and satisfaction with work and, in turn, these positive attitudes may lead to important staff behaviours such as improved performance outcomes. Alilyyani, Wong, and Cummings' (2018) systematic review of research (January 1, 2004 through January 31, 2017) analysing the antecedents, mediators and outcomes of authentic leadership in health care included 21 studies reported in 38 papers. Significant associations between authentic leadership and 43 outcomes were grouped according to staff and patient outcomes. Most studies (71%) were conducted in Canada and the United States while the remainder (29%) were completed in India, South Africa, Iran and Belgium. Studies were carried out predominantly in acute care settings and used correlational designs. However, the review included three time-lagged studies, which provided stronger evidence for determining cause and effect. Review findings showed support for relationships between authentic leadership and trust in managers, job satisfaction, and work environment factors such as work engagement, empowerment and workgroup relationships. In line with authentic leadership theory, negative relationships between authentic leadership and detrimental staff outcomes including bullying, incivility and burnout were presented. Meanwhile, only one study tested a connection between authentic leadership and objective patient care outcomes. For this editorial, we conducted a literature search using Scopus and Google Scholar databases and located 27 studies of authentic leadership in nursing published since the Alilyyani et al. (2018) review. Although not an exhaustive or rigorous review, we found an increasing percentage of studies (63%), conducted outside of the United States and Canada, in 11 countries such as Europe, South, East and Southeast Asia. Most studies continue to be cross-sectional and conducted among acute care nurses leaving gaps in the literature to be addressed in the future. Nonetheless, the increasing international focus of studies may be indicative of the relevance of authentic leadership in health care across the globe. Outcomes examined continue to be work attitudes and behaviours such as empowerment and job turnover intentions. Although there were no studies of patient outcomes, there were examples of studies examining authentic leadership in relation to elements of care quality such as frequency of errors and safety climate. Increasing attention to the measurement of authentic leadership in nursing samples was reflected in four studies assessing the psychometrics of the two main authentic leadership measures, the Authentic Leadership Questionnaire (ALQ; Avolio, Gardner, & Walumbwa, 2007) and Neider and Schriesheim's (2011) Authentic Leadership Inventory (ALI). Notably, one recent intervention study (Frasier, 2019) showed that a pilot leadership development programme contributed to increased use of authentic leadership behaviours by nurse managers. The programme consisted of workshop sessions, peer coaching and support. In a larger study, Baron (2016) demonstrated that a three-year action-learning-based leadership development programme led to increased authentic leadership and mindfulness amongst leaders in a variety of middle management roles in Quebec, Canada. This programme primarily focused on authentic leadership development using application exercises with peers, examining real-world leadership problems and coaching. The results of these studies not only support the notion that authentic leadership can be developed but also suggest that investment in leadership development by organisations may be effective. Together with Western University colleagues and graduate students, we have published 10 papers examining various mediators and nursing work outcomes of authentic leadership in addition to 15 (published and in progress) papers from masters and PhD students' work. Through this work, we added to the validation of the ALQ measure and findings suggested that authentic leadership of unit managers was positively associated with job satisfaction, work engagement, performance, empowerment, voice behaviour, perceived quality of care and interprofessional collaboration and negatively associated with bullying, burnout, job turnover intentions and adverse patient outcomes. Moreover, these relationships were mediated through processes such as positive identification with the manager and the workgroup, trust in the manager, structural empowerment, nursing work environment and person-job fit, which are congruent with propositions outlined in the authentic leadership theory. A couple of current issues in health care are particularly applicable to the principles of authentic leadership: increased reports of incivility and bullying in health care workplaces and decreased trust in leaders and organisations (Berry, Gillespie, Fisher, Gormley, & Haynes, 2016; Hutchinson, 2018). Edmonson, Bolick, and Lee (2017) argued that nurse leaders have “a moral imperative” (p. 13) to not only recognize when bullying exists but also to commit to action in order to prevent and end bullying. Research findings of Laschinger and Fida (2014) showed that authentic leadership behaviours at baseline were associated with reduced work-related bullying and burnout of new graduate nurses one year later. This evidence reinforces the view that authentic leaders may influence workplace relationships by role modelling positive interactions and establishing policies on workplace conduct. Leaders who are open and honest in their communications with others and embody reliability and integrity in their relationships are likely to promote high standards of behaviour and intervene effectively to address bullying. Workplace relationships require a foundation of trust to make work environments safe, healthy and productive; moreover, high trust cultures have been shown to promote psychological and physical well-being (Inceoglu, Thomas, Chu, Plans, & Gerbasi, 2018; Lowe, 2019). Hutchinson (2018) raised concern about the recent deterioration of public trust in organisations and leaders and whether nurse leaders need to be concerned about their influence on the public's trust in nursing and in ensuring the reliable delivery of health care. Except for a few studies (Coxen, van der Vaart, & Stander, 2016; Wong & Giallonardo, 2013), there is still little systematic study of trust in health care settings and examination of how nursing leadership behaviours affect nurses' trust and work outcomes (Hutchinson, 2018; Wong & Cummings, 2009). Authentic leaders build trust with others through positive role modelling of honesty, integrity and ethical principles in the development of leader-staff relationships. Nurse leaders who place the issue of enabling trusting work climates in the foreground in the current era of increasing public distrust of institutions would be acting in concert with key values of authentic leadership (Hutchinson, 2018). Significant growth in authentic leadership research internationally and the relevance of its tenets to current issues in health care work environments suggest authentic leadership offers a sound foundation for leadership practice and development within health care organisations. Although the evidence base is encouraging, future research must include longitudinal and interventional studies to confirm the links between authentic leadership and outcomes. Expansion of studies to include a range of health care professionals in a wider array of settings such as long-term and community care and mental health care is essential (Alilyyani et al., 2018). Finally, the examination of predictors of authentic leadership such as personal history, specific skills and features of organisational climate plus more attention to patient and organisational outcomes associated with authentic leadership are necessary to promote a full assessment of authentic leadership's potential benefits to health care. While it has been almost 15 years since the publication of authentic leadership theory, the desire for authenticity and high ethical standards in leadership persists and the message of authentic leadership is just as relevant today as it was then, perhaps moreso.

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