Original article

Transformational leadership: moving

total quality management to world-class
organizations
A. J.Trofino EdD, CNAA, FAAN
Associate Professor, The University of Nevada, Department of Nursing, Las Vegas, Nevada, USA

Keywords Abstract
Boundarylessness,
Transformational values and competencies will become critically important by the
Community, Learning,
Total Quality
year 2001 if we are to achieve a health system that fosters community well-being
Mangement, and basic care for all, financed through a combined public–private partnership
Transformational, that is cost effective and uses treatments that unite body, mind and spirit. This
World Class article will focus on the use of transformational leadership as a strategy to move
health-care organizations beyond traditional values and approaches by building
upon the core values of total quality management (TQM). Learning organizations
will emerge and finally world-class organizations will evolve, combining the
characteristics of total quality and learning organizations, and more. A world-class
organization can be described as being the best in its class or better than its
competitors in the community, state, nation or world.

Introduction Total quality management to

Correspondence address: Joan
Trofino, The University of
Nevada, Las Vegas, Department
of Nursing, 4505 Maryland
Parkway, Box 453018, Las
Vegas, Nevada 89154-3018,
USA
Tel: (702) 895-3342
Fax: (702) 895-4807
E-mail:
jotrofino@ccmail.nevada.edu
To manage is to control; to lead is to liberate
(Owen 1990, p. 53).
Transformational values and competencies will
become critically important by the year 2001 if we
are to achieve a health system that fosters commu-
nity well-being and basic care for all, financed
through a combined public/private partnership
that is cost effective and uses treatments that unite
body, mind and spirit. Nurses, by virtue of their
knowledge, professional status and numbers, are in
an excellent position to influence the use of trans-
formational strategies in many health-care organi-
zations throughout the world.
world class
Building organizations of the future will re-
quire nursing leaders (at all levels of the organiza-
tion and community) to be willing to say farewell to
command and control, to become committed to
removing or reducing the clutter from exces-
sive policies, procedures (Wheatley 1999) regula-
tions and rituals, and to be willing to share power.
They should seek to partner and collaborate
with colleagues from all groups that impact on
the clients’ needs in their specific health-care
system.
Transformational nursing leaders are needed
to help move total quality management (TQM)

© 2000 International Council of Nurses,

Nurses International Nursing Review, 47, 232–242 232
Transformational leadership: moving total quality
organizations to learning and finally to world-class
organizations. Each stage of development serves
as the foundation for the next: the TQM stage
enhances client satisfaction and the learning stage
liberates employee innovation, thus gaining for an
empowered workforce the knowledge and skills
necessary to achieve the final stage of world class –
organizations with consistently high world-class
client outcomes.
Transformational leadership
defined
Burns (1978) described transformational leader-
ship as a process that motivates followers by appeal-
ing to higher ideals and moral values. According to
Trofino (1992, p. ix), ‘transformational leaders have
the ability to clearly articulate a vision of the
future . . . they are the myth-makers, like story-
tellers they capture our imagination with the vivid
descriptions of the wonderful future we will build
together’. Tichy & Devanna (1990) believed that
transformational leaders engage in a process; this
results in a sequence of phases that include recog-
nizing the need for change, creating a new vision
and institutionalizing the change. House (1995), in
a review of the change orientated or outstanding
leadership literature, which also included the
charismatic and visionary leadership literature,
indicated that the ‘majority of the approaches share
the common perspective that by articulating a
vision, fostering the acceptance of group goals, and
providing individualized support, effective leaders
change the basic values, beliefs, and attitudes of fol-
lowers so that they are willing to perform beyond
the minimum levels specified by the organization’
(Podsakoff et al. 1996, p. 260). Bass & Avolio (1994),
developers of the multifactor leadership question-
naire (MLQ), theorized that transformational lead-
ership comprises four dimensions the ‘Four I’s’.
These comprise:
1 Idealized influence (charisma), described as
leader behaviour that results in follower admira-
tion, respect and trust. This requires risk sharing
from leaders, a consideration of follower needs over
personal needs, and ethical and moral conduct by
leaders.
© 2000 International Council of Nurses, International Nursing Review, 47, 232–242
233
2 Inspirational motivation (IM). This dimension is
reflected by leader behaviours that offer meaning
and challenge to the followers’ work. These behav-
iours articulate clear expectations, demonstrate
commitment to organizational goals and arouse
team spirit through enthusiasm and optimism.
3 Intellectual stimulation (IS) transformational
leaders will solicit new ideas and encourage creative
problem-solving from followers. They will support
fresh and inventive approaches to performing work.
4 Individualized consideration (IC). This attribute
is reflected by leaders who listen attentively and pay
special attention to followers’ growth needs as well
as to their achievements, by providing strategies for
recognition and praise.
Transformational leadership,
vision and strategies
According to Jan Carlzon, the transformational
leader of SAS Airlines, a leader must facilitate for-
mulation of an organizational vision in which as
many stakeholders as possible have participated in
developing. The leader must create ‘an environment
in which employees can accept and execute their
responsibilities with confidence and finesse. To
succeed . . . the leader must be a visionary, a strate-
gist, an informer, a teacher, and an inspirer’ (Ackoff
1999, p. 21).
Ackoff (1999) believed that the transformational
leader can encourage and facilitate the production
of a mobilizing vision of a transformed organiza-
tional system. The leader, however, must be willing
and able to organize, inspire, effectively pursue
and maintain that vision, even when sacrifices are
necessary.
Transformational leaders link their inspiring
visions to strategies for implementing that
vision.Trofino (1996) moved a hierarchical, cen-
tralized, prescriptive, largely dependent nursing
division to a contemporary professional staff that
was self-directed, decentralized, independent and
driven by critical/strategic-thinking nurses at all
levels in the organization. Strategies to facilitate
these changes began when the leader developed a
vision and behaviours reflecting a belief in all nurses
as creative professionals who want to enjoy their
234 A. J.Trofino
work and achieve success; a belief that nurses are
capable of self-direction and, if properly motivated,
can solve even the most difficult and complex prob-
lems. The vision extended to the belief that an
empowering nursing practice environment would
bring out the best in people, concentrate on mean-
ingful systems building, support risk-taking and
innovation, focus on results and rewards, offer pro-
fessional options and treat all people with dignity
and respect. Furthermore, nursing knowledge
should combine clinical expertise with an under-
standing of basic management, financial and lead-
ership theory and skills. Such well-prepared expert
staff nurses would then be better prepared to
increase excellence in care delivery, unit manage-
ment and patient care quality, thus moving a trans-
formed nursing organization closer to world-class
client outcomes.
The following vision statement served as an
active roadmap to progress:
The nursing division’s mission is to provide safe,
quality nursing care that assists patients in
returning to their maximum level of wellness, or
to a dignified death. Each patient is viewed as
unique and is entitled to safe, confidential and
dignified care. As patient advocates, we are com-
mitted to providing the highest level of nursing
care in a cost-efficient manner, through the
creative and innovative utilization of existing
resources.
The nursing division recruits nurses of the
highest integrity and places them in positions
appropriate to their level of education, clinical
experience and expertise. Nursing governance is
reflected in shared decision-making processes
between practice and administrative nurses.
Active staff involvement in a councillor structure
promotes nursing autonomy and delegates
accountability and authority appropriately.
TQM fosters organizational excellence using a
collaborative, multidisciplinary approach to
process improvement for the benefit of the
patients, staff and members of the community.
Professional growth of the nursing staff is fos-
tered through the mentoring process and by par-
ticipation in centralized and decentralized edu-
© 2000 International Council of Nurses, International Nursing Review, 47, 232–242
cational opportunities. Participating in the facili-
tation and implementation of nursing research
expands the body of nursing knowledge and pro-
motes its use in the practice setting.
Nursing practice is differentiated with levels of
practice distinguished by education, experience,
expertise and peer review. Clinical decision-
making and the formulation of nursing diagnosis
is enhanced by Dorethea Orem’s Self-Care Deficit
Theory. State-of-the-art information technology
in the clinical practice setting supports and
enhances nursing documentation (Trofino 1996,
p. 43).
Specific strategies to implement
the vision
Specific strategies utilized to implement the vision
included:
• a decentralized hiring process, which included
involvement and decision-making of expert staff
nurses,
• evaluations, including peer review, merit review
and terminations conducted at the clinical level,
• division-wide education regarding the planning
process with clinical staff participating in goal-
setting annually,
• nursing committees designed with a specific
purpose, objectives and accountability and chaired
by management and expert clinical nurses,
• a participative communication system that in-
cluded nursing management, clinical co-ordinator/
assistant clinical co-ordinator meetings for
problem-solving, networking and systems building
on all shifts,
• a nursing newsletter and professional publica-
tions that included input from staff and manage-
ment nurses as well as physicians, when appropriate,
• quarterly nursing staff meetings to facilitate a
direct communication line to nurses by the com-
mittee chairman and the vice president of patient
care,
• an annual nursing meeting for the purpose of
reporting goal achievements to the entire hospital
and the surrounding community,
• the use of Quality Circles as a multidisciplinary
method of using brainstorming and consensus
Transformational leadership: moving total quality
building to improve selective quality issues, such as
the pharmacies method of medication distribution
and administration of medications by nurses, and
• financial support of academic and continuing
education; promotions and merit raises were linked
to educational achievements and performance.
A trusting environment was developed and con-
sistently enhanced by the chief executive officer and
chief nurse executive making walking rounds on all
shifts, biannually at a minimum. These rounds
offered all employees the opportunity to contribute
ideas directly to top administration and learn first
hand of organizational goals and objectives
(Trofino 1996).
Giving encouragement as a
transformational strategy
According to Davidhizar & Shearer (1997), while
giving encouragement is not considered a high
priority by health-care leaders, there is increasing
appreciation that encouragement is a transforma-
tional leadership technique that is related to job
productivity and quality work. The use of encour-
agement and/or positive reinforcement is a leader-
ship technique that fits in the current people-
orientated work climate. ‘Employees who feel a
supervisor is encouraging and consequently sup-
portive will be better workers. They will be more
willing to go the extra mile to ensure the job is done
well…When a supervisor gives encouragement,
feelings of caring and camaraderie increase in the
department, thus increasing employee morale and
making the unit a more pleasant place to work’
(Davidhizar & Shearer 1997, pp. 16–17). Transfor-
mational leaders take care to praise only when
honest credit is appropriate, as praise that is not per-
ceived as genuine will not be effective. Private and
public recognition are both important, however.
Praise at a public meeting can encourage those in
attendance to also affirm the individual, thus
making the praise more significant than if it was
only shared in private (Davidhizar & Shearer 1997).
Trofino (1990, 1996) identified a variety of mech-
anisms for encouragement and positive reinforce-
ment. These included the nurse’s annual meeting of
goal achievements, nursing excellence and individ-
© 2000 International Council of Nurses, International Nursing Review, 47, 232–242
235
ual commendation awards. Staff nurses were recog-
nized and rewarded with luncheons, plaques, pins,
cash awards, public praise, speaking engagements,
attendance at state and international nurses meet-
ings, and by expert staff nurses offering public testi-
mony before legislators on selective professional
issues.
Storytelling as a transformational
strategy
Transformational leaders often tell stories to break
resistant behaviours, build trust, achieve new atti-
tudes and focus energy towards a desired outcome.
Stories add the dimension of fun and excitement
that remind us, perhaps, of yet another age when
stories brought our childhood fantasies to life, only
now the story can be translated into real-life situa-
tions that might offer insight into and acceptance of
change. Abraham Lincoln, the 16th President of the
United States and known as the great emancipator,
was a legendary storyteller. As a communicator,
Lincoln liberally utilized stories and anecdotes, col-
loquial expressions, and symbols and imagery, in
order to influence and persuade his audience. His
‘down home’ figures of speech attracted people,
kept their attention and, in many cases, endeared
people to him.‘Stories were an important part of his
image as a common man, and he used them so fre-
quently they must have been genuine’ (Phillips
1992, pp. 159–160). Lincoln described his story-
telling to a friend: ‘They say I tell a great many
stories. I reckon I do; but I have learned from long
experience that plain people, take them as they run,
are more easily influenced through the medium of a
broad and humorous illustration than in any other
way . . . (Phillips 1992, p. 155).
Sharing power as a
transformational strategy
Transformational leadership is about sharing power
or empowerment. According to Kanter (1983, pp.
156–160):‘Empowerment is the creation of an envi-
ronment that ensures that people in the organiza-
tion get the power they need to innovate and be
creative. It is power circulation and power access’.
236 A. J.Trofino
Burns (1978, pp. 9–28) viewed power and leader-
ship as relationships:‘Leadership is a form of power,
‘raw’ power has the ability to be negative; while lead-
ership is always positive’.
Jack Welch, innovative chief executive officer and
chairman of the General Electric Corporation
described leadership/empowerment by stating
‘Ultimately, we’re talking about redefining the rela-
tionship between boss and subordinate. Instead of
hierarchy, there will be cross-functional teams.
Instead of managers, there will be business leaders.
Instead of workers being told what to do workers
will be empowered and given responsibility. My
view of the 1990s (and beyond) is based on the lib-
eration of the workplace. If you want to get the
benefit of everything employees have, you’ve got
to free them – make everybody a participant.
Everybody has to know everything, so they can
make the right decisions by themselves’ (Slater
1994, p. 108).
Davidhizar & Shearer (1997) assert that a truly
transformational leader has the ability to gain the
co-operation of all members of the team, depart-
ment, hospital, state, or nation. Feelings of shared
effort and shared power become co-mingled as
employees realize that their suggestion has been
incorporated into the objectives for running the
organization through a shared and motivating
vision. Empathy serves as a catalyst in motivating
others with the vision, building trust and identify-
ing common needs and forming common goals.
Empathy leads to the development of individual
team members and ultimately fulfilment of the
vision; employees gain a sense of increased personal
power and feel respected by leaders as persons with
power in decision-making and goal achievement.
Sharing power with employees encourages feel-
ings of personal strength (Davidhizar & Shearer
1997, p. 20).
Personal characteristics of the
transformational leader
Transformational leaders demonstrate self-
confidence and are dominant in their strong convic-
tion of the moral righteousness of their beliefs. They
© 2000 International Council of Nurses, International Nursing Review, 47, 232–242
are articulate in goal setting, and able to build excit-
ing future images of what can be; through this
image-building they arouse follower emotions and
commitment. Consider the burning passion and
righteous beliefs in the souls and minds of transfor-
mational leaders such as Florence Nightingale,
George Washington, Mahatma Gandhi or Martin
Luther King. Each of these famous transformational
leaders faced enormous challenges from a world
that was less than willing to accept their vision of a
more perfect society.
Transformational leaders are charismatic and
passionate. Senge (1994) identified that personal
power is not sufficient to influence transforma-
tional change. Rather, what is needed to succeed is
individual charisma combined with an engaging
vision, a set of personal values that others would
wish to emulate, as well as an unbounded passion to
serve as coach and mentor.
Hinkin & Tracey (1999) indicate that their
research of the MLQ developed by Bass & Avolio
(1994) demonstrated empirical support for three
behaviourally orientated dimensions of transfor-
mational leadership that are consistent with theo-
retical propositions. However, idealized influence
(charisma) may not be relevant for managers in
stable organizations. Crisis situations may be a nec-
essary precondition for a truly charismatic leader to
emerge. Clearly, studying the usefulness of transfor-
mational leadership in the turbulent times associ-
ated with paradigm shifts, the charismatic dimen-
sion will no doubt add the necessary ingredient to
move present-day TQM organizations to world-
class status. Transformational leaders support
uncensored communication with employees, even
during the uncertain times associated with budget
adjustments or downsizing. By forming focus
groups for employees and clients, making rounds
on all shifts and installing hotlines to answer
questions, they offer truthful, open and candid
responses for employee and client concerns.
Outcomes associated with the use
of transformational strategies
Trofino (1996) reported that over the 20 years from
1974 to 1994, patient/physician surveys were consis-
Transformational leadership: moving total quality
tently good to excellent. Nurse retention over two
decades remained 7 years for registered nurses
(RNs) and 8 years for licensed practical nurses. RN
certification was 44% and academic achievements
among a staff of 424 RNs included 42% with bac-
calaureate degrees. Nursing practice had been suc-
cessfully differentiated, and diverse role expansion
accomplished through ongoing cross-training and
unit clustering. Increased stability, along with con-
tinuing education, ensured that patients received
high levels of nursing expertise and also resulted in
excellent JCAHO surveys over 19 years. Medley &
Larochelle (1995) reported on the outcomes of a
research survey directed to 278 staff nurses selected
from a 40% random sample of 100–300-bed acute-
care hospitals located in Florida. The leadership
style of head nurses was identified by staff nurses
through the use of the Bass & Avolio (1994) MLQ.
The study results indicated that head nurses with
high transformational scores were more likely to
have staff nurses with higher job satisfaction scores
and a longer association with their staff nurses than
transactional-type head nurse leaders (an exchange
of reward for effort). This finding was also sup-
ported by Trofino’s (1996) anecdotal results over a
20-year time frame and may indicate that the TF
leadership style promotes retention, prevents turn-
over and enhances quality through a stable work-
force. Such findings would have economic implica-
tions for hospitals and other health-care agencies as
they strive to maintain quality and reduce turnover
costs. Dixon (1999) reported on the use of transfor-
mational change in an integrated health system
composed of five hospitals, urgent care centres,
behavioural services, home health, assisted living
and long-term care, with revenues in excess of $1
billion.
Throughout the transformational change pro-
cess, the focus remained on outcomes. Results de-
monstrated that client satisfaction surveys for
the flagship hospital, as well as for other hospitals
in the system, had risen to the 90th percentile
based on organizational scores of ‘very good’ to
‘excellent’. Employee satisfaction scores ranked
above the norm. in most indicators, as did physician
satisfaction.
The teamwork that served as the linchpin in the
© 2000 International Council of Nurses, International Nursing Review, 47, 232–242
237
changes within the health system may be credited
with resulting in savings of $27.8 million because of
ideas generated by the target-setting teams in 1997.
Lafferty (1998) views hospice theory and the role of
the hospice RN case manager to be compatible with
transformational leadership theory. She envisioned
the transformational leader as a culture builder and
linked the hospice RN case manager to the role of
culture builder. She believed that Hospice RNs must
develop transformational leadership characteristics
and become builders of a hospice organizational
culture as well as societal culture builders. It would
seem that this same notion should also be true for
nurses in all specialties as they increasingly extend
their efforts towards a global society and reach
towards world-class outcomes for people of all
cultures.
The paradigm shift
The global economy has created increasingly com-
petitive organizational environments. In the past,
efforts to improve quality also resulted in higher
costs, and organizations accepted this as an
expected outcome associated with improvements.
Under the new paradigm, successful organizations,
including health care, must drive up quality while
pushing costs down. Transformational leaders will
be needed to inspire flexible, multiskilled work
forces to bridge the barriers established by rigid job
descriptions and functional departments to achieve
what General Electric’s Chief Executive officer, Jack
Welch, has called ‘boundarylessness organizations’
(Slater 1994).
The boundarylessness company, or health-care
organization removes barriers between functions,
between levels and between locations. It reaches out
to staff and suppliers with the single purpose of
joining intellects and efforts in a common purpose,
to satisfy clients/customers. According to Welch:
‘the winners of the 90s (and beyond) will be those
who can develop a culture that allows them to move
faster, communicate more clearly, and involve
everyone in a focused effort to serve ever more
demanding (clients)/customers . . . Boundaryless-
ness . . . means engaging every mind on every
problem, leaving no one out, weighing no one’s
238 A. J.Trofino

ideas heavier because of the colour of their collar or
their skin, their gender, their nationality . . .’ (Slater
1994, pp. 106, 110).
TQM
According to Hodgetts et al. (1994), total quality is
an organizational strategy that drives a continuous
ongoing programme of process improvements.
Core values include a customer focus with methods,
processes and procedures developed to meet inter-
nal and external clients. Top leadership supports the
strategy both in word and in actions. There is full
organizational involvement, with everyone receiv-
ing a quality education. A system to reward quality
achievements is in place, and efforts to reduce the
time cycle in service is often a motto of the organi-
zation, e.g. ‘If it cannot be done better, focus on
doing it faster!’. The idea of prevention is designed
into the service with the emphasis on preventing
errors rather than detecting them. Real data is used
to measure progress as opposed to intuition and gut
feeling, and there is a constant monitoring of the
external environment. This action attempts to
assess the competition as well as client expectations,
forecasting the level of service necessary for clients
over the next 12–36 months and assessing if it is
attainable. Organizational partnerships among dis-
ciplines, vendors and clients work to create a collab-
orative network to drive up quality and keep costs
down. Organizational commitment and responsi-
bility towards communities is enhanced by sharing
quality-related information with other organiza-
tions, eliminating service defects and reducing
product waste, such as excessive laboratory tests and
duplication of services.
Learning organizations
Senge (1990) believed that organizations that will
truly surpass all others in the future will be those
that draw upon people’s commitment and capacity
to learn at all levels in the organization. Learning
organizations support people in their natural desire
to grow and expand their capacity to create the
results that they really desire. New and expansive
patterns of thinking are encouraged, collective aspi-
ration is released and people are constantly learning
to learn and work collaboratively together. Learning
organizations exist because it is natural for people to
learn and they love to do it. In the learning organi-
zation they can become a part of an extraordinary
team and function together to produce outstanding
results. They trust each other, complement each
others’ strengths, compensate for each others’ limi-
tations and share common goals, which are larger
than individual goals, resulting in extraordinary
results. The cardinal characteristic of a learning
organization is the intense desire to learn, together
with a strong commitment to generate and transfer
new knowledge and technology. There is an open-
ness to the external environment as the learning
organization attempts to learn what is going on in
the world around it. Professional journals, research
reports, leadership briefings, talks and seminars by
distinguished experts that are open to all employees,
not only a select few, help to keep learning organiza-
tions fully aware of the external environment, the
competition, and provide important information
necessary to generate new creative ideas and solu-
tions to organizational problems.
Values developed in the learning organization
include an emphasis on shared vision, which
manages to bind people together around a common
identity as well as a sense of destiny. System thinking
is a conceptual framework, a body of knowledge and
tools developed over the years to help clarify the pat-
terns of interrelated actions, such that they may be
effectively changed. Personal mastery is the disci-
pline of constantly clarifying and deepening per-
sonal vision, focusing energies, developing patience
and viewing reality objectively. It is the learning
organization’s spiritual foundation. In learning
organizations, people expose their own thinking
effectively and permit their thinking to be influ-
enced by others. Team learning allows members of a
team to enter into a genuine ‘thinking together dia-
logue’. Team learning is essential today and serves as
the fundamental learning unit in contemporary
organizations; thus, unless teams learn the organi-
zation will not learn.
‘Metanoia’ is a Greek word that means a change of
heart; a shift in thinking, literally a transcendence.
It may be applied to the learning organization
as learning also involves a fundamental shift or

© 2000 International Council of Nurses, International Nursing Review, 47, 232–242

Transformational leadership: moving total quality
movement of the mind to create a new future.
‘Learning organizations anticipate change and use
adaptive learning and generative learning to
enhance their capacity to be creative and innovative.
Real learning enables people to do things they were
never able to do, to extend their capacity to create, to
view the world from a new perspective and their
relationship to it and to become a genuine part of
the generative process of life’ (Senge 1990, pp.
6–14).
World-class organizations
World-class organizations are recognized as the best
in the world and they strive to maintain that status.
Any organization, regardless of size or type, can
aspire to be world class. While some organizations
have achieved world-class renown in selective areas
such as quality management, information or as
centres for the diagnosis and treatment of cancer
conditions (such as Memorial-Sloan Kettering in
New York, USA), few have achieved the distinction
of world class as whole organizations.
World-class organizations excel in the dimen-
sions that drive both total quality and learning orga-
nizations, and beyond. Their most important char-
acteristic is a total customer focus with all systems
and staff committed to serve external and internal
customers. Their flat organizational structure keeps
all staff close to the client, gathering data connected
with clients’ current and future needs, and thus cre-
ating new demands for their goods and services
based upon a client wish list.
World-class organizations continuously improve
what they do, an attitude of never being satisfied
prevails, as well as a persistent desire to become
increasingly excellent. In pursuing excellence,
world-class organizations utilize global network-
ing, partnerships, alliances and information-
sharing. In an effort to respond quickly and deci-
sively to change, world-class organizations become
‘virtual organizations’. Virtual organizations utilize
outsourcing and temporary alliances; they are then
able to take advantage of rapidly changing opportu-
nities, and can reduce costs and share risks when
appropriate. A multiskilled work force increases
fluidity and resilience; employees who have mas-
© 2000 International Council of Nurses, International Nursing Review, 47, 232–242
239
tered multiple skills and/or have been cross-trained
to perform easily in more than one area provide the
operational flexibility necessary for quick changes,
continued top performance in multiple sites and
quality outcomes, e.g. critical-care nurses cross-
trained to function in multiple critical-care areas
(Brady et al. 1990). Human resources are widely rec-
ognized in world-class organizations as their most
important asset. Employees are effectively energized
in creative decision-making and problem-solving.
There is shared ownership of problems and solu-
tions, strong commitment and involvement by top
management, communication of consistent goals
and objectives to all levels, and effective use of
recognition and rewards.
In world-class organizations an egalitarian
climate prevails. The organization and its partici-
pants respect and value everyone, both those in the
organization as well as those who it serves: clients,
suppliers, the community, the environment, and all
others, both local and global. World-class organiza-
tions are supported and driven by advances in tech-
nology. Information, differentiation and resilience
are essential, as is as a creative staff, for serving the
client most effectively. Information technology
plays a leading role in supporting the world-class
organization (Hodgetts et al. 1994).
Moving health-care organizations
to world class
The most powerful force in the health-care market
must be viewed by all providers as the ultimate
client, the one who seeks ‘whether healthy or ill to be
assured of access to a health care giver’ (Beckham
1999, p. 86). The ultimate client is always a member
of a community (either the local or world commu-
nity), and organizational focus must be on their
needs as identified by them through data collected
from surveys, questionnaires, focus groups, anecdo-
tal stories, town meetings and participation of
health-care providers with community groups and
on community boards. World-class health-care
organizations will demonstrate serious intent by
directing their full energies in responding to com-
munity needs and outcomes; they are always exter-
nally driven.
240 A. J.Trofino
World-class health-care organizations demon-
strate their commitment to people and communi-
ties by placing them first in their mission and vision.
They seek to redesign traditional provider-centred
clinical facilities into client and worker-friendly
havens of warmth, support and quiet, gentle effi-
ciency. As organizations evolve into world-class
health-care systems they will assume responsibility
for total community care. They will focus pro-
grammes and services on the health needs of the
undeserved, improve overall health-care outcomes
through evidence-based practice, and support link-
ages between health and community development.
Community accountability can only be achieved by
partnering with the community.
Community accountability
The boards of world-class health-care organiza-
tions will make a conscious effort to commit a
percentage of all profits to collaborative health-
enhancement projects. Such projects could include
seeking to engage themselves into co-operative ven-
tures with local governments, business and com-
munity organizations to provide free health-care
coverage to the uninsured, over selective periods of
time.
World-class health-care organizations will seek
to enhance school nurse programmes in local ele-
mentary schools to augment immunization drives,
along with health teaching, health promotion and
counselling among elementary school and high
school teenagers.
Block nursing programmes can also be made
available through partnerships with nurses from
local public health services, with the aim of keeping
the elderly of a neighbourhood in their own homes,
rather than in long-term care facilities. Such a
programme, which utilizes both professional and
volunteer community members in an informal
network of family, friends, neighbours and civic
groups, is becoming more interesting to funding
agencies such as the government and third-party
payers, in their efforts to contain costs (Jamieson
1990).
Congregational health ministry programmes led
by experienced nurses, which may include (in some
© 2000 International Council of Nurses, International Nursing Review, 47, 232–242
programmes) nurse practitioners and nurse case
managers, can provide health screening and, in
selected models, primary care to congregations of
neighbourhood churches in middle-class as well as
deprived communities (Acosta et al. 1999). Such
programmes have the power to reach clients unable
or unwilling to utilize traditional methods of care
delivery. The safe haven created by churches and
synagogues offers spiritual renewal and can provide
additional benefits such as improving access, reduc-
ing expensive emergency visits and avoiding crisis
management of health-care problems.
An additional service of a world-class health-care
organization would be support for the development
and implementation of a professional nurse case-
management programme. This programme would
seek to create a cost-effective, seamless continuum
of care for clients between hospital and home or
long-term care facility. The primary focus will be
cost-effective quality outcomes driven always by
client advocacy, and orchestrated by experienced
nurse case managers educated primarily as case
managers in one of the emerging university-based
certificate and or masters programmes.
World-class health-care organizations will
welcome the use of innovative technology for their
employees and clients. They will support the
creation of the most comprehensive technology
network linking clients, physicians, nurses and
other health-care providers through the use of voice
activation, visual technology and other advanced
methods of communication (Marvulli et al. 1992;
Paternostro 1992; Trofino 1993).
World-class health-care organizations will have
an abiding commitment to client education, con-
tinually seeking ways to include the client in the
health and healing process, from the use of jargon-
free critical paths to alternative therapies and to the
role of the internet in client knowledge-building
and empowerment (Trofino 1995).
World-class health-care organizations driven by
transformational leaders will create a corporate
culture that allows all workers to make a contribu-
tion, not just a living, where learning will be empha-
sized over security and personal responsibility over
control. According to Izzo & Klein (1998), such an
environment is characterized by ‘corporate soul’.
Transformational leadership: moving total quality
Corporate soul is about bringing the deepest and
most sacred human energies into the work environ-
ment. Individuals truly become alive in the work-
place, and they pour their energy, creativity and
passion into their work. People who chose health
care as a career have a genuine desire to heal and
help others. Their frustrations often stem from an
increasing bottom-line emphasis, which they view
as an attack on their original motivation in choosing
health care as a career.
World-class health-care organizations that can
thrive in the next century will be those who find
a way ‘to meet both the stringent demands of the
marketplace and the inner needs of the workforce,
thus creating the “corporate soul” ’ (Izzo et al. 1998,
pp. 62–65). Finally, the notion of ‘corporate soul’
calls us to a more profound understanding of the
spirit of leadership. Owen (1990, p. 149) described
spirit as ‘the point of interconnect between us’. The
ability of a transformational leader to lead, and for
an organization to aspire to achieve designation as
world class, stems from a profound sense of respect
for humanity and for the human spirit, a quality to
be found in the transformational leader. However,
as Owen (1990, p. 157) reminds us, ‘The leadership
we need is (also) available in all of us. We have only
to make it manifest’.
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I N T E R N A T I O N A L C O U N C I L O F N U R S E S

Nursing: A New Era for Action

ICN 22nd Quadrennial Congress

10 - 15 June 2001, Copenhagen
C O - H O S T E D B Y T H E D A N I S H N U R S E S’ O R G A N I Z A T I O N

Join thousands of nurses from across the world to explore the excitement and challenges of the For more information
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© 2000 International Council of Nurses, International Nursing Review, 47, 232–242