Dying with dignity in America: the transformational leadership of Florence Wald.

The aims of this study are to examine the constructs of transformational leadership as they played out for one nurse who steered significant change in the care of the dying in the United States and to provide deeper insights into how nursing leaders can design and direct meaningful changes in the delivery of health care in turbulent times. A significant problem was identified in how the terminally ill were treated in this country post World War II. The introduction of hospice care in the United States represented a paradigm shift in how the health care community viewed and treated dying patients. Critical to this transformation was the work of Florence Wald, who organized with community leaders, clergy, and other health care providers to create a vision and synergy around palliative care. She was instrumental in opening the first American hospice in 1971 in Connecticut. Within 15 years, there were more than 1,000 hospices in the United States. A single case study design was chosen for this qualitative research grounded in the theory of transformational leadership (J.M. Burns, 1978). The study used narrative inquiry to conduct an in-depth exploration of Florence Wald's transformational leadership and the perceptions of the group of founders she organized to conceptualize, build, and open the first hospice in the United States. The participants chosen for interview were involved directly in the designing, planning, and beginning of the first American hospice. In addition to the seven in-depth interviews conducted in 2007 in Connecticut, this research examined three groups of documents from The Florence and Henry Wald Archives in the Yale University Library. The findings from both interviews and the Yale Archives showed that Florence Wald based her leadership on the strong values of reverence for life and social justice for all. To direct meaningful change, Florence Wald elevated the consciousness of her hospice team by conducting a 2-year research study on the needs of dying patients to ensure interventions were based on evidence. To encourage a high level of participation, Florence Wald demonstrated a caring component in her leadership with a strong commitment to mentoring. Wald worked to transform the quality of end-of-life care by assessing the readiness for change prior to acting and by working to provide supports for success. Finally, the findings showed that Florence Wald built consensus on vision before executing purposeful change by collaborating with the Founders and asking the hard questions to examine standards of care. Florence Wald provided transformational leadership in creating a value-driven culture of inquiry among the Founders where decision making was evidence-based and significantly improved the quality of palliative care in the United States. Nursing leaders who build upon the shared values to provide direction and promote momentum critical to the change will have more success in reaching strategic outcomes of transformational efforts. Transformational nursing leaders who build consensus on vision before executing purposeful change by collaborating with a wide group of stakeholders will encourage a broader ownership of the change. When nursing leaders work to elevate the consciousness of their work groups to direct meaningful change by developing and sustaining value-driven cultures of inquire, decisions will more directly align with evidence and support successful outcomes.