Nurses work in an ever challenging and stressful environment; in this environment psychological and leadership theory both lend themselves to the idea that work empowerment and decision making participation will contribute to effective leadership and job satisfaction when compared with an environment that does not support the ability of nursing staff to make independent decisions (Lanza, 1997; Berger & Mizrahi, 2005). Further studies suggest that participative and transformational leadership help inspire and motivate subordinates to work toward common "organizational goals" that may overstep individual interests or needs (Berger & Mizrahi, 2005). .

             In the healthcare environment it is easy for leaders to be overwhelmed by the "day-to-day" demands of the job" which can contribute to chaos and disorganization (Kerfoot, 2000). To prevent this leaders must not only work toward the future but also handle daily operations in a knowledgeable and controlled manner so that leaders understand and can translate various patterns and trends within the organization "into strategies that could positively position their teams and departments" in an ever changing work environment (Berger & Mizrahi, 2005:155). A participative leadership style such as that exhibited at PVH enables leaders and managers within the nursing staff team to adopt resilient measures for combating the day-to-day pressures evidenced in the health care environment, particularly when the environment is unstable or volatile (Globerman, et al. 2003). Among the important characteristics of leadership include a strong commitment to values and morals, empowerment within the workforce, strategic vision and effective communication and proactive participation among all members of the organization (Rank & Hutchinson, 2000). .

             Lebrasseru, Ojha & Whissell (2002) note that commitment and implementation of continuous quality improvement processes are also vital to general hospitals and occur as a "paradigm shift in organizational learning.