Leadership in Nursing
Definitions, theories, and styles of leadership
Developing future nurse leaders is one of the greatest challenges faced by the nursing profession (Mahoney, 2001). Powerful leadership skills are needed by all nurses and especially for those providing direct care to those in top management positions. Anyone who is looked to as an authority (including, for instance, a nurse treating a patient) or who is responsible for giving assistance to others is considered a leader (Curtis, DeVries and Sheerin, 2011). A clinical nursing leader is one who is involved in direct patient care and who continuously improves the care that is afforded to such persons by influencing the treatment provision delivered by others (Cook, 2001). Leadership is not merely a series of skills or tasks; rather, it is an attitude that informs behaviour (Cook, 2001). In addition, good leadership can be seen as demonstrating consistently superior performance; further it delivers long term benefits to all those involved, either in the delivery or receipt of care. Leaders are not merely those who control others; they are visionaries who help employees to plan, lead, control, and organise their activities (Jooste, 2004).
Leadership has been defined in many ways within existent academic literature. However, several features are common to most definitions of leadership. For example, leadership is a process, involves influence, usually occurs in a group setting, involves the attainment of a goal, and exists at all levels (Faugier and Woolnough, 2002). In addition, there are several recognised leadership styles. For instance, autocratic leaders set an end goal without allowing others to participate in the decision-making process (Curtis, DeVries and Sheering, 2011), whereas bureaucratic leadership occurs in scenarios where a leader rigidly adheres to rules, regulations, and policies. In contrast, participative leaders allow staff to participate in decision-making and actively seek out the participation of stakeholders within the decision. This type of leadership allows team members to feel more committed to the goals they were involved with formulating (Fradd, 2004). Laissez-faire leadership leaves employees to their own devices in meeting goals, and is a highly risky form of leadership as Faugier and Woolnough (2002) further posit. Finally, a more effective form of leadership than those hitherto mentioned, may be situational leadership. This is where the leader switches between the above styles depending upon the situation at hand and upon the competence of the followers (Faugier and Woolnough, 2002).
There is a difference between theory and styles of leadership. According to Moiden (2002), theory represents reality, whereas style of leadership refers to the various ways one can implement a theory of leadership – the way in which something is said or done. Organisations should, it follows, aim for a leadership style that allows for high levels of work performance, with few disruptions, and that is applicable in a wide variety of situational circumstances, in an efficient manner (Moiden, 2002). Similarly, there is a difference between management and leadership. Managers plan, organise and control, while leaders communicate vision, motivate, inspire and empower in order to create organisational change (Faugier and Woolnough, 2002).
Transactional versus transformational leadership
Outhwaite (2003) suggests that transactional leadership involves the skills required in the effective day to day running of a team. However, transformational leadership also involves ensuring that an integrated team works together and may also benefit from the inclusion of innovativeness of approach in work (Outhwaite, 2003). For example, a leader can empower team members by allowing individuals to lead certain aspects of a project based on their areas of expertise. This will, in turn, encourage the development of individual leadership skills, which improve both the individual’s skills and their future career prospects. In addition, leaders should explore barriers and identify conflicts when they arise, and then work collaboratively with the members of their team to resolve these (Outhwaite, 2003). Furthermore, the leader should remain a part of the team, sharing in the work, thus remaining close to operations and being able to understand the employee’s perspective, rather than being a leader who is distanced from the actual work of the team for which he or she is responsible (Outhwaite, 2003).
Transactional leadership focuses on providing day-to-day care, while transformational leadership is more focused on the processes that motivate followers to perform to their full potential. Thus, the latter works by influencing change and providing a sense of direction (Cook, 2001). The ability of a leader to articulate a shared vision is an important aspect of transformational leadership, as Faugier and Woolnough (2002) observe. In addition, transactional leadership is most concerned with managing predictability and order, while transformational leaders recognise the importance of challenging the status quo in order to enhance positive possibilities within the project that they are delivering as Faugier and Woolnough, (2002) posit.
One group of authors that have described the use of transformational leadership by Magnet hospitals are De Geest et al. (2003). In so doing they discuss how the leadership style deployed within the hospitals allows for faith and respect to be instilled, the treatment of employees as individuals, and innovation in problem solving, along with the transmission of values and ethical principles, and the provision of challenging goals while communicating a vision for the future (De Geest et al., 2003). Transformational leadership is, as they further comment, especially well-suited to today’s fast-changing health care environment where adaptation is extremely important, especially with regard to changing technologies and the seemingly ever-increasing expectations of patients. In elucidating further, the authors cite a range of findings that this leadership style is positively associated with higher employee satisfaction and better performance. These, in turn, correlate positively with higher patient satisfaction (De Geest et al., 2003). One way to facilitate change using transformational leadership involves the use of action learning (De Geest et al., 2003). In this approach, leaders use directive, supportive, democratic, and enabling methods to implement and sustain change and the effects of such leadership enable better outcomes for both nurses and patients to be realised.
Transformational leadership focuses on the interpersonal processes between leaders and followers and is encouraged by empowerment (Hyett, 2003). Empowered nurses are able not only to believe in their own ability but also to create and adapt to change. When using a team approach to leadership, it is important to set boundaries, goals, accountability, and set in motion structural support for team members (Hyett, 2003). Transformational leadership is thus seen as empowering, but the nurse manager must balance the use of power in a democratic fashion to avoid the appearance of their abusing the power that they have been given (Welford, 2002). Finally, as Hyett (2003) also notes, respect and trust of staff by the leader is essential for transformational leadership to work.
Clinical or shared governance
Clinical governance is a new way of working in which e National Health Service (NHS) organisations are accountable for continuous quality improvement, safeguarding standards of care, and creating an environment in which clinical excellence can flourish (Moiden, 2002). The requirements of several recent UK government policies require that new forms of leadership that better reflect the diversity of the workforce and the community being developed. Since Scott and Caress (2005) noted this, leadership needs have continued to be strengthened and the need to involve all staff in clinical leadership further developed. Shared governance has been, as Hyett (2003) notes, one method by which this goal has been realised. It has proven to be an effective form of leadership because it empowers all staff and makes them part of decision making processes, thereby additionally allowing staff to work together to develop multi-professional care (Rycroft et al., 2004). Such shared governance has resulted in the increased utilisation of a decentralised style of management in which all team members have responsibility and managers are facilitative, rather than using a hierarchical which, as Scott and Caress (2005) maintain, has led to increased morale and job satisfaction, increased motivation and staff contribution, the encouragement of creativity, and an increased sense of worth amongst NHS employees at all levels.
Knowledge, attitudes, and skills of an effective nurse leader
In addition to the skills hitherto noted in the opening sections of this assignment, nurse leaders should have knowledge of management, communication, and teamwork skills, as well as a solid understanding of health economics, finance, and evidence-based outcomes (Mahoney, 2001). These core skills should ideally be further enhanced by the possession of a range of key personal qualities. Mahoney (2001) asserts that these are desirable in all nurse leaders and include competence, confidence, courage, collaboration, and creativity. Nurse leaders should also be aware of the changing environment in health care best practice and make changes proactively. Leaders who show concern for the needs and objectives of staff members and are cognisant of the conditions affecting the work environment that also encourage productivity, as Moiden, (2003) notes, which is important as it allows a philosophy of productivity to be established.
According to Jooste (2004), the three pillars essential to a foundation of strong leadership are authority, power, and influence. It follows, therefore, that to be an effective leader in today’s competitive environment, leaders should use influence more, and authority and power, less. It is more important, as Jooste (2004) further notes, to be able to motivate, persuade, appreciate, and negotiate than to merely wield power and, in advancing this line of argument, the author cites three categories of influence for nurse leaders to use in creating a supportive care environment. These include: modelling by example, building caring relationships, and mentoring by instruction (Jooste, 2004). Such skills should also, according to De Geest et al. (2003), be combined with the utilisation of five specific practices that are fundamental to good leadership: g inspiring a shared vision, enabling others to act, challenging processes, modelling, and encouraging. For example, a leader may challenge others to act by recognising contributions and by fostering collaboration. Such techniques are important because recognising contributions also serves to encourage employees in their work whilst team leadership moves the focus away from the leader towards the team as a whole (Mahoney, 2001).
Applications to practice settings
Hyett (2003) describes several barriers to health visitors taking on a leadership role and observes that visitors usually work in a self-led environment, which causes problems because there may be no mechanism for self-control or decision-making at the point of service, —thus stifling innovation. In addition, if nurses who do try to initiate change are not supported, they lose confidence and assertiveness and may feel disempowered and unable to support one another, which will lead to declining standards of motivation and may negatively impact upon patient care (Fradd, 2004). Management often focuses on the volume of services provided, leading to loss of self-esteem and a rise in dependence; this, as Hyett (2003) recognises, may cause workers to become disruptive, or to leave the organisation, which culminates in organisational upheaval. Further, when staff leave as a result of feeling disempowered, replacements need to be found and trained – which involves not only additional recruitment costs but training as new people are introduced into the culture of the organisation.
In addition to the comments made by Hyett, focus group data from a study of implementing change in a nursing home suggests that nurses want a leader with drive, enthusiasm, and credibility to lead them and to inspire them, for they do not merely want a leader who has superiority (Rycroft-Malone et al., 2004). Further, focus group members identified the qualities desired in a leader who is attempting to facilitate change. This person should have knowledge of the collaborative project, have status with the team, be able to manage others, take a positive approach to management, and possess good management skills (Rycroft-Malone et al., 2004).
Applications to the wider health and social context
Nursing leaders function at all levels of nursing from the ward through to top nursing management. Over time, the function of leadership has changed from one of authority and power to one of being powerful without being overpowering (Jooste, 2004). Boundaries between upper, middle, and lower level leaders are becoming increasingly blurred, and responsibilities are becoming less static and more flexible in nature. In other words, there is a trend toward decentralisation of responsibility and authority from upper to lower levels of health care delivery (Jooste, 2004).
An ongoing programme of political leadership at the Royal College of Nursing describes a multi-step model for political influence (Large et al., 2005). Some of the steps include: identifying the issue to be changed, turning the issue into a proposal for change, finding and speaking with supporters and stakeholders to develop a collective voice, pinpointing desired policy change outcomes, and constructing effective messages to optimise communication (Large et al., 2005). These can be all be viewed as important for through learning them the nurse leader can adopt to the organisational expectations of the twenty-first century NHS.
Education for leadership
In order for nursing practice to improve, an investment must be made in educating nurses to be effective leaders (Cook, 2001). Cook contends that leadership should be introduced in initial nursing preparation curricula, and mentoring should be available for aspiring nurse leaders not only during their formal training but throughout their careers (2001). The importance of this enlarged approach can be seen, for example, in the use of evidence-based practice which requires nurses to be able to evaluate evidence and formulate solutions based upon the best available evidence (Cook, 2001). In order for these things to occur, it is important that nurses have educational preparation for leadership during training to prepare them to have a greater understanding and enhanced control of events that may occur during work situations (Moiden, 2002). This can be seen as a step towards the greater professionalisation of the nursing profession – a movement that has also increasingly seen nurses gaining formal academic qualifications over the previous ten years.
Indeed, such is the embracing of professional accreditation that the NHS has adopted the Leading an Empowered Organisation (LEO) project in order to encourage the use of transformational leadership (Moiden, 2002). By doing so, the NHS hopes to ensure that professionals may empower themselves and others through responsibility, authority, and accountability. The programme also aims to help professionals develop autonomy, take risks, solve problems, and articulate responsibility (Moiden, 2002). Strategies such as the Leading and Empowered Organisation (LEO) programme and the RCN Clinical Leaders Programme are designed to produce future leaders in nursing who are aware of the benefits of transformational leadership (Faugier andWoolnough, 2002). This is therefore not only a programme that is relevant to today’s NHS but is also one that is preparing the nursing leaders of tomorrow.
Challenges and opportunities to stimulate change
The health care environment is constantly changing and producing new challenges that the nurse leader must work within (Jooste, 2004). Leadership involves enabling people to produce extraordinary things whilst simultaneously performing their daily duties and adapting to challenge and change (Jooste, 2004). While management in the past took a direct, hierarchical approach to leadership, the time has come for a better leadership style that includes encouragement, listening, and facilitating (Hyett, 2003). Hyett (2003, p. 231) cites Yoder-Wise (1999) as defining leadership as “the ability to create new systems and methods to accomplish a desired vision”. Today, the belief is that anyone can be a leader and thus leadership is a learnable set of skills and practices (Hyett, 2003). All nurses must display leadership skills such as adaptability, self-confidence, and judgment in the provision of health care (Hyett, 2003). Indeed, the expectation of both higher professionals and the general public receiving care is that nurses lead care, and that they are able to move seamlessly between roles of leading and following, depending upon the individual scenario faced (Hyett, 2003).
Empowering patients to participate in the decision-making process
Only when health care services are well-led will they be well-organised in meeting the needs of patients (Fradd, 2004). Nurses have considerable influence on the health care experience enjoyed by individual patients, especially as patient involvement in care is most often nurse-led (Fradd, 2004). Today, patients are more aware of their own health care needs and better informed about treatments and practice; it is also imperative that patients are able to enunciate their own health care needs and contribute to discussions relating to their treatment options. Such enhanced levels of health care communication require nurses to be better equipped with analytical and assertiveness skills, especially if they need to ‘fight the patients’ corner against the opinion of an individual doctor who may place his own opinions above those of the patient (Outhwaite, 2003). Transformational leadership is ideal for today’s nursing practice as it seeks to satisfy needs, and involves both the leader and the follower in meeting needs (Welford, 2002). It is also flexible and this allows the leader to adapt in varied situations. It is logical, therefore, that if the leader accepts that things will change often, followers will enjoy this flexibility. As a result, both nurses and patients benefit because the avoidance of hierarchical structures and the embracing of new ways in which to work help organisations to put resources together to create added value for both employees and consumers (Mahoney, 2001). Into this health care mix, transformational leadership is pivotal, for it allows team nurses to enhance their role as both teachers and advocates (Welford, 2002).
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