Theories of Leadership in Healthcare Settings

INTRODUCTION

Leadership

Defining leadership is a complex task, while many scholars and intellectuals have given meaning to this word, still people find another connotation or gives more meaning to it as time goes by. In the book Leadership Theory and Practice written by Peter Northouse, he defines ‘Leadership as a process whereby an individual influences a group of individuals to achieve a common goal’ (Northouse, 2016). Leadership has four main components: (1) it is a process, (2) involves influence, (3) transpires in groups and (4) includes shared goals. It involves not only the leader but also its members as active participants in the process and must be accessible to everyone. Leadership involves influence rather than coercion and takes the group, not just the leader but also the members by persuading the whole organization to realize their mutual purpose or goals. Though many leadership theories and models have been developed overtime, the concept of leadership is relatively new in Healthcare sector and since most of leadership theories were based on business setting, an intellectual adaptation of these theories must be critically chosen to be effective in healthcare. Healthcare is not the same as running a business that manufactures products, it involves human beings and the complexities in dealing and treating them individually. One may improve the techniques, practices and even the system but might lose the whole purpose of healthcare. Healthcare leadership looks into the complex components of the organization such as the multidisciplinary staff, various departments and different medical professionals and give them support so that they will go in harmony and move as a whole towards the wellbeing of the patients (LG Bolman, 2003). Leadership in healthcare focus on the connection with patients and quality which also may be referred to as clinical leadership. Clinical leadership focuses on enabling evidence-based practice and delivering patient outcomes. This assignment will examine some of the leadership theories that may be applied to healthcare setting and how they can help in combating the challenges that arises.

LEADERSHIP CHALLENGES IN HEALTHCARE ORGANIZATIONS

• Challenge of Multicultural and Diversity 

People are becoming more interconnected as what can we observed in schools and organisations, communities are far more global because of globalisation or the interdependence among nations, which started during the World War II. The challenges that globalisation brings does not exempt leadership as a function. Today, leaders has to faced many challenges like understanding cultural difference, what leadership style to use for a multinational organisation and how to lead a culturally diverse group. Leading a multicultural organisation takes into account an approach that must cater various cultures such as Asian, American, African, European and Middle Eastern or can also be by race, ethnicity, gender and age. It must also address diversity or the existence of different cultures or ethnicities within the organisation. In healthcare setting it is a challenge for leadership because one must understand, accept and value people’s differences, avoid ethnocentrism (tendency for the individual to give priority to their own group above others) and prejudice (largely fixed belief towards an individual). Take for example in a big hospital, it’s hard for an Asian leader to lead an American nurse because one may think that the other is superior in terms of ethnicity. According to a recent research, the fast-changing demography and economies of our growing multicultural world and the long-standing disparities in the health status of people from culturally diverse backgrounds have challenged healthcare providers and organizations to consider cultural diversity as a priority (Bacote, 2003).

• Challenge of Education & Leadership Development

When a leader leaves, the organisation will be in chaos if there is only one person who knows how to lead. In the environment where there is only one who decides on everything for everyone and no space or chance for others to contribute in the decision-making because they are not trained to do so, like in the UK, they see the need for current development on leadership programmes in the NHS that gives priority to the distributed nature of leadership instead of individualistic approach which has become obsolete this time. There is a need to provide training and education to more individuals in every level so that many will have the skills and competencies that they might use when the situation calls for it (Fulop and Day, 2010). Healthcare organisations should also provide training for their staff so that they will be skilled and competent to deliver care. Leadership development and education must start from the pre-registration period of the individuals or when they are still students, that they must fully understand their professional boundaries and must be practice-based rather than just theoretical in nature and will not stop there but will be an essential continuation when they are already practicing the profession. Healthcare is a complex environment that require a set of skills and knowledge too broad to be possessed by any one individual that makes the stress level of leadership too high.

• Challenge of High Turnover of Staff

With the growing demand for providing excellent healthcare delivery, healthcare providers are faced with many challenges, high turnover rates of staff is one of these especially nurses. Nursing is a very demanding profession and when they are not lead effectively may result to burnout and attrition. Healthcare organisations sometimes ask too highly from nurses but neglect them and don’t give such importance to them and don’t see their value in the organisation. Staff nurses may feel dissatisfied and may feel toxic that would lead to a poor performance or poor quality in their care delivery to patients, in turn patients are also affected. According to a study conducted, an estimated 30-50% of fresh graduate nurses, decide on either to change positions or leave nursing totally within their first three years of clinical practice. When nurses leave, the overall patient quality care is affected because of the loss of expertise and it will be costly for the organisation to loose expert nurses (Belsky, 2016).

• Challenge of Bullying in the Organisation

Workplace bullying among healthcare workers has become a persistent phenomenon. According to Rowell, today, bullying in the workplace has predominantly increased and is four times more rampant in the health and community care sectors than issues on sexual harassment (Rowell, 2005). Both nurses and physicians are occasionally victims of hostility in the workplace. Bullying can be define by its social manifestations, such as aggressive behaviour (e.g. intimidation, harassment, victimization, aggression, emotional abuse, and psychological harassment or mistreatment) that mainly occurs in interpersonal interactions in the workplace. On the same note, the intention, frequency, duration, apparent imbalance and misuse of power between the perpetrator and target, inadequate support, and the inability of the target to defend himself from such aggression, as well as having to cope with negative and constant social interactions, physical or verbal harassing, insulting comments, and intense pressure must be take into consideration when we speak of bullying. The impact of bullying does not only affects the victim’s health and but also the morale in the workplace which in turn affects the organisation’s productivity as a whole. Like when a new nurse started his first day in the hospital, he has this ideal perception of clinical setting but he will realize that he has to adapt the kind of clinical set-up that is already going on and if he will not abide by it, he will encounter difficulties with the senior staff.

• Challenge of Role Ambiguity  and Work Overload

According to a research done in Australia (Chang and Hancock, 2003), a new nursing graduate first few months in the profession are the most challenging and most stressful. Role ambiguity was the most prominent part of role stress in the first few months, while role overload was prevalent source of stress after 10 months. Role ambiguity occurs when professionals are unclear or uncertain about a certain role in their workplace, it arises when the definition of the job is vague or not clearly define. While role overload is a situation in which there is no enough time in which to carry out all of the projected role functions. This challenges arise when leaders do not effectively delegate task to the staff. For example, in a ward, new nurses will mostly be doing most of the jobs to the extent that they don’t have enough time even for a quick break while their seniors are chatting and their alibi is that they want the newbies to learn the hard way so they will be better in the future but sometimes it’s too much.

LEADERSHIP THEORIES AND MODELS     

• Cultural Leadership

Learned beliefs, rules, values, symbols, norms, and traditions that are mutual to a group of people is called culture and it is dynamic in nature. It is these shared collective qualities that make them distinct from others. In short, culture is the way of life, customs, and script of a group of people (Gudykunst, Ting-Toomey, 1988). Due to globalisation, the world became flat and most of the time, it is evident that we can see many cultures mixed together in one organization especially in multinational companies and also in healthcare settings, so understanding different cultures are needed for the leaders to be able to be effective in leading. Cultural leadership requires three interactive components such as cognitive, motivational, and behavioural or the capability to generate actions needed. This type of leadership style needs the understanding of one’s own cultural biases and preferences, which is the first step to understand that individuals in other cultures might also have different preferences, just like everyone else.

In a hospital where nurses are composed of different ethnicities, it is best that a leader must have a clear understanding of their diverse cultures in order to lead the organisation because different cultures have different ideas about what they want from their leaders. This will help the leaders in communicating effectively across geographical and cultural boundaries. This leadership style can address the challenge of multicultural and diversity, by having an essential understanding on cultural differences, leaders can become more empathic and accurate in their communications with others that have different cultures. Information on culture and leadership has also been applied in very practical ways like designing new employee orientation programs, conduct programs in relocation training, and improve global team effectiveness. These examples clearly indicate the wide range of applications for research on culture and leadership in the workplace. Integration of skills in culturally competent care meets six aims for healthcare excellence that is safe, effective, patient-centred, timely, efficient and equitable that all care providers truly understand the patient individually while taking into account cultural knowledge, differences and preferences.

• Transformational Leadership

James McGregor Burns, a political sociologist tried to see the relationship between the roles of leadership and followership in order to better achieve their goals and it’s not about power after all. Transformational is different and better than that of transactional leadership because the latter focuses on an exchange dimension wherein the followers will be rewarded if they will do this and that, like when a tutor gives high mark for students after completing a good assignment. On the other hand, transformational leadership is a practice wherein a person take part with others and creates connection that nurtures the level of motivation and morality in both the leader and the members (Northouse, 2016). Transformational leader not only focuses on making today better but also the future. They have a clear vision that is well-communicated with all the members and at the same time inspires them to achieve their goals through their integrity and authentic commitment to the mission and not for their personal gratification. They also exhibits an advanced mind-set by investing time and effort to attain personal and professional development together as an organization. Creativity is also encourage to develop new ideas through allowing measured risks to build a culture of innovation and continuous transformation for the better. Transformational leaders are vision driven and must be a shared one to be truly effective.

In healthcare setting, transformational leadership has been mainly positive in the organization’s driving force for progressive change (Manley, 2000) and also for developing and empowering the team (Thyer, 2003). This leadership style enhances nurses’ creativity to bring about meaningful change. An example of this is the creation of clinical nursing consultants in the UK’s National Health Service. It supports the role of expert nurses as clinical leaders that will improve the quality of service and being more responsive and it also solves the shortages in junior doctors. It guarantees that nurses with the highest levels of clinical skills and practice will be at the forefront to the delivery of care. This ensures that the nurse consultants, as the leaders will have a great influence in care delivery strategies and spent most of their time in clinical environment. A concrete example of this, was the creation of Older Person’s Outreach and Support Team (OPOST) – a core team consisting of consultant nurse, senior elderly care nurses, senior elderly care occupational therapist, and superintendent physiotherapist, social worker, audit facilitator and team administrator, to improve the older people’s care management in an acute settings and the model of choice is transformational leadership. Everyone was articulated by the team’s vision and captures their hearts and minds about their objectives as a team and their specific roles in the group to avoid role ambiguity and to achieve their commitment in developing services for older people. Everyone is encourage to do what they seem beneficial to the client but taking full responsibility as well. It significantly reduces the length of confinement associated with complications by working and collaborating with the staff.

Like that of the OPOST setting, the core team members belong to different specialty fields so when they go back to their professional groups they were treated as outsiders and they are experiencing confidence crisis. Transformational Leadership comes in when dealing with the challenges in diversity, where leaders must motivate, inspire and remind the team the importance of their role and what they are doing. After 9 months, team members saw their achievements in the project and counted them as positive experiences that will help the organisation change for the better and ultimately for the benefit of the patients.

• CLINLAP and LEADLAP Model

Clinical Nursing Leadership Learning and Action Process Model (CLINLAP) is specifically used for nursing and midwifery or known as Leadership Learning and Action Process Model (LEADLAP) in a more general perspective is a result of a 15-month Action Science Research Project designed to specify the set of attitudes, skills and knowledge needed for the 46 District Nurse Team Leaders (DNTLs) to carry out their roles efficiently and ways how to develop such characteristics (Jumaa, 1997). The research outlined the core problems that clinical teams face are generally circling around the goals, roles, processes and relationships and the viable solutions would be having specified and agreed goals, explicit roles which avoids ambiguity or confusion, clear processes and an environment that encourages open relationships, be present in the education of health and social care, in research, in practice and also in clinical environments (Moxon, 1993). The Modernisation Agency (in the UK) launched in 2001, positively recognized the roles of the professions and healthcare managers, specifically nurses, to manage the organization and healthcare delivery more effectively and efficiently according to the framework of clinical governance which has 3 aspects: setting quality standards, delivering quality standards and monitoring quality standards (Department of Health, 1998).

In a complex environment setting, as that of healthcare with many uncertainties and dilemma which are present in a day to day occurrence, knowledge and experience is the competitive advantage of the team so they need to educate and update the skills of the whole organization and overcome the challenges of education and leadership development in the long-run. The CLINLAP model as a whole is a “strategic clinical leadership process that positions strategic learning as a force that drives the health and social care organisations on a day to day basis, in the management of clinical nursing goals; nursing roles; nursing processes; and nursing relationships (Jumaa, M.O. and Alleyne, J., 1998).” CLINLAP model addresses the issue on role ambiguity and work overload since this provides a clear strategy and specified goals and how to deliver quality care to patients. Each member has explicit roles in the group and they know the clinical process that needs to be followed in a certain clinical scenario. It also encourages up to date education and training for their staff to be highly competitive in practice.

Other Contemporary Models/Theories

• Servant Leadership

It is an approach that focuses on the leader’s point of view of leadership and his behaviours. Its emphasis is on the leader’s attentiveness to his followers’ concerns, showing empathy and nurturing the group. Followers’ always come first and servant leaders must empower them so they will develop their full potentials as individuals. And also, these leaders are considered ethical, who serve in ways that seek the greater good of the organisation and the society as a whole. To summarize this model, one can remember the 3 components that consists servant leadership these are antecedent conditions, servant leader behaviours, and outcomes. The primary focus of the model is on the 7 behaviours, servant leaders must have (conceptualizing, emotional healing, putting followers first, helping followers grow and succeed, behaving ethically, empowering, and creating value for the community) that mainly influenced by one’s context and cultures, the leader’s attributes, and the followers receptivity to servant leadership style. Improvement at individual, organisational and societal levels will be observed if individuals will take part in servant leadership. It is similar to transformational and authentic leadership at some point but altruism at its centrality makes it unique.

Others argued that servant leadership may be the best model for a healthcare setting for the reason that the team’s strength, trust development and serving the needs of others are its main focused as a model. Servant leaders help people develop individuals and let them flourish to attain their full potential as a person and as a professional. This kind of leadership show genuine concern for others and put their interests first. A high turnover of staff which is a major threat in healthcare organisations is a result of staff burnout in their jobs and servant leadership style may help in facing this challenge. A significant study showed that this kind of leadership promotes psychological well-being of nurses because it can decrease emotional exhaustion thus improving job performance and satisfaction that decreases their intention to leave the organisation. Treating nurses as humans with emotions and the tendency to be exhausted as well, is an important aspect that servant leaders can address because they do not only care professionally but also for the personal well-being of their followers. They support followers to overcome their personal problems so their job will not be affected, they want their followers to be whole so that they can build a community or a place when everyone feel safe, valued and connected with others but are also encouraged to express their individuality.

• Shared or Distributed Leadership

Shared leadership is when members of the team assume leadership behaviours to influence the team and to take full advantage of its effectiveness. Members know when to step forward when situations arise, providing necessary leadership, and then step back to let other members lead. This kind of leadership has becoming important in different organisations today to allow faster responses to complex issues. Also, team leaders make sure they delegate sufficient autonomy and responsibility to all members of the team, involve them in decision-making, and encourage to self-manage its performance to the extent possible.

Healthcare organizations have responded to the need for new leadership styles, and shared leadership is one that can improve outcomes because it is highly practical in this environment, as the nature of the healthcare environment requires much collaboration (Merkens & Spencer, 1998). According to a study (Konu & Viitanen, 2008), patient care quality mostly depends on how well a group of diverse medical and administrative experts work together and shared leadership can create uniform decision-making and define responsibilities but it must be an ongoing process that requires continuous assessment and evaluation in order to be responsive to the ever-changing healthcare environment. A study showed that nonmedical staff favoured shared leadership than clinicians, but both groups were generally satisfied with the shared leadership model, according to them it seems to provide nurse empowerment and promotes good nurse-physician relationships (Steinert, Goebel & Rieger, 2006). Shared leadership may give a solution for education and leadership development challenge since one of its benefits is that it promotes an inclusive decision-making process and emphasize on participative styles of leadership, where members take on leadership tasks for which they are good at and where they are most motivated in accomplishing, thus gives the organisation the luxury of wealth of talent of all the members. Take for example a group of doctors, shared leadership enhances doctors’ engagement in the decision-making process and add to the improvement of cost-effective systems of delivery and are likely to be important drivers in the process of implementing policy reforms at local level such as services redesigning and resources shifting from acute to primary care.

• Emotional Intelligence

In the 20^th century, intelligence quotient (IQ) which measures one’s cognitive ability and intellect became the gold standard to test one’s ability but many argued that IQ is not the sole basis to gauge one’s capability because there’s the existence of many types of intelligence. Thus, emotional intelligence come to being. It is the combination of abilities in personal, emotional and social aspects that influence a person’s ability to become successful in coping with the demands and pressures of his environment (Reuven, 1992). Let us look at the five-competency model of emotional intelligence according to Goleman’s description that includes: (1) self-awareness: understanding your emotions that will guide you confidently in decision-making, (2) self-regulation: handling emotions well that it will not interfere with work and be able to recover from emotional distress, (3) motivation: perseverance even in times of frustrations, (4) empathy: can sense another’s feelings and understand people that cultivates rapport despite diversity, and (5) social skills: smooth interaction that comes from negotiating differences.

In any organisation, challenges of bullying in any form may take place, thus having EI, prepares an individual on how to process and handles such conditions. It will help the person to cope with these ill-behaviours around him and how to address such so that it will not affect his personal life and also his job. A person with EI knows how to negotiate differences in a win to win situation. If for example, a senior nurse is mean to her junior nurse, the junior must show her skills to her senior in a way that the former will see that the latter knows what she is doing and will not be intimidated by her but will use this scenario to prove her value and worth in the organisation. One must persevere in trying times and not just give up because there is challenges everywhere, it just depends on how you handle it.

CONCLUSION

Leadership still is a word that is hard to give a specific meaning that is why the search and research about this topic is still on-going especially in healthcare environment because leadership is essential to transform and in pursuing excellence in the delivery of care. With the many books, journals, research paper and other sources I have read, an individual that assumes leadership in healthcare must have the personal qualities, may be innate or acquired through time that aids the person to lead and set the direction for the organisation in order to deliver care in an excellent way. The heart of all healthcare organisations is the patient, giving them the highest quality care possible and an effective leadership is fundamental in meeting that ultimate goal. There are many models and theories about leadership but the choice of style depends on the organisation and the leaders because what may be effective to one, may not be effective to the other. Though there is no gold standard for leadership style in healthcare, for me, transformational leadership stands out. Its assumptions are very ideal but it is in application that it became difficult. Many have tried, but many also failed because leadership, just like in this literature cannot stand alone by the presence of the leader but also with the support and cooperation of the members. Change is something that must be mutually wanted to be attainable but there will always be a reluctant to change, so the challenge still lies on the leader on how to inspire and motivate the whole organisations so they can all attain the change they want and need for the organisation. The most important for leadership is trust, a leader must have trust in himself and his abilities, trust with his followers, trust with their shared vision or goal. For the healthcare sector, whatever leadership style you will select for your organisation, may it be servant, transformational, cultural, CLINLAP or shared leadership, the success lies within the leader and his followers because there is no perfect theories or model, it’s the people who wants to make it work, succeeds.

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