Perspectives: Leadership: What is it good for?

We are all leaders now, or so we are frequently told. But who are we leading and to what end? That is less clearly described. There is no shortage of people offering opinions and courses in the latest fashions for leadership, but surely we should draw from our clinical practice and recognise that we need to assess needs and goals before deciding on our leadership behaviours.

I often hear people talk about their preferred leadership style, as though leadership is a personal quality and its nature is entirely dependent on the individual. There are many quizzes and homilies to help the confused uncover their leadership vocation. However, if we look at the research evidence, we find that different approaches work in different circumstances. Wong et al. (2015) describe studies that assert newer approaches to leadership in nursing, such as transformational and resonant leadership, are associated with lower patient mortality, but they also report studies that show transactional leadership is associated with higher patient satisfaction. How can two apparently diametrically opposed approaches both produce good outcomes? It must be that leadership relates to the objective rather than the preferred style of the individual.

Leadership decisions need to consider three things: the task, the people involved in the task and the practice environment. When I first qualified as a nurse, my first Ward Sister was my role model for leadership. She was very clear what the role of the nurses on her ward was and held us to account for those standards. Sometimes that meant being transactional, like making sure the fluid balance charts were completed and calculated at the end of every shift. At other times it was role modelling, such as her daily round of every patient to sit down and ask them how they were – an early version of asking what mattered to them. My biggest error on her ward was agreeing to put up extra beds in her absence. She was very clear that without extra staff this was unacceptable for patients, and managers knew better than to ask her but saw an opportunity with me, a newly qualified nurse. Was I frightened of her? Definitely, but she adapted her leadership style to meet the professional values she held dear and I respected her ability to deliver nursing excellence.

The role of leader is to be a figurehead for a group. We all belong to multiple groups simultaneously and different people can become a figurehead for a particular group, be they a student, a patient or any other role. A figurehead does not necessarily hold a formal position of authority from an organisation, although the success of a leader without such positional authority is highly dependent on the prevailing culture acknowledging and legitimising them. Those encouraging everyone to lead should be mindful of the potential challenges those without positional authority will face in a hierarchical culture, and ensure they are equipping these people with the skills to determine how to navigate the challenges. To do otherwise is simply to set them up to fail.

But neither is the role of leadership automatically acquired by those appointed to positions with organisational authority. Leaders cannot lead without followers, and without a voluntary followership leaders have only their managerial authority and threat on sanctions for noncompliance to influence behaviour. Whilst that can work for certain tasks, it isn’t enough for others.

The second leader who inspired me was my health visiting tutor, who had no organisational authority over my practice. She inspired me with her vision of neighbourhood health, where the professional role was about unlocking the potential of individuals and communities by empowering them rather than by instructing them. Her vision was something I chose to pursue rather than was required to implement. She created a sense of us as a team with a purpose. Without being aware of it, she was embodying the values of the group and creating a shared social identity as described by Haslam et al. (2011). Group dynamics mean that this is not one-way traffic, and Uhl-Bien et al. (2014) note the recent move in leadership theory away from leaders themselves towards the relationships they develop. I have certainly found that good leaders need good relationships with their followers, but I would go further and say that leadership is not the actions of a single individual but is the product of the relationship between the figurehead and the rest of the group. The ‘followers’ are far from passive, and their response determines how successful a leader’s proposals can be in practice. As we become a more digitally connected world, the impact of social media in amplifying the voices of followers (although perhaps less successfully in nursing than in other spheres) is blurring the line between who creates the vision; it is increasingly being co-produced, with the ‘leader’ function being more about facilitation and co-ordination than about direction. Like many, I’ve experienced the gap between work as imagined and work as done. The best leaders close that gap and ensure full alignment of the objectives of those who devise strategy, those who translate the strategy into working practices and those who deliver the service at the frontline (Schein, 1996).

So what are leaders facilitating and co-ordinating? It can be a range of things, but for nurse leaders it surely must be about professional issues. I remember strong professional nurse leaders like Jacqui Flindall, Chief Nurse at Oxfordshire Health Authority in the 1970s and 1980s, who created an atmosphere of professional creativity in Oxfordshire which birthed the Nursing Development Unit in Oxford and Burford (Pearson, 1988). However, the move to New Public Management, where leaders (including senior nurses) have become increasing focused on operational leadership (Newman and Lawler, 2009) has seen senior nurses move away from such innovations. Embracing New Public Management is often accompanied by a move away from patient care, physically and metaphorically (Ericsson and Augutinsson, 2015), and therefore from professional issues, thereby resulting in a generic approach to leadership, supported by some senior leaders and culminating in the Smith (2014: 45) review of the funding of leadership training in the English NHS recommendation to ‘cease to commission or deliver uni-professional programmes e.g. the Nursing and Midwifery programme’. This significant change, with its deleterious effect on nursing, went almost entirely unnoticed and certainly was not challenged by nurse leaders.

If nursing and midwifery are indeed professions, then every leadership action needs to be considered through a professional lens as well as through a strategic, a design and an operational lens. I would argue that professional leadership is more than clinical leadership (the leadership of clinical practices). I contend that we need professional leaders to constantly evaluate new demands on the profession using a common set of principles informed by rigorous research, not just personal experience and policy directives. It also needs critical thinking and intellectual agility to respond to the unexpected and to maintain alignment with an ever-changing system.

Benner and Wrubel (1989) distinguish between nursing as a professional activity and nursing as a lay activity. The scope of professional nursing practice and its boundaries with lay nursing are not self-evident and are fluid. The various debates about whether nursing is really about ‘caring’ or whether nurses should ‘practice at the top of their licence’ and substitute for other professions illustrates just how contested the definition of the profession is. In the World Health Organization’s International Year of the Nurse and the Midwife, this failure is particularly acute. The absence of any explicit discussion or risk assessment of the proposal to create a ‘family’ rather than a profession, with the introduction of nursing associates, shows just how little professional leadership is valued in England at present. Professional leadership requires high-level skills obtained through education and development; I contend this requires dedicated professional leadership preparation. Professional leaders need bespoke education to lead professional issues and to create a social identity that professional nurses feel they share. Without this it is difficult to argue for any professional nurses at all.

What we need now is not more exhortations to nurses to all be leaders, but a recognition of how professional leadership differs from general public management. Nearly 40 years after the Griffiths reforms in the NHS (DHSS, 1983), it is time for nurses to debate what professional leadership is, could and should be – in other words work out ‘what leadership is good for’ and what good it brings.

Biography

Elaine Maxwell worked as a nurse in a number of clinical and managerial roles before undertaking her PhD. Since then she has worked as a Strategic Lead for Safety at the Health Foundation and as an Associate Professor of Leadership at London South Bank University. She is currently Clinical Advisor at the National Institute for Health Research Dissemination Centre, promoting the accelerating of evidence into practice.