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Issues in Mental Health Nursing

ISSN: 0161-2840 (Print) 1096-4673 (Online) Journal homepage: https://www.tandfonline.com/loi/imhn20

Aesthetic Leadership: Its Place in the Clinical Nursing World

Judy Mannix, Lesley Wilkes & John Daly

To cite this article: Judy Mannix, Lesley Wilkes & John Daly (2015) Aesthetic Leadership: Its Place in the Clinical Nursing World, Issues in Mental Health Nursing, 36:5, 357-361, DOI: 10.3109/01612840.2015.1011361

To link to this article: https://doi.org/10.3109/01612840.2015.1011361

Published online: 19 Jun 2015.

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Issues in Mental Health Nursing, 36:357–361, 2015 Copyright © 2015 Informa Healthcare USA, Inc. ISSN: 0161-2840 print / 1096-4673 online DOI: 10.3109/01612840.2015.1011361

Aesthetic Leadership: Its Place in the Clinical Nursing World

Judy Mannix, MN (Hons), RN and Lesley Wilkes, PhD, RN University of Western Sydney, School of Nursing and Midwifery, Penrith, New South Wales, Australia

John Daly, PhD, RN, FACN, FAAN University of Technology Sydney, Faculty of Health, Ultimo, Sydney, New South Wales, Australia

Clinical leadership has been identified as crucial to positive patient/client outcomes, across all clinical settings. In the new mil- lennium, transformational leadership has been the dominant lead- ership style and in more recent times, congruent leadership theory has emerged to explain clinical leadership in nursing. This article discusses these two leadership models and identifies some of the shortcomings of them as models for clinical leadership in nursing. As a way of overcoming some of these limitations, aesthetic lead- ership is proposed as a style of leadership that is not antithetical to either model and reflects nursing’s recognition of the validity of art and aesthetics to nursing generally. Aesthetic leadership is also proposed as a way to identify an expert clinical leader from a less experienced clinical leader, taking a similar approach to the way Benner (1984) has theorised in her staging of novice to expert clinical nurse.

INTRODUCTION There is little doubt about the importance of clinical lead-

ership, given the complexities of the clinical nursing world, regardless of the setting. The significance of leadership in clin- ical settings has been reiterated in recent reports into the fail- ings or otherwise of various health systems around the world (Committee on Quality of Healthcare in America 2001; Francis, 2013; Garling, 2008), resulting in calls for more effective clin- ical leadership. Professional nursing organisations have recog- nised this with global organisations, such as the International Council of Nurses (2014) and Sigma Theta Tau International (2014), positioning nursing leadership development at the fore- front of their activities. At a national level, nursing organisa- tions (e.g. Australian College of Nursing, 2014; Royal College of Nursing, 2014) recognise the importance of leadership, as do discipline-specific nursing organisations. For example, the Australian College of Mental Health Nurses (2010) empha- sises leadership in one of their nine standards of practice. Simi- larly, healthcare organisations have supported clinical leadership

Address correspondence to Judy Mannix, University of Western Sydney, School of Nursing and Midwifery, Locked Bag 1797, Penrith, NSW 2751, Australia. E-mail: [email protected]

programmes (e.g. American Association of Colleges of Nurs- ing, 2007; Clinical Excellence Commission, 2007), particularly for health professionals in designated clinical and non-clinical leadership positions.

Given the widespread calls for more effective clinical lead- ership, it is prudent to review what leadership theories and frameworks are influencing contemporary clinical leadership in nursing and what alternative leadership styles may be avail- able for consideration. Because nurses have long recognised the epistemological and ontological validity of art and aesthetics to nursing and its practice (Finfgeld-Connett, 2008), it is worth considering if aesthetic leadership could help address some of the reported failings of leadership in the clinical practice world. Aesthetic leadership is an established theory of leadership that increasingly has gained traction in the leadership studies litera- ture (Bathurst, Jackson, & Statler, 2010; Guillet de Monthoux, Gustafsson, & Sjostrand, 2007; Hansen, Ropo, & Sauer, 2007) but as yet, has not been considered in relation to clinical leader- ship in nursing.

In the new millennium, transformational leadership has dom- inated the nursing discourse as the preferred leadership model offered in professional development programmes (Martin, Mc- Cormack, Fitzsimons, & Spirig, 2014), a reality also reflected somewhat in the nursing leadership research (Cummings et al., 2010). Other leadership theories and frameworks less promi- nent, include servant leadership, authentic leadership, transac- tional leadership, leadership practices and situational leadership (Cummings et al., 2010; Stanley, 2008). While these theories and frameworks can all have some application to the clinical setting, none are specific to clinical leadership. One leadership theory to emerge in relatively recent times is congruent leader- ship theory, proposed by Stanley (2008). This particular theory is somewhat unique in that it is specific to nursing and clinical leadership. With the domination of transformational leadership and the uniqueness of congruent leadership to clinical leader- ship it is reasonable to initially critique these two theories to determine why calls for effective clinical leadership continue in various reports (Francis, 2013; Garling, 2008). This article dis- cusses aesthetic leadership as a theory for application by clinical

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leaders from community-based settings to inpatient practice ar- eas and across the range of nursing specialties, including mental health.

TRANSFORMATIONAL AND CONGRUENT LEADERSHIP THEORIES

It is clear from the leadership studies’ literature that the dom- inance of neo-charismatic leadership theories, including trans- formational leadership and charismatic leadership, go beyond nursing and healthcare areas (Dinh et al., 2014). According to Kuepers (2011), the intent of this style of leadership is for lead- ers to transform followers so they are aware and accepting of the organisational missions and goals. Therefore, it is not difficult to see its appeal to organisations wishing to achieve their goals. In healthcare facilities with Magnet status and those aspiring to it, transformational leadership is a fundamental component of the organisational framework (Kramer, Schmalenberg, & Macguire, 2010). As a leadership model, transformational leadership is one of a number of relational styles of leadership that focus on individuals and relationships (Cummings, 2012), and not out of place in a nursing world that involves human interac- tions and experiences. Transformational leadership encourages leaders to be visionary, be able to inspire others to share that vision through effective communication, and empower others to lead, while leading to meet organisational priorities (Clavelle, Drenkard, Tullai-McGuiness, & Fitzpatrick, 2012). To ensure effective transformational leadership, it is important for leaders to possess an extensive range of personal and social emotional intelligence capabilities, including behaving ethically and being able to challenge the status quo to facilitate change (Hutchinson & Hurley, 2013). As a leadership style, it has been shown to be compatible with how nurses function in their various clini- cal settings. For example, in the area of mental health nursing, transformational leadership processes support the collaborative involvement of consumers in care delivery (Cleary, Horsfall, Deacon, & Jackson, 2011) and the development of essential in- terpersonal skills of nurses working in mental health settings (Blegen & Severinsson, 2011). Studies in nursing have shown transformational leadership to be a style of leadership to support high job satisfaction among nurses, increased organisational commitment, enhanced role clarity, reduced workplace conflict, and lower levels of stress, anxiety and emotional exhaustion among staff (Cummings et al., 2010).

First proposed by Nicholls (1986) for business organisations, congruent leadership was adapted from the situational leader- ship model, and identified to occur when an appropriate lead- ership style is used, once an understanding is gained of aspects specifically related to the leader, the followers and the setting. Apart from the name, there are few similarities between the original congruent leadership model and the newer congruent leadership theory developed by Stanley (2006), specifically as a theory of leadership for clinical leaders. This newer theoreti- cal proposition aligns more with authentic leadership (Huston,

2008), one of the value-based leadership models (Mumford & Fried, 2014). The foundation of Stanley’s (2006) congruent lead- ership theory is the way in which values and beliefs about care and nursing are reflected in and shape the activities and actions of the clinical leader. Leaders who are experts in their clini- cal field and who demonstrate this congruence in the clinical setting are ‘guided by their passion for care’, and seek to em- power colleagues, rather than elevate their own status (Stanley, 2006, p. 139). In relation to emotional intelligence capabilities, congruent leaders require effective interpersonal and commu- nication skills that are enacted with integrity (Hutchinson & Hurley, 2013). Another feature of the theory, is that it is de- rived from a study of clinical leaders who mainly were either not in a designated leadership position or not trying to lead in the clinical setting (Rolfe, 2006). Because of the relative new- ness of the congruent leadership theory, a search of the extant literature found no studies that have directly tested the theory. Finally, Stanley (2008) argues that congruent leadership pro- vides a sound foundation for clinical leaders in nursing because it is reflects the core values of the nursing profession and places patient-focussed care as the main consideration, ahead of man- agers and medical officers.

Limitations of Transformational and Congruent Leadership

As in all leadership theories, some limitations or shortcom- ings of both transformational leadership and congruent leader- ship theories have been identified in the literature (see Table 1).

When considering leadership in the clinical nursing context, it is not difficult to see the potential issues that could arise for clinical leaders when embracing transformational leadership as their leadership style. Stanley (2008) has argued that as a theory of leadership, transformational leadership is not a suitable the- oretical foundation for developing clinical leaders in nursing. Instead, he proposes congruent leadership theory. While this may be the case, because of its relative newness, the lack of em- pirical evidence needs to be taken into account. Nonetheless, as a leadership theory for clinical leadership, the identified short- comings are not particularly relevant to the clinical workplace. Findings of the research from which the congruent leadership theory was developed call into question the appropriateness of it as a leadership model outside acute hospital settings (Cameron, Harbison, Lambert, & Dickson, 2012).

AESTHETIC LEADERSHIP Aesthetic leadership is a style of leadership that has been var-

iously positioned in the leadership studies literature. It has been identified as one of the established leadership theories that focus on followers and their subjective views of leader qualities in the leader–follower dyad, views gained through sensory awareness and knowledge (Dinh et al., 2014). Others similarly argue that aesthetic leadership is fashioned by ‘sensory knowledge and

AESTHETIC LEADERSHIP 359

TABLE 1 Shortcomings of Transformational and Congruent Leadership

Models

Transformational leadership Congruent leadership

Lack of a balanced gender outlook (Hutchinson & Jackson, 2013)

A new theory—limited empirical evidence (Stanley, 2006)

Narrow representation of cultural values and beliefs (Hutchinson & Jackson, 2013)

Similarities with authentic leadership (Stanley, 2006)

Lack of explicit emphasis on leader integrity (Hutchinson & Jackson, 2013)

Does not encourage change (Stanley, 2006)

More suited to nurse leaders distant from clinical areas (Hutchinson & Jackson, 2013)

Of little use to distant leaders and managers (Stanley, 2006)

Fail to adequately address altruistic leader behaviours (Dinh et al., 2014)

Creativity not considered a valued attribute (Rolfe, 2006)

Lack of consideration for emotional, embodied, and aesthetic dimensions of leadership (Kuepers, 2011)

May be more suited to clinical settings where nurses work in close proximity (Cameron et al., 2012)

felt meaning associated with leadership phenomena’ (Hansen et al., 2007, p. 552). Hansen and colleagues also contend that a significant feature of aesthetic leadership is the way in which followers’ views about the leadership qualities of leaders are as important as the leaders’ qualities. In other words, aesthetic leaders are not self-appointed but emerge from the perceptions of colleagues (Guillet de Monthoux et al., 2007). Mumford and Fried (2014) position aesthetic leadership as one of a number of ideological models of leadership that are, together with servant leadership and ethical leadership, values-oriented and focus on moral behaviours. In the organisational studies literature, aes- thetic leadership has been offered as a way of enabling flow between the fields of management, administration and aesthet- ics in organisations, where all three fields are regarded as being of equal importance (Guillet de Monthoux et al., 2007). In this interpretation of aesthetic leadership, the management field is where visionary, action-oriented managers and economists op- erate and seek profits, while the administration field is occupied by those who value tradition, regulation, equality and a place for controlling costs. They go on to describe the aesthetic field as that part of the organisation where one seeks to determine what it means to provide or produce quality through ‘creative philosophizing’ (Guillet de Monthoux et al., 2007, p. 267). In

some ways, the aesthetic field provides a buffer between the other two fields.

Aesthetic leaders are those leaders who count on tacit knowl- edge, a type of knowledge that resembles sensory/aesthetic knowing, and is gained from deep indefinable know-how that defies a logical explanation (Hansen et al., 2007). Proponents of aesthetic leadership also argue that knowledge is formed, trans- formed and transferred through interactions and connections with others. This aesthetic knowledge and awareness is a way to make meaning and realities on the basis of embodied experience (Woodward & Funk, 2010) and gives leaders a variety of intel- lectual and emotional tools that complement conventional ways of knowing (Bathurst et al., 2010). It is also argued that aesthetic leaders need to be effective relational leaders, especially when negotiating between and with managers and administrators in an organisation (Guillet de Monthoux et al., 2007). In a review of the literature, aesthetic leadership was determined to be a style of leadership underscored by sensory, somatic and emo- tional awareness, and a strong moral purpose around the values of being just, fair and truthful (Katz-Buonincontro, 2011).

What Aesthetic Leadership Could Offer Clinical Leadership

It is evident from the leadership studies’ literature that lead- ership can be variously described, influenced by a number of factors including culture and context (Casey, McNamara, Fealy, & Geraghty, 2011). It is also evident that with the complexities of modern organisations, one particular leadership style cannot be the only model followed, regardless of the situation. Within the context and culture of the clinical nursing world, aesthetic leadership is a style of leadership that would not be out of place in supporting clinical leader effectiveness, especially with the long held recognition of the relevance and importance of aesthetics and art to nursing practice. As a leadership model, aesthetic leadership is not antithetical to either transformational leadership or congruent leadership, and could go some way to overcoming some of the identified shortcomings of these partic- ular leadership models. All three leadership models recognise the importance of relationships in the leader–follower dyad. Aesthetic leadership, with its follower-centric position (Dinh et al., 2014), could provide a more holistic and balanced view of the leader–follower dyad if used to complement either trans- formational or congruent leadership models, both of which tend to focus on leader traits (Hutchinson & Jackson, 2013; Stanley, 2006).

Given calls for more effective clinical leadership, and the dominance of transformational leadership in nursing, it is evi- dent that its place in the clinical practice world needs reframing. The reframing of its place does not necessarily mean discarding it as a useful leadership model. Instead, by drawing on aes- thetic leadership and aesthetic processes, some of the identified shortcomings of transformational leadership as a model for clin- ical leadership could be overcome. By incorporating aesthetic

360 J. MANNIX ET AL.

processes that emerge from embodied, symbolic and sensual elements shaped from one’s cultural perspective and experi- ences (Woodward & Funk, 2010), the cultural and moral limi- tations of the transformational leadership model (Hutchinson & Jackson, 2013) may not prevail. The way in which transforma- tional leadership encourages leaders to be visionary and creative (Hansen et al., 2007) sits well with aesthetic leadership because, as Hansen and colleagues (p. 549) argue, ‘visions are sensory rich’ and ‘appeal to aesthetic senses’. Kuepers (2011) contends that aesthetic transformational leadership evokes in both lead- ers and followers, an enthusiasm and sense of satisfaction when confronting workplace challenges.

The way in which Guillet de Monthoux et al. (2007) regard aesthetic leadership as a way of facilitating flow between man- agement, administration and aesthetic fields could be beneficial to the clinical practice setting. In the nursing world, one could equate these different fields as management being where senior executives, including nurse leaders, operate, answerable to hos- pital boards/shareholders; administration where nursing admin- istration, including nurse managers function; and the aesthetic field being the clinical practice setting, where clinical leaders provide leadership and where all necessary clinical leader com- petencies may be difficult to pinpoint (Guillet de Monthoux et al., 2007).

The emergence of congruent leadership as a theory to explain the relatively unique and complex world of clinical leadership has enhanced the understanding of what is required for leader- ship in this context. Congruent leadership theory’s centrality of the values and beliefs of the leader (Stanley, 2006) sits well with aesthetic leadership’s focus on leaders displaying a strong moral compass (Katz-Buonincontro, 2011; Mumford & Fried, 2014). However, the idea that clinical leaders with clinical knowledge and expertise need not be in designated leadership roles (Stan- ley, 2006) is contentious, especially if, as Rolfe (2006, p. 146) suggests, congruent leadership is ‘a natural way of being, rather than a skill to be taught’. This notion does not specifically take account of designated clinical leadership roles that carry with them an expectation that these positions be occupied by nurses with advanced clinical knowledge and skills in a particular clin- ical field.

It is perhaps useful to consider clinical leadership expertise in the same way Benner (1984) theorised levels of clinical practice expertise, from novice to expert. To be an expert clinical leader, the central ideas of congruent leadership theory around visible leader values and beliefs would need to be considered. There would also be an acknowledgement that to be an expert clini- cal leader, nurses would also demonstrate aesthetic leadership through a recognition and reliance on tacit knowledge; the aes- thetic knowledge gained from deep indefinable know-how that defies a logical explanation (Hansen et al., 2007). It is this aes- thetic knowledge that can really only be gained and utilised with the professional maturity that comes with clinical experience and high level moral maturity, reflecting developmental stages of maturity, a notion proposed by Habermas (1995). Sumner

(2010) describes moral maturity to be at the post-conventional level when nurses are at Benner’s expert stage, where nurses, rather than having to consciously focus on the task at hand, purposefully and skilfully use their emotions.

One could imagine expert clinical leaders engaging in these types of behaviours across all clinical nursing contexts, from community to acute settings and across discipline areas of nursing. For example, consider contemporary clinical lead- ership expertise in mental health nursing context. The de- institutionalisation of care for people with mental health prob- lems to community-based care leads to changes for nursing lead- ership in mental health (Holm & Severinsson, 2010), resulting in part in the development of specialist roles like consultant nurses and clinical nurse specialists (Bonner & McLaughlin, 2014). Clinicians occupying these specialist positions require well developed levels of skills to manage challenging clinical situations (Ennis, Happell, & Reid-Searl, 2015), expertise that could benefit from aesthetic knowledge and professional matu- rity. The community-based nature of much mental health care means that clinical nurses undertake their practice in diverse and sometimes less predictable and less controlled settings. Clinical leaders in these settings may also find themselves practicing across both community and inpatient settings. Consequently, clinical leaders could benefit from the way in which aesthetic leadership can facilitate flow between management, administra- tion and aesthetic fields involved in the delivery of mental health services.

CONCLUSION Leadership has been referred to as being extremely complex,

involving actions that are interpreted subjectively, affected by politics and all forms of communication (Block, 2014). Some writers contend that leadership is inherently aesthetic (Ackoff, 1998), a performing art (Biehl-Missal, 2010, p. 279) or an em- bodied practice (Hansen et al., 2007, p. 554). It is evident in the clinical world of nursing that one leadership style does not fit all contexts and that the complexities of clinical nursing prac- tice and leadership require an approach to clinical leadership that maximises the potential for positive outcomes for both re- cipients of nursing care and those charged with administering that care. This article has proposed that by considering aesthetic leadership in relation to clinical leaders, some of the shortcom- ings of both transformational leadership and congruent leader- ship could be overcome. At the same time, embracing aesthetic leadership as a relevant leadership model in nursing opens up the possibility of incorporating art and aesthetics into clinical leadership and recognising how an expert clinical leader might differ from other clinical leaders in nursing.

Declaration of Interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

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