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O R I G I N A L P A P E R

In command of care: Toward the theory of congruent leadership

David Stanley MSc HS, BA Ng, Dip HE (Nursing), RGN, RM, TF, NursD

Senior Lecturer

University of Worcester

Abstract This is the second of two papers that discuss clinical leadership in the

light of a research study which explored who the clinical nurse leaders are, what the

characteristics and qualities of clinical leaders might be, why some nurses are seen as

clinical leaders and what their experiences might be (Part 1 (Stanley, 2006)).

Outlined are contemporary views about leadership and nursing, with emphasis on

transformational leadership. Also explored is the new theory of congruent leadership.

It is proposed that congruent leadership is a theory best suited for understanding

clinical leadership because it is defines leadership in terms of a match (congruence)

between the activities, actions and deeds of the leader and the leader’s values,

principles and beliefs.

Keywords clinical leadership, nursing leadership, transformational leadership,

qualitative research, congruent leadership

Introduction: leadership and nursing Nursing leadership has grown in significance over the past 20 years (Jasper, 2002;

Moiden, 2002); however, the theory and practice of nursing leadership has been

poorly developed (Hurst, 1997), and apart from anecdotal accounts, little was

written about nursing leadership in the United Kingdom (UK) until Rafferty (1993)

published a discussion paper addressing nursing leadership issues. Rafferty con-

cluded, in relation to developing nursing’s leadership potential, that:

Getting it ‘right’ was less important than being prepared to take risks and make a start. It

was felt important that different kinds of leadership were needed at different levels and

times and therefore it was vital to have a pool of leaders upon which to draw. For this to

happen, a number of different models of leadership needed to be fostered.

(1993: 25)

Rafferty also recommended that more attention should be paid to leadership training,

management development, research into nursing leadership and clinical leadership.

The nursing profession, she declared, required nurse leaders who were ‘visionaries’

(1993: 27) who could support the development and creation of a healthcare system

that allowed nurses to express their values and the value of nursing. Rafferty recog-

nised that the development of nursing leadership was in ‘crisis’. She also saw the

complexity, contradiction and confusion associated with leadership issues and

Journal of Research in Nursing

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SAGE PUBLICATIONS

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VOL 11(2) 132–144

DOI: 10.1177/

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David Stanley In command of care

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recognised that immediate and vital action was needed if the nursing profession was

to ‘claim legitimacy in the leadership stakes’ (1993: 26).

Malby (1997) felt that the ‘crisis’ persists because there was a belief that nursing

was incapable of promoting a leadership culture or consciousness. However, The

Royal College of Nursing (RCN) and the King’s Fund Centre were quick to respond,

and soon set up a series of educational programmes facilitating ‘managerial’ support

for ward sisters and charge nurses. Other programmes soon followed, and a plethora

of opportunities opened for nurses looking to develop their leadership potential.

Prominent among these was the RCN Clinical Leadership Development Programme

(Cunningham and Kitson, 2000) and, more recently, the NHS Leadership Centre has

developed a range of courses.

The Government’s change agenda also supported a resurgent focus on leadership

development within nursing. A First Class Service: Quality in the NHS (DoH, 1998)

described part of its aims as the development of ‘organisations to support a change in

culture and to deliver change’ (1998: 75). Making a Difference (DoH, 1999) and

The NHS Plan (DoH, 2000) also set out their support for effective nursing leadership

in promoting change. Further research and literature has appeared and a considerable

amount has been achieved with still greater developments likely as the NHS Leader-

ship Centre exerts further influence.

Much has been achieved and different levels of leadership have developed,

although all appear in what Antobus and Kitson call the ‘academic, political and

management domains’ (1999: 751). Numerous studies or articles (Rafferty, 1993;

Antrobus and Kitson, 1999; McKeown and Thompson, 1999; Kitson, 2001; Beech,

2002; Firth, 2002; Jasper, 2002; Faugier and Woolnough, 2003) have focused on

nursing leaders who hold senior levels within organisations, Trusts, nursing divi-

sions, wards and/or departments. Although clinical leadership is often mentioned, it

is rarely the subject of research because of its low status (Antrobus and Kitson, 1999)

when compared with other leadership domains. For this reason, the uniqueness of

clinical leadership has remained largely unrecognised and under-valued (Lett, 2002).

Indeed, research specifically focusing on clinical leadership is sparse, and the term

‘clinical leadership’ is often used interchangeably and inappropriately, alongside or

in conjunction with ‘nursing leadership’ (Lett, 2002) or even ‘nursing management’.

This problem is compounded because much of the literature related to nursing

leadership was developed to support nurses in management positions or with man-

agement responsibilities. This has meant that literature and research to support one

concept (e.g. nursing management) has been accepted as transferable when seeking

insights or understanding of the related areas.

Another reason for the lack of different leadership models and the slow develop-

ment of different kinds of leadership within nursing is that leaders were needed in

the NHS who could support an organisation that was trying to adapt and be success-

ful in an environment of constant change. This led to a dependence on leadership

theory that supported change and understood leadership from the perspective of

facilitating and developing change. This required a theory where the followers could

be inspired and influenced by pulling them towards a vision of some future state.

With constant change as a theme in the NHS, nursing leadership programmes and

the profession’s view of leadership has focused on an understanding of leadership

based on the dominance of transformational leadership theory and on the assump-

tion that leaders must have ‘vision’ and influence or power to see the vision through.

The NHS Confederation supported this perspective when they indicated that ‘as the

NHS seeks a new model for a new century, transformational leadership presents itself

Journal of Research in Nursing 11(2)

134

as an evidence based technique’ (1999: 4). In many respects this perspective is

sound, and for some levels and types of nursing leader this is the case, although,

when addressing other types of leadership at different levels, this assumption may be

counter-productive and inaccurate.

The net effect is that Rafferty’s (1993) suggestion that nursing needed to develop

different leadership models for leaders at different levels has not been followed up and

the transformational leadership model dominates.

Transformational leadership Transformational leadership (Downton, 1973; Burns, 1978) is strongly associated

with Bass (1985, 1990) and his work to try to tease out the distinctions between

management (associated with transactional leadership) and leadership. Transforma-

tional leadership is seen as a process that changes and transforms individuals (Nort-

house, 2004). It involves emotions, motives, ethics, long-term goals and an

exceptional form of influence that moves the followers to accomplish more than is

usually expected of them, incorporating both charismatic and visionary leadership

(Northouse, 2004). Leithwood (1999) considered transformational leadership from

an educational perspective and identified that it involved setting directions, establish-

ing a vision, developing people, organising and building relationships.

Transformational leaders are seen as being connected to a process of attending to the

needs of the followers, so that the interaction of each raised the motivation and energy

of the other. This results in a challenge to the status quo, a new vision and the sharing of

that vision, so that the successful transformational leader gains support for the vision and

is consistently and persistently driven to maintaining momentum and empowering

others (Kakabadse and Kakabadse, 1999). Day et al. (2000: 15) add to this perspective,

saying that ‘transformational leaders not only manage structure, but they purposefully

impact upon the culture in order to change it’. The transformational leader is not associ-

ated with status or power and is seen as being appropriate at all levels of an organisation.

The interdependence of followers and leaders within this theory has meant that

transformational leadership has found favour in care-related and teaching fields and,

according to Welford (2002: 9) ‘transformational leadership is arguably the most

favourable leadership theory for clinical nursing in the general medical or surgical ward

setting’. Thyer (2003: 73) also feels it is ‘ideologically suited to nurses’, while Sofarelli

and Brown (1998) indicate that it is a suitable leadership approach for empowering

nurses and, as mentioned, the NHS Confederation (1999) indicate that transforma-

tional leadership is, in their view, best suited to modern leadership of the NHS.

Transformational leadership has gained favour because it is related to the estab-

lishment of a vision and adaptation to change. Rafferty (1993) sought the develop-

ment of ‘visionary’ nursing leaders, who could take nursing forward and, to some

extent, Rafferty set a precedent whereby the development or possession of a ‘vision’

is seen as central to nursing leadership. However, where ‘doing’ dominates over ‘cre-

ating’, transformational leadership may, in fact, fail to fulfil its promise as a suitable

leadership theory.

Therefore when vision or creativity are not regarded as attributes associated with a

role or post and partly in reponse to Rafferty’s (1993) call for different models of

leadership to be fostered. A new leadership theory (Congruent Leadership) is

proposed. Congruent Leadership offers a framework that accomodates and demon-

strates all the qualities and characteristics of clinical leaders and the vital contribution

they make.

David Stanley In command of care

135

Recognising clinical leaders Research undertaken as part of the author’s doctoral thesis proved a rich source of

information about clinical leadership, who the clinical leaders are and the attributes

of clinical nurse leaders (Part 1).

The results demonstrated that clinical leaders appeared to be present at all nursing

levels and in considerable numbers, but they were often not the most senior nurses

and their approach to clinical leadership was based upon a foundation of care that

was fundamental to their view of nursing and care. The study also indicated that the

type of clinical area had an influence on who might be seen as a clinical leader, and

although F-grade sisters were most commonly recognised in all areas as clinical

leaders, in specialist areas of practice, F and higher grades were nominated.

However, in more general clinical areas, F and lower grades were more commonly

identified as clinical leaders.

Cook’s (2001) study of clinical leadership attempted to identify the attributes of

effective clinical leaders by focusing not on nurses at the ‘hierarchical apex of the

organisation . . . but on those nurses that directly deliver nursing care’ (Cook, 2001:

33) and, as such, his enquiries were directed toward nurses not deemed to be in

conventional nursing leadership positions, but who displayed many of the attributes

of highly effective leaders. Cook (2001) indicated that clinical leaders were recog-

nised because they were ‘discoverers’, ‘enablers’, ‘shapers’ (with ‘creativity’ to gen-

erate new ways of working) and ‘modifiers’ who supported and helped others with

the process of change. This author’s study, in keeping with many of Cook’s (2001)

findings, recognised clinical leaders because they knew and could do the work

central to their clinical area and practice (Figure 1).

In this author’s study, clinical nurse leaders were seen as role models for nursing

practice with high-level clinical skills and sound clinical knowledge. They were

described as effective communicators, both in terms of listening to and talking to

others. They remained open and approachable, were decision-makers and, signifi-

cantly, they were visible and accessible in the clinical area. Being viewed as ‘control-

ling’ was consistently seen as least associated with the qualities of a clinical leader

and, as with Cook’s (2001) study, having a vision or articulating a vision appeared

unrelated and unrecognisable as a dominant feature of the qualities and character-

istics for which clinical leaders were recognised. This could be because nurses were

drawn to or identified clinical leaders who could lead them through the ‘here and

• Approachable and open.

• Empowered/decision-makers.

• Visible.

• Clinically competent and clinically knowledgeable (usually within the spe-

cific area in which they work).

• Seen to be displaying their values and beliefs (they lived out what they

believed to be important to them. They know were they stand and hold fast

to their guiding principles).

• Effective communicators.

• Positive clinical role models.

Figure 1 The characteristics and attributes identified with clinical Leadership.

Journal of Research in Nursing 11(2)

136

now’ issues of busy and chaotic clinical work, and who could cope with the

demands of each day as it came.

A significant difference between these more recent results and Cook’s (2001)

study was that Cook saw clinical leaders as ‘creative’, identifying the typology of

‘shapers’ to describe them. However, creativity was rarely identified as a defining

characteristic in this author’s study, with the questionnaire’s results demonstrating

that ‘creative/innovative’ was ranked twenty-fifth out of a list of 42 qualities and

characteristics ‘most’ associated with clinical leadership, and ‘artistic’ was ranked

forty-first (second only to ‘controlling’ as a characteristic least associated with clinical

leadership).

Antrobus and Kitson (1999: 750) identified ‘understanding self and having a clear

understanding of values, purpose and personal meaning’ as part of the skills reper-

toire they identified for effective nurse leaders. Cook (2001) also saw clinical nurse

leaders as ‘valuers’ who empathised with others and who tried to gauge their own

feelings as well as those of other nurses, while McCormack and Garbett (2003) indi-

cated that ‘practice developers’ valued and strove for an emotional engagement with

their work. In this author’s questionnaire and interview results, clinical leaders

described themselves as being driven by their values and ‘passion’ for high-quality

patient care. Ultimately the holding and demonstration of values and beliefs emerged

as strongly related attributes of clinical nurse leaders. They were followed, therefore,

not for their vision and creativity (although they may have had these attributes), but

because their values and beliefs were on show and evident in their actions.

Because they display their principles about the quality of care, they dealt with

patients in a ‘hands-on’ fashion. And, because they lived out their values and beliefs,

they stood apart from novice clinicians, poor decision-makers, staff who were ‘hide-

bound’ and managers who were tied up with other functions and those who were

less visible in the clinical environment.

There is a view that values are inextricable to vision, although Pendleton and King

(2002) declare that it may be even more important to know where you stand (a values-

centred position) rather than where you are going (pertaining to vision). This implies

that values are rooted in understanding an individual’s or organisation’s principles,

while vision is about being able to drive through or respond to changes in the future.

From a leadership perspective, Pondy (1978) supports this by suggesting that leadership

is the ability to make actions meaningful and allow others to gain a sense of understand-

ing, not necessarily change one’s behaviour. But values and vision do appear to be linked

and, although they may not be dependent upon each other, they may point to motiva-

tions that drive individuals and organisations from different perspectives.

The Department of Health (1999: 52) recognised that ‘strong nursing, midwifery

and health visiting leadership is needed at every level’ and although many studies

exploring nursing leadership exist, few focus on clinical leadership, with most

studies focusing on senior nurses, the development of ‘visionary’ leaders (Rafferty,

1993), the development of ‘strategic-level leaders’ (Malby, 1997: 27) and nurses

with leadership responsibilities implied by their title or who hold senior hierarchical

positions within a ward or Trust. This author’s study allowed nurses from across a

large NHS Trust to nominate or identify who, for them, were clinical leaders and

indicate why.

Results indicated that 326 nominations were made for clinical leaders as a result of

the questionnaire responses, and in the four clinical areas of the focused interviews,

130 clinical leader nominations were made by the 42 individuals interviewed, with

over 60% being for nurses at F-grade level or lower.

David Stanley In command of care

137

Clinical leaders were found to be present in large numbers and at all levels. Man-

agers and modern matrons were nominated, but their nominations were vastly over-

shadowed by nominations for nurses with predominantly clinical roles, often at

staff-nurse level, particularly in general wards. Cook (2001) also suggested that leader-

ship qualities exist at all levels and Ogawa and Bossert (1995) argue that leadership

could be associated with roles throughout an organisation. These views are supported

by Burns (2001) who also believes that, in a chaotic healthcare environment, ‘frontline

leaders’ are not only ‘required at all levels’, but they may ‘understand the environ-

ment’s complexities even more than executive leaders’ (2001: 478).

It could be that, in the nursing literature or prior studies, nurses have been

unrecognisable as clinical leaders because most function at the bedside, doing

‘nursing work’. Doing the invisible (Robinson, 1991: Davies, 1995) and ‘dirty work’

(Roberts, 1983; Wilkinson and Miers, 1999) of nursing implies that they become

invisible too, and as doing ‘dirty work’ makes one ‘dirty’ by association (Wolf,

1996), clinical nurse leaders may be overlooked or go unrecognised by themselves,

their professional colleagues or by the healthcare community in general. This was

confirmed when half of the clinical leaders interviewed were ‘surprised’ at their

nomination and didn’t recognise themselves as clinical leaders. This invisibility is

compounded because clinical leaders are often measured against a set of criteria,

characteristics and qualities more in keeping with general leadership or management

ideologies and attributes, such as those from the NHSE (2000). As such, clinical

leaders who do not demonstrate attributes of being creative, visionary or fit the man-

agement profile, may be overlooked, and their contribution to leading at the

bedside, doing nursing’s ‘dirty work’ goes unrecognised.

Clinical leaders can therefore be recognised and are almost certainly found

working in a predominantly clinical capacity and in all types of clinical areas. The F-

grade junior sister is a candidate likely to be viewed as a clinical leader by her col-

leagues and although modern matrons and nurse managers are acknowledged to be

in clinical leadership positions, there is considerable dispute about their effectiveness

and validity in a clinical capacity.

This point at least is not new, and it highlights discussions within nursing that

draw attention to the tension between some nurses’ clinical leadership responsibil-

ities and their management function (Rafferty, 1993; Christian and Norman, 1998;

Antrobus and Kitson, 1999; Firth, 2002; McCormack and Garbett, 2003; Thyer,

2003). For the senior nurses interviewed as part of this study, the conflict commonly

felt was one that pulled them between their desire to remain clinically focused and

demands from the NHS or their Trust managers to maintain the management and

resource capabilities of their clinical area. Most nurses become nurses to care for

patients, and their values are based on maintaining or promoting high standards of

care. Increasingly, nurses describe being pulled or pushed to work in ways that inter-

fere or contradict the core values they hold with a target-driven NHS complicating

and compromising their professional values system. This is an issue not restricted to

senior nurses: as Government targets and tight budgets strike, all levels and types of

healthcare staff are caught in what Pendleton and King (2002: 1354) call the ‘ethos

gap’. The challenges identified by clinical leaders in the author’s study related to

maintaining staff moral and the increasing gulf between management and clinical

expectations and responsibilities is evidence of the effect of this ‘ethos gap’, where

managers and senior nurses are increasingly perceived to be further and further

removed from clinical care and nursing’s core values.

Being creative and having a vision remains central to the successful application of

Journal of Research in Nursing 11(2)

138

transformational leadership, although they do not appear to be features for which clini-

cal leaders are recognised. Their omission brings into question the suitability of the

transformational leadership theory to explain or support the role and function of clinical

leaders. It also questions the suitability of transformational leadership as the most appro-

priate leadership theory for understanding and developing future clinical nurse leaders.

The research outlined in Part 1 indicates that clinical leaders are selected because

they have their values on show and act in concert with them. Being controlling

(associated with a management function) was overwhelmingly regarded as being

least connected with clinical leadership. Therefore nurses with management as a dis-

cernible feature of their job or role were much less likely to be seen as clinical

leaders. As such, when nurses are promoted away from the clinical area or lose direct

client contact, many encounter conflict as they are drawn into areas of management

and administration, often either removed from or in conflict with their values and

beliefs about patient care. Even if this is not the case and a crisis of conscience is

avoided, others may recognise the controlling elements and this diminishes the like-

lihood of their being identified as an effective clinical leader.

Discovering who the clinical leaders are and recognising their qualities and

characteristics has resulted in the proposal of a new theory of leadership, ‘congruent

leadership’. This explains and captures the nuances of clinical nurse leadership.

Congruent leadership Bhindi and Duignan (1997) described what they called ‘authentic leadership’ where,

in order to lead, leaders were required to be true to themselves and leadership was

based on the leader’s personal credibility and integrity. This view ran parallel to

Pondy’s (1978) description of leadership, where leaders are encouraged to explore

their values and lead from a recognition of what was identified as important to them,

rather than on a vision or set of goals. George (2003), writing about leadership from

a business perspective, also describes what he calls ‘authentic leadership’, where

leaders are guided by ‘qualities of the heart, by passion, and compassion, as they are

by qualities of the mind’ (2003: 12). They lead, George suggests, ‘with purpose,

meaning and values’ (2003: 12). Likewise, ‘breakthrough leadership’ (Sarros and

Butchatsky, 1996) requires the leader to be a role model and, again, lead from the

perspective of having clarified their own values, while respecting and listening to

others. These theories, in part, explain why a nurse who is being ‘true to herself’

might wish to stay at the bedside rather than become a ward manager (Lett, 2002)

and runs closely in line with the themes identified in this author’s research.

These alternative theories of leadership and the results from this author’s study

prompted a view of clinical leadership from a new perspective, with congruent

leadership proposed as an alternative theory to explain clinical leadership.

Congruent leadership can be defined as where the activities, actions and deeds of

the leader are matched by and driven by their values and beliefs about (in this case)

care and nursing. Congruent leaders may have a vision and idea about where they

want to go, but this is not why they are followed. Congruent leadership is based on

the leader’s values, beliefs and principles, and is about where the leader stands, not

where they are going. Congruent leaders are motivational, inspirational, organised,

effective communicators and build relationships. Many have no formal, recognised

or hierarchical leadership position and, as such, congruent leadership may offer a

better theoretical framework to explain how and why they function (Table 1 com-

pares the features of congruent and transformational leadership).

David Stanley In command of care

139

Congruent leaders are guided by their passion for care. They build enduring rela-

tionships with others, stand the test of their principles and they are more concerned

with empowering others than with power or their own prestige. Congruent leader-

ship explains why and how nurses and other non-titled leaders at all levels can func-

tion and be effective without formal influence in the clinical area. One clinical leader

in the study summed this up by saying:

Honesty, loyalty, passion, integrity those sort of things are probably more important . . .

years ago when I was less experienced I would have said knowledge would have been oh,

right up there, but because of the way I have changed, I don’t think that this is necessarily

so any more . . . these other qualities out-weigh them.

The interviews with clinical leaders and with nurses talking about what they look

for in a clinical leader indicate that not all leadership is about changing people’s

vision of the future. Some leaders lead because they demonstrate where their values

lie and are followed because others identify with them and stand with them. This is

reinforced by the following comments from the interviews:

I am not only able to empathise with patients and their relatives, but with staff as well . . .

trying to think ‘what would they be going through?’ . . . it makes my ability to communic-

ate with them much better.

I think people know that I am quite passionate about what I do and I also like to support

others to be . . . erm . . . to achieve the best they can achieve and very strongly centred on

patient care and good standards of care.

Congruent leadership in action can be seen by describing the following example

offered during one of the interviews. It relates to an account of a D-grade nurse who

was faced with an anxious husband whose wife had undergone emergency surgery.

The husband wanted to visit her and be at her side, but he needed to work when the

ward had visiting times. The ward enforced strict visiting times for all relatives and

other visitors and, although the ward was ‘open’ for a number of hours, this particular

man was unable to attend at these times. The D-grade nurse, knowing she was acting

against the specific instructions of the ward manager and senior sister, allowed the man

onto the ward at 10.30 a.m. to visit his wife. The D-grade nurse undertook to allow

this husband on to the ward because she believed that, had this been her husband, this

was the action she would have wanted the nurse to follow. The nurse knew that she

could have incurred the disapproval and, indeed, on this ward, a reprimand from the

ward manager and senior sister, but she undertook to support the husband and defend

Table 1 A comparison of the features of Transformational and Congruent leadership

Transformational leadership features Congruent leadership features

• Establishing direction. • Motivating and inspiring.

• Aligning people. • Approachable/open.

• Motivating and inspiring. • Actions based on values and beliefs.

• Produces change – often dramatic. • About where you stand (principles).

• About where you are going (vision). • Effective communicators.

• Effective communicators. • Visible.

• Creative/initiative. • Empowered.

NB: Although there are some similarities, the key differences relate to what motivates the leaders: vision

or values and principles.

Journal of Research in Nursing 11(2)

140

her stance against the more senior nursing staff. The incident caused some discomfort

for the more junior nurse, and the fallout from her action was that she was repri-

manded. This initiated debate at the regular ward meeting that ultimately resulted in

many of this nurse’s colleagues agreeing that they would have liked to have done the

same and this, in time, led to a revision in the ward’s visiting processes and procedures.

The D-grade nurse employed no long-term strategy in admitting the husband

outside of the permitted visiting times, and had not set out to disrupt the ward’s vis-

iting procedures. However, by following her beliefs about respecting the needs of

patients and their relatives, the nurse initiated what developed into a slow revolution

that resulted in significant change and an improvement in the access relatives enjoyed

to their ill, worried and isolated friends and family.

Followers are attracted to congruent leaders because of the banner or standard

they carry. They may not even intentionally show it, or they may not be conscious

that others see it, but it is this that followers recognise and rally to. Their metaphori-

cal banner or standard is usually a statement of what the clinical leader believes is

important to them. It might say: ‘I care for patients like they were my family’;

‘I teach these children as if they were my own’; ‘I’ll be here at the bedside with you’;

‘I know what it’s like’; or I’m on your side’.

Clinical leaders who display congruent leadership match their values and beliefs to

their actions and, in the example above, the D-grade nurse took a risk in following

her beliefs. However, her colleagues recognised this action as part of the qualities

and characteristics associated with clinical leadership and, as the D-grade nurse was

visible and present in the clinical area, and because of her commitment and passion

for the core values of nursing, she was (even unintentionally) able to motivate and

inspire others to follow. The more senior nurses who had developed the visiting

policy were not as present on the ward, did not deal as regularly with dissatisfied or

upset relatives and friends, and were not as commonly in positions of having their

nursing and caring values and beliefs challenged.

This example is in accord with the examples from Manley’s (2000a, b) study

where it is evident that she led with her values first and was successful as a clinical

leader because others saw her values on show. Her values supported and matched her

actions and this congruence formed the basis for her success as a clinical leader.

Manley (2000b) recognised that her leadership brought about ‘cultural change’

because her values were used to ‘highlight the contradiction between espoused

culture and culture in practice’ (2000b: 34). Manley (2000b) identified her leader-

ship style as transformational because it was her aim to affect and change the culture

of the unit. But when reading the examples given by respondents in Manley’s

(2000b) research, they were influenced more by her actions than by her vision. One

said, ‘the enthusiasm of the consultant nurse incited enthusiasm in myself’ (2000b:

37) another said, ‘her influence has definitely influenced me’ (2000b: 37); Manley

supported practitioners to become aware of their own values and beliefs, and helped

in this process by allowing others to see and recognise her own values and beliefs

and how they supported a change in the culture of the ward.

Roberts (1983), when considering oppressed group behaviour, indicated that it

may be necessary to view current nursing leadership with scepticism because nursing

leaders, in order to break free from oppression, adopt the leadership attributes of the

oppressors. In so doing they become unwitting or even complicit co-oppressors,

who through their approach to leadership and educational structures support the

status quo, maintaining or relegating nurses and nursing to a second-class or sub-

servient status. This approach to leadership leads to divisiveness and competition

David Stanley In command of care

141

among nurses and, to avoid this, Roberts suggests that elite leadership should be

shunned and nursing should aim to develop leadership from the ‘grass roots’ (1983:

29) perspective. In many respects this is what Manley was able to achieve, as her col-

leagues became more empowered and emancipated as ‘practitioners become aware

of their values, beliefs and assumptions and helping them to act on them’ (Manley,

2000b: 38). In effect, Manley’s research and the example offered are centred on

‘grass roots’ leadership that is in keeping with the principles of congruent leadership.

If nursing is to develop effective nursing leaders, it needs to do so without losing

the core values and principles that guide nursing. Congruent leadership establishes a

foundation from which all good or effective nursing leaders can start, because it

grounds the leader’s principles within the core values of the nursing profession and

ensures that the dominant cultural narrative of nursing is one of patient-centred care,

with nursing values and care-centred attributes placed ahead of those associated with

the dominant (potentially) oppressor groups of managers and physicians. Transfor-

mational leaders, in an effort to achieve their vision or goals, could at times move

from positions of influence and power to positions of control. Unwittingly, in doing

so, they run the risk of losing their connection to their core values and guiding prin-

ciples, or at best become embroiled in a state of conflict as their managerial (control-

ling) demands conflict with their professional and often personal desire to remain

focused on patient care.

Congruent leadership is not power-neutral and the power of congruent leadership

comes from unifying groups and individuals around common values and beliefs.

This is not a strategy as such, but results from this author’s research appear to

demonstrate that nurses seek out or follow clinical leaders who are more inclined to

display or hold values and beliefs that they themselves hold. Manley (2000b) also

found that as she displayed her values and beliefs others began to share them, and the

clinical area united as colleagues began to identify with the common purpose of

‘providing patient centred care’ (2000b: 38).

Nurses seeking to lead in a clinical environment will find greater success if their

values and beliefs are consistent with the dominant values and beliefs of their col-

leagues, or if they are able to bring their colleagues to a point where their values and

beliefs about care coincide. Conflict can result if the principles and values of one

group or individual are at odds with others, and power and influence in terms of

leading often falls to the dominant group or leader.

In relation to transformational leadership, power and influence arise from being

able to articulate a vision that is accepted and acted upon by the majority of the fol-

lowers. The leader is held in high regard because they are trusted and because their

own self-belief is evident. Change is the goal and as the new vision is worked

towards, the leader is able to take the followers forward.

In relation to congruent leadership, the leader’s power and influence is derived

from being able to articulate and display their values, beliefs and principles. Follow-

ers and others recognise or align themselves with these same values or beliefs, thus

supporting and promoting these values and beliefs, increasing the leader’s credibility

and worth and promoting the significance of ‘this’ leader’s values and beliefs over

any others. Change, although often not the intention (although it was for Manley),

results when new values and beliefs are displayed, promoted and then adopted.

Successful clinical leadership is therefore proposed to rest on a model of congruent

leadership that is based on leaders who respond to challenges and critical problems

with actions and activities in accordance with (congruent with) their values and beliefs.

The strengths of congruent leadership are that:

Journal of Research in Nursing 11(2)

142

• It supports the promotion of ‘grass roots’ (Roberts, 1983) leaders.

• It offers a foundation for other theories of leadership to be built upon. From this

foundation, clinical leaders, nurses and ‘grass roots’ leaders can develop an under-

standing and connection with the core values and beliefs about nursing. No longer

invisible, nursing work is recognised and clinical leaders can have a positive

impact on nursing care and lead nursing forward by standing by the principles

central to the profession.

• It may offer nursing an opportunity to develop greater influence in the leadership

stakes (Rafferty, 1993). However, until nurses themselves can influence and initi-

ate this and recognise themselves as congruent leaders, others will continue to see

clinical nursing as ‘dirty’, ‘invisible’ (Roberts, 1983; Robinson, 1991; Davies,

1995; Wilkinson and Miers, 1999) work and clinical nurse leaders will remain of

low status (Antrobus and Kitson, 1999), invisible and dirty by association.

• There may be a greater realisation that values need to become the focus of devel-

opment in the NHS.

• It builds a strong link between values/beliefs and action. In this regard it is not

static, but dynamic. Congruent leadership is not just about being, but about

acting, displaying, demonstrating, living the leader’s values and beliefs.

• The result of congruent leadership is a change or identification with the culture of

a group or organisation rather than simply addressing group structure.

• It represents a new perspective on clinical nursing leadership and is helpful for

advancing our understanding of clinical leadership.

The limitations of congruent leadership are that:

• It is a new theory. It is untried, unsubstantiated and untested by further research.

The research undertaken in this study, although substantial, stands alone in its

scope and findings and until further research is undertaken, congruent leadership

has to be acknowledged as resting on a narrow platform.

• It is similar in some respects to ‘authentic leadership’.

• Congruent leadership is not as obviously in keeping with the dominant NHS drive

to seek out and promote leaders who can ‘change’ practice and lead change. There

is a tension between striving to practice within a set of professional values related

to care and compassion and having to achieve this within a target-driven and

resource-poor NHS.

• It is of limited use to leaders who are required to exercise control over others

(managers) or who are not visible or engaged in the process of doing the ‘work’

of the people or groups they lead.

Conclusion Significantly, the nurses in command of care were recognised not because of their

position or seniority, creativity or vision (although some displayed these character-

istics), but because their values and beliefs about care were on show and were

matched by their actions. They built their approach to clinical leadership on a foun-

dation of care that was fundamental to their view of nursing and how patients should

be cared for. Clinical leadership is commonly demonstrated in the ward or unit, by a

clinical leader who is directly involved in providing nursing care. Clinical leaders are

visible to their colleagues and considered to be knowledgeable, competent clinicians,

who motivate and inspire others because their values, beliefs and guiding principles

David Stanley In command of care

143

are on show and are recognised as such. Leaders who control and manage from

within offices or who fail to display their values and beliefs in congruence with their

actions are rarely seen as clinical leaders.

Greater depth has been added to the nursing profession’s understanding of clinical

leadership and indicators have been found that point towards the significant contri-

bution clinical leaders can make if they are recognised as such and encouraged to see

that leadership does indeed exist at many levels. Clinical leaders commonly display

congruent leadership, and their passion for participation in hands-on patient care and

in striving to contribute to high quality nursing adds to the pool from which nursing

leaders can be drawn. However, they need to be recognised as such, by themselves

and the profession in general, because the nurse leader who stands by what they

believe is as valuable, and as effective, as the leader with the grand plan. Congruent

leadership, if recognised, demonstrated and established can also become a firm foun-

dation on which to bolster leadership within the nursing profession.

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