HMGT 320 WEEK 5 DISC DOCX

T he Francis Report (2013), which was commissioned following identified failures in care at Mid Staffordshire NHS Foundation Trust, highlighted the priority of leadership within health care and emphasised the consequences for patients of deficient

leadership. This article takes a critical took at leadership issues by analysing a case study and looking at different leadership models and approaches.

There is a large body of literature focused on leadership, yet opinions frequently conflict, and the evolving nature of the practice and theory on the topic means that there is no consistent definition of what constitutes leadership. Theories have advanced through five stages over the past century

Taking a case study approach to assessing alternative leadership models in health care Jonathan Harris and Paula Mayo

ABSTRACT Good leadership is essential to patient-centred care and staff satisfaction in the healthcare environment. All members of the healthcare team can be leaders and evidence-based theory should inform their leadership practice. This article uses a case study approach to critically evaluate leadership as exercised by a charge nurse and a student nurse in a clinical scenario. Ineffective leadership styles are identified and alternatives proposed; considerable attention is given to critiquing both ‘heroic’ and ‘post- heroic’ transformational leadership theories. The concept of power will also be discussed, as power and leadership are closely related, and the importance of empowering members of the healthcare team through altering organisational structure is emphasised. This article advocates leadership that encourages innovation, enhances patient-centred care, encourages excellence and has ethical integrity. Recommendations of appropriate models of leadership are provided, while existing gaps in the healthcare leadership literature are highlighted.

Key words: Leadership models ■ Engaging leadership ■ Authentic leaderships ■ Transformational leadership

Jonathan Harris, Staff Nurse, Emergency Department, Leeds Teaching Hospitals NHS Trust, [email protected]

Paula Mayo, Lecturer, School of Healthcare, University of Leeds

Accepted for publication: May 2018

and include trait theories, behavioural theories, situational theories, ‘heroic’ transformational theories and ‘post-heroic’ transformational theories (Alimo-Metcalfe, 2013). Nursing literature frequently highlights transformational leadership as best practice, but rarely distinguishes heroic and post-heroic types. Therefore, this article gives considerable space to critiquing heroic and post-heroic transformational leadership theories in the context of health care and the included case study.

The article uses Yukl’s (2012) definition of leadership because this covers a broad spectrum and recognises that leadership can occur at every level of an organisation. It was developed following a synthesis of existing leadership literature:

‘Leadership is the process of influencing others to understand and agree about what needs to be done and how to do it, and the process of facilitating individual and collective efforts to accomplish shared objectives.’

Yukl, 2012:26

The article evaluates the leadership practices described in a case study scenario and makes recommendations to improve leadership practice, before concluding with a discussion on power, empowerment, and their applicability to leadership.

Case study A third-year nursing student who was on ward placement in a large teaching hospital approached a charge nurse who had 5 years’ managerial experience with the purpose of promoting an evidence-based intervention to enhance patient care and reduce costs. The student had been on the placement for 10 weeks and felt like an established member of the team.

The proposed intervention was to change current practice, whereby peripheral cannulas were removed and replaced every 96 hours, and align practice with the findings of a Cochrane review, which stated that peripheral cannulas should be removed only when clinically indicated (Webster et al, 2015). Such an intervention would reduce costs and improve the patient experience (Webster et al, 2015). After hearing an explanation of the intervention the charge nurse was dismissive, stating that care was delivered in a certain way and that this would not change.

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The case study takes place within the context of a busy practice environment in which patients are typically older and dependent, where the charge nurse is frequently absent because he bears extra managerial responsibility as a result of the ward manager being signed off on long-term leave. Staff satisfaction on the ward is low.

Evaluating the charge nurse’s leadership practice The case study highlights the leadership practice of the charge nurse, which can be described by the behaviourist theory developed by Weber (1905). He identified two types of leader: bureaucratic and charismatic. Bureaucrats lead by protocol and guidelines, resulting in a workforce that is unstimulated, lacking initiative and having low satisfaction (Sullivan and Garland, 2013). The charge nurse was unreceptive of new ideas, which may have been due to a lack of trust in both his own decisions and the ideas of the nursing student (Sullivan and Garland, 2013).

According to Weber (1905), charismatic leadership rests upon a leader being exceptional in their field. Such leadership may result in a workforce becoming dependent on the ‘extraordinary’ leader and on his or her egocentric ‘superiority’ (Ciampa, 2016). The charge nurse’s dismissal of new ideas may stem from an erroneous self-confidence in himself being the expert in his field, which outweighs the knowledge of those he leads. Weber’s (1905) behaviourist theory of leadership is insufficient to effectively assess the leadership displayed by the charge nurse because it focuses solely on outward behaviour with no regard for internal processes.

A further behaviourist theory was developed by Lewin et al (1939) and describes three styles of leadership: autocratic, democratic and laissez-faire. It may be theorised that the charge nurse uses laissez-faire leadership due to his frequent absences and general lack of direction. Laissez-faire leadership is described by Bass (1985) as non-leadership, while a study by Skogstad et al (2007) surveying 2273 employees from various workplaces in Norway concluded that this style of leadership is a destructive approach that results in interpersonal conflict, psychological distress, bullying and a stressful work environment.

No studies have been identified evaluating the impact of laissez-faire leadership on job satisfaction in UK healthcare settings, but Lorber et al (2015) used data from a cross-sectional survey conducted in Slovenia; this revealed that laissez-faire leadership is frequently used by nurse leaders and the authors hypothesised that this leadership style may go some way to explaining nurses’ low morale. It is unclear whether the results from Lorber et al (2015) are generalisable to the UK due to sociocultural differences between the two countries, and research needs to be conducted to evaluate the impact of this leadership style in the UK healthcare environment.

The charge nurse’s approach is not compatible with the definition of leadership provided by Yukl (2012), in that he spent little time trying to understand and agree on a course of action and did not collaborate in the greatest healthcare task of promoting patient-centred care (Health Foundation, 2014). Such leadership breaches the Nursing and Midwifery Council (2015) code of practice, which requires care to be delivered in line with the best evidence and that the contributions of colleagues are respected and valued.

Transformational leadership theory Early heroic theories A systematic review by West et al (2015) revealed a limited amount of robust healthcare leadership research, and they found that transformational leadership practices predominate in the literature. Early transformational leadership theories emphasised leading through charisma and inspiration. Bass (1985) sought to shift leaders from transactional models of leadership, which aim to maintain the status quo through leaders who reward or punish followers depending on their ability to perform tasks, to transformational leadership. Leaders who embody early transformational leadership theory (Bass, 1985) emphasise change, a key feature of the healthcare environment, and have been shown to enhance staff wellbeing (Skakon et al, 2010).

Bass (1985) and similar transformational leadership theorists such as Conger and Kanungo (1988) focused on leaders as ‘heroic’ individuals who hold top managerial positions and exhibit big personalities. Their theories therefore resemble charismatic leadership theory, which emphasise the behaviour of the leader as a key determinant of success (Sullivan and Garland, 2013). These leadership theories have been criticised because they result in socially distant leaders—leaders are not directly engaged with their followers. Instead, many leadership scenarios require socially ‘nearby leadership’, whereby leaders minimise power and status differentials, and engage closely with their followers (Shamir, 1995).

Early heroic transformational leadership theories are based almost entirely on observation of white, male executives, and they are anti-democratic because they rely on a single great leader to influence followers (Alimo-Metcalfe et al, 2005).

Khurana (2002), in reference to the Enron financial scandal, stated that heroic transformational leaders can be encouraged to destabilise organisations to bring about change through using risky (even illegal) behaviours to maximise personal potential and power. While change always carries a degree of risk, in the context of the healthcare environment it is essential that patients are prioritised and that any risk is weighed against patient safety.

Concerns have been raised about the ethics of these leadership theories due to their focus on leader behaviour in preference to leader values, in that this encourages individualism, ruthless behaviour and risk taking, characteristics incompatible with safe, person-centred care delivered by health professionals (Mangham, 2011). The nursing profession has been slow to acknowledge the limitations of heroic transformational leadership theories, but Hutchinson and Jackson (2013) have raised awareness about it, highlighting in particular concerns related to their lack of attention to ethics—an issue that should be taken seriously in healthcare environments. While applying early ‘heroic’ transformational leadership theory to the practice of the charge nurse might be effective to some extent, the concerns raised about it are considerable, and alternative leadership theory should be applied to the practice of the nurse in the case study.

Post-heroic theories Alimo-Metcalfe and Alban-Metcalfe (2005) advocated a post- heroic transformational leadership: they suggested that this is relevant to the 21st century and in the UK context; it is also

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ethical and has no gender bias. On undertaking a grounded theory research project that involved administering questionnaires to middle and top managers in the NHS and local government, Alimo-Metcalfe and Alban-Metcalfe (2005) supported leadership that is ‘nearby’ and focused on servanthood. This is leadership that puts emphasis on what the leader can do for the follower rather than how followers can serve the leader. They warned against relying on dominant models of leadership focused on a specific culture, gender and organisational construct.

Engaging leadership These findings have been theorised within a construct called engaging leadership (Alimo-Metcalfe and Alban-Metcalfe, 2008; Alban-Metcalfe, 2017) (Figure 1). Alimo-Metcalfe et al (2007) reported on a large longitudinal study undertaken within the NHS environment, which sought to test the effectiveness of this model. Their findings demonstrated that the leadership behaviours embodied by the model correlated positively with staff wellbeing, attitudes to work, productivity and positive change. They reported that a flattened hierarchy, where managers and staff are considered partners and leadership is distributed throughout the team, is important for organisational performance.

There are contextual issues that may have a negative effect on teams, including the extent to which services are reorganised through circumstances beyond the control of team leaders and managers. In such circumstances, ensuring positive relationships with neighbouring and external agencies may go some way to resolving these issues as is demonstrated by Alimo-Metcalfe et

al (2007: L132–47) in case study L1. In the context of a large teaching hospital, as described in the case study scenario, certain organisational determinants will influence on the culture of the ward, including the leadership of senior managers. The charge nurse cannot be held wholly responsible for the leadership failings because whole-organisation reform is necessary to enabling the ethical, partnership-driven leadership demonstrated in the engaging leadership model (Alban-Metcalfe, 2017).

Collective leadership Other post-heroic transformational leadership theories should be noted. Collective leadership (West et al, 2014) demands that everyone within an organisation take responsibility for its success, resulting in democratic leadership that focuses on teams rather than individual leaders. Such a leadership strategy has been shown to stimulate the workforce and result in innovative, engaged and patient-centred leadership at all levels in a healthcare organisation (West et al, 2014).

Authentic leadership This leadership model (Avolio and Gardner, 2005) centres on a relational leader who is open, honest, self-aware and builds trustworthy relationships with those with whom he or she works, and therefore emphasises the ethical duty of leaders. Wong et al (2010) and Wong and Giallonardo (2013) revealed that nurse leaders who practise authentic leadership can facilitate improvements in patient care, improve patient safety and promote a positive working environment.

This leadership model (Avolio and Gardner, 2005) focuses almost entirely on the ethical responsibility of leaders but may be considered hard to implement because it does not describe how leaders might attain the values it endorses. Although this may promote creativity in working out how to apply the model, for others it will result in frustration.

How the models compare The engaging leadership model (Alban-Metcalfe, 2017) places a leader’s ethical values at its heart, but allows ethics to inform the applied branches of the model, revealing how leaders should lead and develop others, lead and develop the organisation, and lead the way forward (Figure 1). These tangible elements are built into the model, and they are well defined and measurable. This may make it easier to apply to practice than the albeit legitimate authentic leadership model (Avolio and Gardner, 2005), which is more abstract.

The evidence cited reveals that leadership should be characterised by a nearness to team members, which displays itself in accessibility, embodying genuine concern, enabling team members or partners to better themselves through collective leadership, and positively encouraging innovation and change. In the case study, it is evident that other influences should bear some responsibility for the disabling of good leadership, including various organisational factors that resulted in the charge nurse having less time on the ward and less time available to staff. However, regardless of organisational factors, leadership could be improved by listening actively to staff concerns and taking staff and students seriously when current practice is challenged.

Figure 1. An illustration of engaging transformational leadership (Alban- Metcalfe, 2017)

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Leading and developing individuals Showing genuine concern

Being accessible

Enabling

Encouraging change

Personal qualities and

values Being honest and

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Acting with integrity

Leading and developing the organisation Supporting a

developmental culture

Inspiring others

Focusing team efforts

Being decisive Leading the way forward

Building shared vision

Networking

Resolving complex problems

Facilitating change sensitivity

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The charge nurse may not have the power to amend hospital policy personally as per the proposed intervention, but encouragement and signposting the student to appropriate personnel may have been a sufficient leadership activity in the context of the case study. Furthermore, a charge nurse should embody ethical characteristics, including patient-centredness and integrity. Ethical leadership qualities and behaviours are encouraged by the Care Quality Commission (2016), which has stressed the necessity of good leadership in health care and stated that this is characterised by, among other things, strength and transparency, and an openness to challenge and change.

Post-heroic transformational leadership theories focus on the necessity of change and encourage the change process to originate from engaged team members at all levels of the organisation (Alimo-Metcalfe and Alban-Metcalfe, 2007). The healthcare environment is particularly prone to change due to constant new technologies and evidence emerging. Some authors would define ‘change’ as the key element of healthcare leadership because of its necessity, inevitability and complexity (Sullivan and Garland, 2013). Engaging leadership promotes change by dispersing leadership throughout the workforce, although it recognises that change should be facilitated sensitively due to its delicate nature (Alimo-Metcalfe and Alban-Metcalfe, 2008; Alban-Metcalfe, 2017). Alimo-Metcalfe and Alban-Metcalfe (2008) show that the dispersion of leadership positively affects staff members, which in turn is related to patient satisfaction (West et al, 2011).

The case study reveals that the charge nurse’s style of leadership was one that discouraged change, despite strong evidence the proposed change would enhance patient care. This resulted in the inhibition of innovation, and a reduction in patient satisfaction and safety.

There are some excellent examples of leadership in the NHS (see case studies in NHS Improvement (2017)), however, a King’s Fund report (Roebuck, 2011) highlighted concerns about leadership throughout the NHS, stating that leadership should be considered an organisational priority. Roebuck (2011) recommended that talented and aspiring leaders are identified and developed, and commended the use of training programmes to ensure that individuals in leadership positions are not only competent but also use leadership approaches that are consistent with the organisation.

The NHS Leadership Academy has development courses for staff at every level of the NHS and seeks to embed post- heroic transformational leadership in the workforce. Although no quantitative research has been published to evaluate these courses, the case studies reveal that their on-the-ground impact is substantial and they are frequently highlighted as enabling innovation and positive change (NHS Leadership Academy, 2018). The case study scenario reveals leadership failings that may stem from poor knowledge or understanding of leadership theory. The above would suggest that leaders and their organisations would benefit from training to ensure competence and to develop talent.

Informal leadership According to Sullivan and Garland (2013), leadership is not restricted to managers but may be exercised by all health workers regardless of whether they have a specific management

or leadership role. Informal leadership within nursing has received little attention compared with formal leadership roles, but Downey (2011) recognised the value of this model and identifies informal leaders as individuals who have knowledge to share, who encourage teamwork and humbly influence those around them.

The concept of informal leadership appears to draw on post- heroic transformational leadership theory due to the emphasis on humility and serving as the key attributes of great leadership. Turnbull James (2011), in a report for the King’s Fund, stated that the NHS should draw on the knowledge of all through a relational, collective leadership, thus reducing the hierarchical structure of institutions, which depend on the abilities of a single person. A further King’s Fund (2011) report entitled No More Heroes highlighted the necessity of extending hospital leadership from executives to staff at ward level, thus stipulating the need for informal leadership to take place throughout the organisation to ensure the delivery of good patient care.

The case study identifies a nursing student who is aware of their responsibility in influencing patient care, and practises informal leadership by approaching the charge nurse to discuss an area of evidence-based nursing practice. However, the negative experience of having the idea dismissed and the manner in which this was done resulted in the student assuming a more passive role in the team and becoming less able to challenge current practice for the remainder of the placement. For the sake of their ongoing personal and professional development the student nurse may benefit from developing resilience, which is defined as the ability to overcome adversity (McAllister and McKinnon, 2009). Resilience is considered an important leadership quality (Patel, 2010) and may be developed through reflective practice and peer mentoring (Grant and Kinman, 2013). Such resilience may encourage the nursing student to continue promoting evidence- based practice despite negative experiences.

Power and leadership It is useful to examine the use of power as displayed in the clinical scenario as power and leadership are closely related. Power is defined as the ability to influence someone (Nelson and Quick, 2007), and is used frequently in the pursuit of organisational goals (Lunenburg, 2012). A seminal study by French and Raven (1959) identified five sources of power that can be used or abused within organisations, including legitimate, reward, coercive, expert and referent powers.

The case study scenario suggests that the charge nurse used legitimate power, in that he was in a position of authority. However, coercive power was also used illegitimately—this power is defined as a person’s ability to influence a person’s behaviour through punishment or threatened punishment (French and Raven, 1959). Although the case study made no reference to punishment, the immediate dismissal of the nursing student’s proposed intervention did result in a type of punishment, namely that the student was disempowered to propose further changes to care. Yukl (2012) asserted that coercive power should be used cautiously, as it can result in negative outcomes, which is evidenced in the case study. Manojlovich (2007) stated that the disempowered nurse is

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ineffective and less able to provide outstanding patient care, highlighting the importance of empowering staff nurses because they usually work in closest proximity to patients, and thus may have the most meaningful insights into how patient care can be enhanced.

Power has been viewed negatively by nurses, with some thinking it to be incompatible with caring (Gorman and Clark, 1986), but empowerment cannot happen in the absence of power (Rao, 2012). Empowerment of nurses may occur through a variety of methods, but particularly important is the organisational structure. A phenomenological study by Van Bogaert et al (2015) revealed that flattening hierarchical structures in the hospital environment to promote shared decision-making resulted in empowered staff members, improving professional attitudes and enhancing quality of care. A further study by Van Bogaert et al (2016) revealed through interviews that staff nurses thought that the supportive leadership of ward managers was essential to the success of attempts to empower nurses, although workplace culture was equally important.

In an extensive review of the literature West et al (2015) identified that the primary influence on the culture of a given organisation is how it is led, which means leadership behaviours have a significant effect on whether nurses are empowered in their workplace. While the engaging leadership model does not specifically mention empowerment, it may be hypothesised that its application in practice would result in an empowered workforce, due to its emphasis on partnership working and supportiveness. The case study scenario revealed a style of leadership that resulted in the disempowerment and disillusionment of a member of staff. Applying the engaging leadership model to the situation would have transformed the experience of the student, who would have been encouraged and empowered to take responsibility for the evidence-based intervention. It is critical that such leadership models are applied in hospital settings to enable staff to make shared decisions, informed by the evidence base, about what is best for patient care and to enable organisations to flourish.

While the literature on the empowerment of nurses is extensive, that relating to the empowerment of nursing students is limited. Kennedy et al (2015) reported in a review of the literature that it is unclear how and if nursing students are empowered on placements. Bradbury-Jones et al (2011) stated that the failure to acknowledge the importance of empowering students may in future result in a weaker workforce that is less able to care for patients. Further research should be conducted into the empowerment of nursing students, but it may be hypothesised from the existing literature on registered nurses that they are empowered best through post-heroic transformational leadership, which minimises hierarchical imbalances, encourages innovation and welcomes individuals into existing teams (Van Bogaert et al, 2015; West et al, 2015; Van Bogaert et al, 2016; Alban-Metcalfe, 2017).

Conclusion The case study outlines the behaviour of a charge nurse who, due to organisational and individual reasons, used an ineffective leadership style in the ward and, specifically, in relation to his

interaction with the nursing student. Early transformational leadership approaches have been widely advocated in nursing, but existing business leadership and recent nursing literature have highlighted concerns about the heroic nature of these models and the focus they put on leader behaviour over leader values.

Post-heroic transformational leadership theories are to be encouraged due to their ethical nature, their focus on teamwork and partnership, and due to the evidence showing that these models improve patient care and positively enhance the working environment. Specifically, the engaging leadership model is to be recommended because it has a relatively strong evidence base and may be more easily applied in practice in comparison with other theories.

It should be noted that post-heroic transformational leadership theories are still in their infancy and the publication of further research across all healthcare settings should inform future practice in future. Leadership can be informally practised by those who do not hold official positions and organisations should adopt models that flatten hierarchies to empower staff.

Organisations should invest in training leaders at every level to help build competence and develop talent, thus bettering individuals, encouraging innovation and enhancing patient care. Such informal, collective leadership should be encouraged to ensure staff satisfaction and patient-centred care. Power is closely related to leadership, and the case study reveals how it can be exercised detrimentally, resulting in disempowerment, and so has a negative effect on nurses and patients. It is likely that adopting models such as engaging leadership (Alban-Metcalfe, 2017) will devolve power to each member of the workforce, giving all health workers, including students, the opportunity to share and implement evidence-based practice and enhance patient care. BJN

Declaration of interest: none

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KEY POINTS ■ Leadership practice should be informed by evidence and, as such, it is

essential to the provision of patient-centred care

■ Leadership is reserved mainly for managers and senior staff, but it may be practised by anyone, regardless of job title

■ Post-heroic transformational leadership theories advocate practice that focuses on servanthood, encourages innovation by team members, is patient centred and has ethical integrity

■ Power is closely related to leadership, and how it is wielded will affect staff and patient satisfaction. Flattening hierarchical organisational structures results in an empowered workforce that is better able to practise patient-centred care

CPD reflective questions

■ Reflecting on your own practice, how would you describe your leadership style?

■ Taking into consideration your role, how might you embody post-heroic transformational leadership theory in your daily practice?

■ Does your workplace foster a culture of empowerment for staff? How might you change practice to allow for this?

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