Health and human science class

Leadership: a new perspective

KARIEN JOOSTE D L i t t e t P h i l ( U n i s a )

Associate Professor, Department of Nursing, Rand Afrikaans University, South Africa

Introduction

It was not until the early 19th century that leadership as

a concept first appeared as a word in the English lan-

guage (Davis & Cushing 1999, p. 12). Effective

leadership is about enabling ordinary people to produce

extraordinary things in the face of challenge and change

and to constantly turn in superior performance to the

long-term benefit of all concerned (Charlton 2000,

p. 30). The following brief wording from many

Correspondence

Karien Jooste

Department of Nursing

Rand Afrikaans University

PO Box 100477

Moreletaplaza

Pretoria 0167

South Africa

E-mail: [email protected]

J O O S T E K . (2004) Journal of Nursing Management 12, 217–223

Leadership: a new perspective

Aim This overview article aimed at outlining the image of an effective future-ori- entated nurse leader in the health care context through a pragmatic approach. The

future nurse leaders on different levels in health care institutions is challenged in the

current health care environment of culturally diverse countries, such as South Africa. This article should make all nursing leaders more aware of their important role in

taking the lead in challenges faced in the current health service environment.

Background Leaders have the essentials of authority, power and influence to

lead followers to their goals. The use of these essentials has changes from the past,

to the present and into the future health care environment. Different changes and

challenges are facing nurse leaders and they need to implement an effective leade-

rship style in a complex health care environment.

Evaluation This overview article focuses on key elements of an effective future

leader using a conceptual framework as departure, incorporating relevant literature.

It analyses and evaluates the efficiency of past and present roles of authority, power

and influence in leadership and summarizes a new perspective of a future nurse

leader. Solutions and future actions are indicated for the future role of the nurse

leader.

Key issues The past, present and future leadership setting, role of authority, power

and influence in leadership, components of the arch of leadership and solutions to

effective leadership in a future dimension is all domains that is presented with the

intention of motivating future nurse leaders.

Conclusion It was identified that a different kind of leader should emerge to lead in

a new way, different from those leadership styles that we have known in the past.

The 21st century is a new timeframe and different timeframes demand different

leadership approaches.

Keywords: behaviour, influence, leadership, transformation

Accepted for publication: 23 October 2003

Journal of Nursing Management, 2004, 12, 217–223

ª 2004 Blackwell Publishing Ltd 217

definitions is chosen to describe the difference between

management and leadership: �legitimate power and control vs. empowerment and change�.

The role of nurse leaders in South Africa and the

global health care environment is continuously moving

to new dimensions. No longer is the leader the person

who controls the employees. The role of leaders is to act

as visionary leaders, who assist employees to plan,

organize, lead and control their activities. The devel-

opment of employees in order to create a learning

environment and to emphasize self-management and

entrepreneurial behaviour is the responsibility of

today’s leader-leader.

Different kinds of leaders will emerge to lead in ways

different from those that we have known in the past,

because different times and different conditions demand

different approaches (Apps 1994, p. 39).

Conceptual framework

The nurse leader of the present is faced with challenges

and changes in the health care environment. The nurse

leader functions at functional, middle and top nursing

management levels in various health care settings

(Figure 1).

Many political, economical, professional and other

factors influence the essence of her/his leadership role in

the health care environment in future. Over the years

the role of authority, power and influence in leadership

have changed. A paradigm shift is occurring in the

leadership styles of nurse leaders.

The arch of leadership could provide guidelines for an

effective leader for the future. Possible solutions to fulfil

an effective leadership role should be the focus.

Problem statement

Throughout the history, there have been calls for lead-

ership. Today, it is more important than ever in society

and its institutions. Things are changing at an aston-

ishing pace in the health care environment and chal-

lenges are huge. Yet by all accounts, there are too few

leaders to go around. However, effective leadership is

not the product of a simple formula.

Leaders should know how to use power, authority

and influence in meeting the new challenges in leader-

ship in current health services. Some of the following

are questions that leaders often ask themselves and are

examples of their uncertainties:

• How should I use influence to obtain the organiza- tional goals of the institution?

• What role does authority play in leading subordinates to the desired goals?

• How can I be powerful without being overpowering? • How long do I have to keep working at being a good

leader?

New beliefs that empower one’s dream are needed to

become an effective leader. The following main ques-

tion should therefore be answered:

What is the essence of the role of an effective nurse

leader in future health services delivery?

This article aims to highlight the image of an effective

future orientated leader. By addressing this image the

article focus on:

• past, present and future leadership setting; • role of authority, power and influence in leadership; • components of the arch of leadership; • solutions to effective leadership in the future dimen-

sion.

�Begin with the end in mind� means to start with a clear understanding of your destination – the behaviour

and criteria you define as supremely important – to be a

good leader. It means to know where you are going so

that you better understand where you are now and so

that the steps you take are always in the right direction.

The past–present–future leadership scenario

Past patterns and characteristics were hierarchical

structures and authority, formalization, centralized

controls, a stable environment, inflexible structures, less

competition and leaders not leaders. Organizations

believed that change was for someone else, it remained

organized, as it has been organized, it attempted to

produce a product to the receiver as it has always

produced.

A new organizational context is currently emerging in

which positions and responsibilities are less static and

more open-ended, and the familiar boundaries

distinguishing upper, middle and lower level leaders are

LEADER

Authority Power Influence

Factors influencing the leader

The arch of leadership

Possible solutions

PresentPast Future

Figure 1 Conceptual framework.

K. Jooste

218 ª 2004 Blackwell Publishing Ltd, Journal of Nursing Management, 12, 217–223

being redrawn. In the past the emphasis has been on

how leaders/leaders oversee the work of people within

fixed units (Chapman 2001, p. 55).

Presently leadership competence is important, asses-

sing past impacts and current reality, job suitability,

strategic human resource systems to address the future.

Future functional level leaders should undergo trans-

formation from implementers to aggressive entrepre-

neurs in running cost units. Those at middle level

management are slowly starting to move away from

their previous role as administrative controller to sup-

portive coaches, and top-level leaders are becoming

institutional leaders rather than resource allocators

(Chapman 2001, p. 56). Learning from the past, leaders

should identify future trends in technology, social and

culture developments, demographics, economics, polit-

ics and market expectations that can influence health

services.

Factors in current health services that demand changes and challenges

Different factors affect our current health services such

as political and economical changes, population

growth, nagging world problems that are continuing,

for example hunger, poverty, and the technology that is

increasing ever more rapidly.

The ethical codes and oaths of health professionals,

with their rules of conduct, may require extension and

augmentation in the future to include ethical theories

developed to suit difficult health care situations. Present

medical technology has created many situations with

conflicting alternatives, each of which represents some

degree of �good�. The very objectives of the medical and nursing profession – to save life, to cure disease and to

alleviate suffering – are now seen to be in some cases

conflicting with ethical codes. Devices are available that

can prolong life at the cost of increasing suffering, and

the problem of the morality of euthanasia thus becomes

more pronounced.

The South African health summit (Department of

Health. Health Summit 2001) focuses on reaching out for

better health for all citizens of South Africa. The National

patients� rights charter (Department of Health 1997) outlines the patient’s rights in the national health care

setting. Among others it stipulate that every patient has

the right to participate in decision-making on matters

affecting their health, that health care providers should

display and demonstrate courtesy, tolerance, provide

adequate health information and continuity of care.

In South Africa, white governmental papers (Depart-

ment of public service and administration 1997) for

transforming health service delivery, focus on among

others, the decentralization of responsibility, account-

ability, power and authority to the lower levels of health

care delivery, greater involvement of the community,

reduction of bureaucratic practices that are far removed

from the community, and effective use of resources.

Putting the above-mentioned principles into practice

is the challenge now facing the nurse leaders of the

South African health care sector.

Authority, power and influence

Three essentials are needed to control other people,

namely authority, power and influence.

In 1911 Fred Taylor initiated the careful study of

tasks and jobs, and trained workers in standard meth-

ods to be productive. He tended to regard workers as

uninformed and ignored their ideas and suggestions.

Under this system, workers often felt exploited. In the

era of Max Weber the authority position was the means

to exercise authority as a bureaucrat. Positions were

organized in a hierarchy of authority, with each posi-

tion under the authority of a higher one. These

approaches mainly focused on the concepts of authority

and power and less on the concept of influence.

Nursing leadership later emerged as a product of the

competing power relations reflected in the bureaucratic

authority of the hospital and the voice of professional-

ization (Davis & Cushing 1999, pp. 15–16).

Fifty years later the scenario changed to an equal

proportion between authority, power and influence

where a person strived towards a certain position with

authority/competence, wanting to have influence over

other people and wanting power. The humanistic per-

spective emerged and emphasized understanding human

behaviour, needs and attitudes in the workplace.

A more holistic approach is being followed since the

1990s, which seeks to blend the 1970s the inner-direc-

ted focus of the neo-human relations, and the hard-

nosed, profit-focused themes of the 1980s (Sofarelli &

Brown 1998, p. 202). Nelson Mandela changed the

rules of the political game, from revolution to demo-

cracy, from bitterness to forgiveness, from massive

inhumanity to the human spirit on a new journey

(Charlton 2000, p. 8). In 2002 we should move towards

a scenario of more influence and less power and

authority. In new organizational forms influence is used

to ensure that work, behavioural and change processes

flow smoothly. Hierarchical authority is less effective

for getting things done. More important are the

capacity to motivate, persuade, appreciate, understand

and negotiate. These dimensions of influence are critical

Leadership: a new perspective

ª 2004 Blackwell Publishing Ltd, Journal of Nursing Management, 12, 217–223 219

for ensuring a smooth flow of cooperative and mutually

enhancing productive activity (Chapman 2001, p. 57).

Practices, which help to deal with and respond to new

uncertainties, should be promoted, such as improved

intra-organizational communication and support, and

the inverting of organizational hierarchies whereby

senior staff actively support front-end personnel, rather

than the traditional one-way onus on junior staff to

support senior staff (Mullins et al. 2001, p. 117). Nurse

leaders could use three basic categories of influence to

create an environment supporting culturally appropri-

ate care namely (1) to model by example, (2) to build

caring relationships and (3) to mentor by instruction

(Lambert & Nugert 1999, p. 174).

The arch of leadership

The arch of leadership could be viewed with the

dimensions of clarity, commitment, self-image, price

and behaviour. This arch could have several uses, one

being the lens of the characteristics of an effective lea-

der, the other to identify and solve problems in the

health management sector (Figure 2).

The leader has an enormous role to play in influen-

cing followers in the right direction. Shortcomings in

the characteristics of the leader could lead to problems

among followers in the work place. As a problem sol-

ving framework for leaders the following questions

could be asked to identify reasons for and address any

problematic scenario with followers:

• Clarity: are workers clear of their tasks? • Commitment: what do followers need from their

leader?

• Self-image: do followers know their own abilities, what they can and cannot accomplish?

• Price: what is the price they pay or receive for working hard?

• Behaviour: does the leadership style promote positive and effective behaviour among followers?

Answers to these questions could help to determine

reasons for problems in the work place.

Clarity

The two pillars of the leadership arch are clarity and

behaviour. Everything starts at clarity. The leader

should conceptualize what is right and communicate the

future picture of the service to followers. The comp-

elling picture of the future should focus more on people.

The leader should communicate the future picture of

managing the service more effectively to followers by:

• sharing the vision and mission of the service with them;

• setting time frames for their tasks; • being positive, and having openness towards follow-

ers;

• establishing team building projects in the service; • promoting research strategies in the service; • operating within the legal/ethical/professional

framework of the profession and country; and

• using her/his listening skills.

The leader is responsible for communication and

should check for clarity of communication, she should

not assume, and should involve all followers in decis-

ion-making and setting standards, for more commit-

ment. Less involvement leads to less commitment. How

does your leader looks like? Is she/he competent, qual-

ified, skilled, with effective body language, willing and

able in the job? How does the leader climb the career

ladder?

Commitment

You know people are committed when they take action,

and have the will to stick with something they have

started to the very end. A leader devotes her/his life to

doing what they need to do, each day. What do a leader

need to be committed? The answer has facets of self

motivation, inner norms and values, job satisfaction,

the necessary challenges in the work place, success

stories, knowledge and expertise, freedom to make

choices, good working conditions, incentives and peo-

ple skills. Every leader has her/his own hot buttons that

leads to more commitment.

Self image

This concept is the centre of the arch. Knowing what you

can and cannot do. Inner leadership helps us to bring our

hidden qualities of leadership into reality and to apply

them in our lives and work situations. Inner leadership

provides a practical process for: increasing self aware-

ness, uncovering assumptions and beliefs which limit Figure 2 The arch of leadership.

K. Jooste

220 ª 2004 Blackwell Publishing Ltd, Journal of Nursing Management, 12, 217–223

our effectiveness, becoming autonomous individuals

acting from our values and purpose; using our awareness

and inner will to realize our deepest resources and self-

leading potentiality. �Nothing changes without personal transformation�. We do have the potentiality to think and act in other new ways, ways that better suit the real

needs of the situations we encounter.

Understanding our own personality is not easy. Some

things about us are known by others and ourselves.

Other aspects of our personality are obvious to others

but not to us. There are things about our past we never

disclose. Inner leadership provides tools to help us

understand our own personality, these tools are body,

emotions, thoughts and constituents of personality.

We should explore the parts of our selves, how they

behave, how they serve use, what qualities they bring to

our personality, how they interact. We should become

aware that we are identified always with some part of

our personality, and that we have a choice – this is the

awareness function of our centre of identity – and that

we have the power to bring about change – this is the

will function of our centre of identity.

Inner leadership should be practised in one’s working

live, which means allowing space for transformation,

realizing our self leading potential, and gaining the

clarity to respond to the real needs of each situation

with awareness, will aptitude and purpose (England

2002, pp. 21–27).

�To become an effective leader is the ultimate act of free will … becoming a leader is synonymous with becoming yourself.� (Sofarelli & Brown 1998, p. 202).

Price

What is the price you pay, or incentives you receive for

your hard work?

The way management treats their employees is exactly

how the employees will treat the clients and provide

total quality nursing care. Employee satisfaction

towards the job and the organization has a positive

effect on employee loyalty and behaviour towards cli-

ents/patients (Mullins et al. 2001, p. 123). This pro-

motes client retention, and is the most effective

marketing strategy.

Behaviour

There are many different leadership styles that could be

used to lead health care systems into the future.

Transformational leadership is an empowering leader-

ship style and one which is highly suited to the profes-

sion of nursing, characterized as it is as being caring and

highly ethical (Sofarelli & Brown 1998, p. 202).

The ability to effectively use a transformational lea-

dership style in health care will become increasingly

critical as we approach the 21st century.

Five of the fundamental practices in an effective lea-

dership style should be pointed out:

• Inspiring a shared vision. • Enabling others to act. • Challenging the process. • Modelling the way. • Encouraging the heart.

Inspiring a shared vision

Leaders are people who thrive on change and inspire their

followers by having and communicating a vision, which

is arrived at jointly by their people, for whom they show a

great deal of concern (Sofarelli & Brown 1998, p. 202).

The leader should have a personally created dream about

how one would like things to be in the future, be com-

mitted to this vision and should empower others with

that vision (Lambert & Nugert 1999, p. 174).

Enabling others to act

Challenges facing our extraordinary profession include

maintaining a skill mix and patient allocation that will

safely and effectively meet our carefully conceived

professional standards for care. Further challenges lie in

working within multi-disciplinary teams with highly

refined communication and negotiation skills. The

heightened expectations of an informed public, ethical

and legal obligation to the patient and families, growth

of health and health care knowledge need adequate

educational preparation for nurses.

Some of the commandments for leadership in

enabling others to act are:

• Enlist others. • Strengthen others. • Foster collaboration. • Celebrate and cheer accomplishments. • Recognize contributions.

Challenging the process

Leaders are prepared to take risks that bring out

change, challenging the status quo. But change is not

necessary synonymous with growth (Charlton 2000,

p. 1). The ability to initiate individual and organiza-

tional growth-directed change has become a core com-

petence in the changing health care environment.

As nurses, we are never far from change; it is a hall-

mark of our profession. One of the new challenges of

Leadership: a new perspective

ª 2004 Blackwell Publishing Ltd, Journal of Nursing Management, 12, 217–223 221

this century is the impetus to reflect on change, both past

and future. Undoubtedly, our reflections would lead us

to predict that the speed and magnitude of changes to

health and health care in the last century will be greatly

surpassed in the following centuries (McMurray 2001,

p. 6). The impact of new developments in health and

health care often translates into better lives for our

patients and us. However, change also brings challenges.

Leaders should keep abreast of the pace and direction of

change, to ensure that nursing takes it rightful place

alongside other professions in securing and maintaining

health and health services. The ICN is offering a lead-

ership for change programme – one of many pro-

grammes available. Perhaps the biggest challenge that

looms in the coming decades for leaders is the need to

devise programmes that will inculcate a global mindset

in their people. To become a global leader, one must

transform one’s mindset (Oddou et al. 2000, p. 159).

The emerging paradigms in health care require lead-

ers who are able to be strategic in their thinking and

facilitative in their style. In a changing health care sys-

tem there seems to be a need to devise new ways to

approach its management.

Modelling the way

Effective leaders should create a friendly environment,

which supports collaboration, enthusiasm and com-

mitment from staff. Leaders are people who get others

to perform at consistently high standards – voluntarily.

In these times of scarce resources and long hour work-

ing weeks, the leader should strive to create a fun place

to work. Leaders should be flexible, using their own and

everyone else’s skills to the limit.

Leaders have fast reactions to change, encourage

innovation, and have a questioning mentality. They

are focused on specific goals, which are owned by

everyone.

Encouraging the heart

Leaders recognize contributions that individuals make

celebrate accomplishments and enable individuals to

share in the rewards of others. Leadership is only partly

about yourself and largely about those people around

you. You have to look inward to have outward influ-

ence. You have to recognize that to keep on being

acknowledged as a leader, you have to keep earning it.

Future solutions

Key attributes of modern nurse leaders are vision,

strategic thinking ability, change management skills,

strength, confidence, negotiation skills, knowledge

management and willingness to form strategic alliances.

I believe the key to nurturing these attributes is soli-

darity. There is a special bond between nurses that cuts

across language, culture, specialist knowledge and

practice circumstances that allows us to share with one

another our art, skill, knowledge and wisdom.

The time has come for leaders in nursing to take the

profession into the future and to shape nursing practices

that changes in society, policies and health care services

demand. Nursing must do this before other professions

dictate what the nursing role in health care organiza-

tions will be.

• Leaders should be proactive and see the present as a springboard to achieve future aims.

• Skill management is essential in assessing competen- cies and skills of followers to determine and plan for

changes in individual and team performances.

• Build a global perspective through short-term inter- national travel assignments to understand different

viewpoints and stretching one’s mental maps.

• Have a strategic attitude and accept that there is more than one way to do something, be willing to take

risks and move towards more participation.

• Manage negative emotions cognitively and focus on people rather than principles. Use principle-centred

leadership with fairness and kindness.

• Strategic actions should focus on building trust through behaviour that represents openness, accept-

ance and appreciation. The team leadership style

moves the focus away from the leader towards the

team as a unit.

• As an evolving concept, knowledge management should be applied by capturing and communicating

information to those who seek it or who need it,

provide information to the right person at the right

time (Quible 2001, p. 336).

• Emotional intelligence is becoming increasingly popular as a measure for identifying potentially

effective leaders and should be used as a tool for

developing effective leadership skills.

Every nurse leader should keep the leader within her/

him alive and should believe there is a way to be the

leader she/he want to be and that leadership is one of

her/his true gifts. It is never to late to become a leader

and one should have the courage to change and do

things differently.

Conclusion

With the above mentioned solutions in mind, the

nurse leader in the current health care environment of

K. Jooste

222 ª 2004 Blackwell Publishing Ltd, Journal of Nursing Management, 12, 217–223

South Africa, should maintain the following princi-

ples:

• Stewardship, recognizing the limitations of the health plan’s resources, promoting policies that ensure

continued availability and equitable distribution of

those resources. Her/his stewardship should focus on

prevention, community healthy and individual

responsibility.

• Respect, which refers to protecting and supporting the important relationship between caregivers and

their patients as well as honouring the individual

needs of people.

• Caring, valuing patient’s emotional and spiritual needs, respects their preferences, prizes good com-

munication skills, and focus on multidisciplinary

team approaches to care.

• Advocacy, which involves involving doctors in setting good policies so that the best quality care is delivered.

• Honesty, making sure those relevant individuals have all the information they need to understand how their

health plan works.

• Confidentiality, which means supporting the protec- ted relationship between caregivers and patients and

guarding the use of private information (Ehlen &

Sprenger 1998, pp. 219–220).

• Initiating an ethics program. In today’s multicultural environment it is a complex task but a clear code of

conduct should be developed for employees that is

value based and address cross-cultural issues.

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Leadership: a new perspective

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