Leadership discussion board
NurseyNurse77
ROckingtheBoat.pdf
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Rocking the boat: the link between transformational leadership and advocacy Corri Antill, Healthcare Assistant, West Middlesex University NHS Trust
To protect the true importance of advocacy in healthcare will require education and training to reduce the risks to the advocate.
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umerous leadership models exist, mainly developed for the business realm (a point which will
be examined more in depth later). The predominant models of leadership are variously classified as the ‘trait approach’, the ‘behaviour approach’, the ‘contingency approach’ and the ‘leader-member exchange approach’ (Curtis et al, 2011). Within these broad classifications, specific models emerge such as the ‘trait theory’, the ‘situational (contingency) theory’ (Dawes and Handscomb, 2005), the ‘democratic’ model (Frankel, 2011), the ‘servant leadership’ and ‘authoritarian/ autocratic leadership’ (American Association of Nurse Assessment Coordination (AANAC), 2014) and the ‘affiliative’ (Williams, 2014).
This assignment will focus on the transformational leadership model, as originally developed by James MacGregor Burns (1978) in his book, Leadership (see also, Figure 1).
Transformational leadership centres around the ability of the leader to ‘transform’ followers to a higher ‘level’, as exemplified by the leader themselves and a core of ethics that puts values such as liberty and equality uppermost (Burns,
1978; cited in Leadership-Central.com, 2013:1). In transformational leadership, the leader attempts to ‘lift’ the followers to their ‘better selves’ (Burns, 1978; cited in Leadership-Central.com, 2013:2).
When transformational leadership is examined in the context of nursing and healthcare, its aims are clearly of value: ‘Effective and transformational leadership is pivotal to the success of healthcare organisations’ (Govier and Nash, 2009:1). Traditionally, healthcare organisations fulfilled only the basic three levels of a ‘hierarchy of need’ as outlined in Maslow’s model (see Figure 2); whereas transformational leadership strives to fulfil the higher levels, even to the point of ‘self-actualisation’ (the ultimate level on Maslow’s scale), whereby the follower becomes themselves a leader (Habel and Sherman, 2011).
Transformational leadership encourages people to achieve more than just the basics expected of their job role (Aarons, 2007).
At this point, it is pertinent to examine the definition and notion of advocacy, in line with this article’s structure and aim. The dictionary definition of advocacy cites ‘active support, especially of a cause’
(Collins English Dictionary, 2014). The word derives originally from the Latin ‘advocatus’, in relation to giving evidence (Jugessur and Iles, 2009:188), a legal term that still retains its original ethos today. However, and crucial to this article’s objectives, the term advocacy has gone beyond its legal context to encompass healthcare settings in particular (Jugessur and Iles, 2009:187).
Advocacy in a more modern context to nursing is defined as ‘influencing those who have power—on behalf of those who do not’ (Teasdale, 1998:1). The notion of power in the medical profession and the implications for the less powerful—for example, the patients—will be examined in the concluding segments of this paper. A more comprehensive and definitive concept of advocacy states that the role of the advocate is to ‘work on behalf of self and/or others to raise awareness of a concern and to promote solutions to the issue’ (Tomajan, 2012:2).
The notion of advocacy is ingrained in most nursing codes of conduct and profession (Jugessur and Iles, 2009:187). The Nursing and Midwifery Council (NMC) Code states: ‘You must act as an advocate for those in your care’ (NMC,
A sense of value guides the individual in issues of morality.
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Abstract
This paper aims to develop and explore certain leadership skills in particular with regard to the notion of patient advocacy, as detailed in the case study (Appendix 1). The paper will initially investigate definitions and theories of leadership models, with specific attention focused on the ‘transformational’ model of leadership. The role of patient advocacy will then be examined and the author intends to establish links between the qualities in transformational leadership skills and the idealised role of patient’s advocate. The article will conclude with the proposals related to future education and development, and the completion of the action plan (Appendix 2).
Keywords Patient advocacy Nursing Transformational model of leadership Risk
Dignity Maslow’s hierarchy of need
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2008:2). Although almost universally accepted as a prerequisite of nursing conduct, advocacy is little understood or clarified, as will be discussed further later.
Of central importance in a discussion about advocacy are the notion of risk and the clarification of the positive and negative consequences resulting from the adoption of advocacy. The negative aspects associated with advocacy centre around the notion of risk, for example, the risk of conflict between colleagues, patients, relatives, employers and the public (Jugessur and Iles, 2009:191), if advocating for an individual infringes on these other bodies. There is also the suggestion that advocacy has a paternalistic overtone, with the nurse acting as though they know better than the patient (Jugessur and Iles, 2009:190).
Importantly, the point is made that a negative effect of advocacy is that it implies that there is an intrinsic fault in the healthcare setting if advocacy is indeed needed (Bird, 1994). This point can be examined in detail in the conclusion of this paper, as also one of the main contributory positive factors in the need for advocacy.
The core assumptions in all the negative factors apparently inherent in advocacy (with regard to nursing) revolve around the theme that if a healthcare organisation is fundamentally concerned with the wellbeing and protection of its patients, then advocacy is redundant. This assumption also presumes that any attempts by an individual nurse to advocate for their patient betrays a paternalistic attitude that suggests the patient does not know their own best interests or is incapable of clearly expressing them.
The positive factors associated with advocacy are surprisingly few in defined print, although their ethics are fundamental to healthcare professionals and their practice. Curtain (1979) was influential in vocalising the notion of advocacy as a prerequisite in nursing,
based on the idea that ‘nursing is to assist with the welfare of other individuals’ (Curtain, 1979; cited in Jugessur and Iles, 2009:191). Furthermore, it has been clearly stated that advocacy is a requirement of nursing practice (Hanks, 2012:2).
Additional positive attributes to the notion of advocacy revolve around the fact that nursing staff are in the closest contact with the patient and as such have an increased knowledge and awareness of the individual patients—as opposed to, for example, the doctor, who may not have such intimate knowledge of the patient (Bird, 1994:152). It has also been pointed out that in the unequal power balance between the might of the medical profession and the patient, it is the nurse who can best act as a ‘mediator’, in the role of advocate (Bird, 1994:152).
At this point, it is imperative to acknowledge this paper’s primary premise, that the skill and ‘core values’ inherent in transformational leadership are also the identical skills and values required in the role and function of advocacy (Box 3). To clarify, note will be made of several key areas that are linked in both advocacy and transformational
At the heart of the notion of advocacy lies the belief that it is correct to follow basic and core values, even if it means upsetting the status quo.
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“Advocacy can be seen as the last threshold of original nursing. Its core principles are embedded around the protection of the individual.”
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leadership. The notion of morality (or ‘core’ values/principles) is readily linked to both leadership and advocacy (Schwartz, 2002:3). Indeed, George (2007) highlighted the notion of ‘internal compass’—that is, a sense of value that guides the individual in issues of morality (George and Sims, 2007; cited in Govier and Nash, 2009:12).
A further key area linked to both concepts is that of adversity/conflict. Advocacy is noted as being adversarial in nature (Schwartz, 2001) and, profoundly, at the heart of Burns’s transformational leader lies the notion that leadership is ‘exercised’ when there is conflict (Leadership-Central. com, 2013:2). Additional features that share the same goals between advocacy and transformational leadership revolve around the notion of emotional identification with another (which includes the concept of empathy). To illustrate, advocacy can be initiated by the empathy of the advocate towards a patient and this may lead them to take risks that others might not (Teasdale, 1998:19).
Similarly, in leadership, empathy is quoted as a necessary tool to understand ‘followers’ and their motivations
(Williams, 2014:2). Collaborative links are also found within the context of empowerment and a ‘counter balance’ to authority. In advocacy, it has been stressed that the empowerment of those who are vulnerable is key (Jugessur and Iles, 2009:188). Likewise, in transformational leadership, empowerment lies at the core of its ethos (Curtis et al, 2011:30).
If further clarification is needed on the intrinsic links between the notion of a transformational leader and that of advocacy (in its truest sense), then an examination of the skills required by both should facilitate this. It has been noted that a successful advocate would possess skills such as ‘problem solving, communication, influence, and collaboration’ (Tomajan, 2012:2).
A transformational leader would require identical skills, including charisma, and the ability to act with confidence as an inspiration to others (AANAC.ORG, 2014:2) and the initiative to solve problems, instead of just raising them (Govier and Nash, 2009:13).
Significantly, an additional link between the two concepts of transformational leadership and advocacy is that which concerns the
idea of assistance and the protection of human rights. In advocacy, it is clarified as ‘standing up for the rights of your patients and firmly defending them, even if you personally may not agree’ (Wood, 2010:1). In transformational leadership, we have the same core theme of assisting others (Curtis et al, 2011:30).
In concluding this assignment, five key points will be made for reflection. A proposal for future development of these ideas is submitted as Box 4. First, it has been recorded that in England 162 000 written complaints were made about NHS organisations between 2012-2013 (Health and Social Care Information Centre (HSCIC), 2013:1). Of these, the majority were made against the medical/surgical profession, totalling 47.1% (HSCIC, 2013:1). This paper proposes that this dissatisfaction (as exemplified in the complaints data) is largely due to the dissonance created by the western world’s heavy reliance on a biomedical model of healthcare, which deals with the scientific notion of disease but not necessarily the person behind it (Vallis and McHugh, 2005:1).
This concept of dissonance suggests tensions between the original and historical role and ethos of nursing as a
Box 1: Case study 06/05/2014
A patient and her husband came into the fracture clinic after being called by a doctor to attend this clinic. The patient was a North American tourist who had fallen down the stairs and fractured her arm.
There was no appointment for the patient and they both were very anxious and distressed as they were in a foreign country with no knowledge of our healthcare system or processes. The patient was in pain and needed to be reviewed to decide if she was safe to fly back to the US in a few days’ time.
At first, no doctor in the fracture clinic would see her, as all said they were ‘too busy’ to do so. It was clear to me that the patient was in pain and that if I did not intervene on her behalf she would be left sitting in the busy clinic room and not get seen.
I spoke to the orthopaedic specialist nurse and explained the situation and that the patient needed to be seen by a doctor. I also approached two other orthopaedic doctors and repeated this information. One of the doctors couldn’t confirm if the patient was indeed safe to fly after such a recent fracture and so I contacted the registrar and asked for the patient to be seen by a doctor. I stressed that it was not right to leave this lady (clearly in pain) unseen and left waiting.
Finally, the patient was indeed seen by a doctor, who reviewed her fracture and completed the necessary documentation. The patient and her husband thanked me and left satisfied with the treatment they received in the end.
This case study highlights the situation where, although it was not my role or responsibility to intervene in this situation (I was in fact running another clinic at the time), I was aware of the situation evolving and could see the distress of the patient and that nothing was being done to help her. In this sense, I acted on my inherent basic values and intervened to assist the patient and to make sure that an injustice was not done to her.
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the modern emphasis on healthcare as a business and technological realm (Davison and Williams, 2009). They see the role of advocacy as a means for the individual to stand up for the rights of
the vulnerable against the mechanisms of science and business technology: ‘advocacy was needed because of serious errors and mistakes arising from judgement made by professionals, resulting in a lack of confidence in the
healthcare system’ (Jugessur and Iles, 2009:190).
Advocacy, in its purest sense, can be seen as the last threshold of original nursing as a vocation. Its core principles are embedded around the notion and protection of the individual, which encompasses their rights against the onslaught of the biomedical model of healthcare, which seeks to depersonalise and detach the individual from their disease. ‘Science and technology have both been linked to the decline in the caring nature of some nurses,’ say Davison and Williams (2009:34).
The core values of advocacy, which have also been attributed to the qualities required of a transformational leader, should be embraced by modern healthcare as vital to its continuing function and success: ‘Advocacy ceases to be something separate from everyday experience; instead, it becomes an integral part of the caring enterprise which is a health service’, says Teasdale (1998:155). In fact, the level of complaints and dissatisfaction against the health service illustrate that this point has not yet been reached (HSCIC, 2013).
To protect and acknowledge the true importance and dignity of the role advocacy plays in healthcare will require education and training to explore the legal and ethical implications and reduce the risks to the person playing the advocate. ‘If it is agreed that advocacy is a useful role, then guidelines can be drawn up to provide some protection from harm both for the patient and the advocate,’
Box 2. Action plan
Objective: To develp leadership skills in relation to patient advocacy
AIm: Timing Goals Evidence Date of review
Demonstrate an understanding of transformational leadership skills and develop on these in relation to the idea of patient advocacy in nursing practice
Short-term Using the case study as a prompt to research leadership models and skills
Case study (Box 1) Research from relevant sources Initial meeting with mentor
2 weeks
Medium-term Understanding the role and importance of patient advocacy in relation to leadership
Documentation on patient advocacy and leadership skills Evidenced in the assignment submitted
4 weeks
Long-term Develop future plans to educate myself and others on the skills required
Develop ideas to promote good practice and organise teaching sessions/workshops on this theme
12 weeks
Moving forward together
Building shared vision Networking
Resolving complex problems
Facilitating change sensitively
Engaging the organisation
Supporting a developmental culture
Inspiring others Focusing team effort
Being decisive
Engaging individuals
Showing genuine concern Being accessible
Enabling Encouraging questioning
Personal qualities and core values
Being honest and consistent
Acting with integrity
Figure 1. Model of transformational leadership. Source: Burns, 1978.
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says Schwartz (2001:4). At the heart of the notion of advocacy
lies the belief that it is correct to follow basic and core values, even if it means upsetting the status quo. Today, perhaps more importantly than ever before, the idea that a single individual can stand up to the might of a profession, such as the healthcare service, with the sole aim of defending and safeguarding another individual, must be protected and valued in its principle and action.
It is not that advocacy has to align itself with the organisation and keep quiet for fear of upsetting others; it is in fact the responsibility of the organisation to listen to voices that signify errors in its operation or practice. Should this need clarification, we have only to look at the numerous widely publicised cases where tragedies have occurred as a result of no-one speaking up for injustice.
Sometimes it is necessary and morally imperative to ’rock the boat’ and those that do so are the true leaders and advocates who help the progression of humanity and do not tolerate or stay silent against injustice in any of its forms. That is the essence of a great leader and an advocate for humanity. BJHCA
References American Association of Nurse Assessment
Coordination (AANAC) (2014) Nursing Leadership: Management and Leadership Styles. http://tinyurl.com/patnms9 (accessed 5 January 2015)
Aarons GA (2007) Transformational and transactional leadership: association with attitudes toward evidence-based practice. Psychiatr Serv 57(8): 1162–9
Bird AW (1994) Enhancing patient wellbeing: advocacy or negotiation? J Med Ethics 20(3): 152–6
Burns JM (1978) Leadership. Harper and Row, New York NY. Cited in: Leadership-Central.com (2013). http://tinyurl.com/kdggteq (accessed 5 January 2015)
Collins English Dictionary (2014) Definition of ‘advocacy’. http://tinyurl.com/q7b2aex (accessed 5 January 2015)
Curtain L (1979) The nurse as advocate: a philosophical foundation for nurses. ANS Adv Nurs Sci 1(3): 1–10. Cited in: Jugessur and Iles, 2009
Curtis EA, de Vries J, Sheerin FK (2011) Developing leadership in nursing: exploring core
factors. Br J Nurs 20(5): 306–9 Davison N, Williams K (2009) Compassion in
nursing/2: factors that influence compassionate care in clinical practice. Nurs Times 105(37): 18–9
Dawes D, Handscomb A (2005) A Literature Review on Team Leadership. The European Nursing Leadership Foundation. www. nursingleadership.org.uk/publications/ teamreport.pdf. (accessed 5 January 2015)
Frankel A (2015) What leadership styles should senior nurses develop? Nurs Times
Figure 2. Maslow’s hierarchy of needs. Source: www.simplypsychology.org/maslow.html.
Self-actualisation
Self-esteem
Love/belonging
Safety
Physiological
Box 3. List of key skills and values for advocacy and transformational leadership
Advocacy skills/values Transformational skills/values
Morally ‘appropriate’ to help patients Power imbalance means vulnerable need representation if it arises Adversarial role is for the patient and is courageous Protecting the rights of patients Emotional identification with suffering will impel to help, even with risks evolved (see case study, Box 1)
‘Clear head … strong heart’ Is about ‘fairness’ Skills include problem solving, communication, influence and collaboration
Challenge injustice
Inspire and ‘transcend’ self-interest for sake of others Have a vision, trust and the ability to empower others A leader guides and challenges and has confidence to act Use of empathy to understand others’ needs and motivations Mobilise in competition/conflict with others becomes their ‘best’ self Living by example/attention to values Trust, fairness, service, courage, humility, integrity, human dignity and empowerment are core values
Follow ‘internal compass of core values’ Leaders use their initiative to find solutions Influencing and inspiring others is the key to transformation Being open, accessible and transparent
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104(35): 23–4. www.nursingtimes.net/ Journals/2011/08/24/j/n/i/Leadership-Skills-for- Nurses.pdf (accessed 5 January 2015)
George B, Sims P (2007) True North—Discover Your Authentic Leadership. Jossey-Bass, San Francisco CA. Cited in: Govier and Nash, 2009
Govier I, Nash S (2009) Examining transformational approaches to effective leadership in healthcare settings. Nurs Times 105(18): 24–7
Habel M, Sherman R (2011) Transformational Leadership: A Growing Promise for Nursing. http://tinyurl.com/qbkqgpe (accessed 5 January 2015)
Hanks R (2012) From our readers … Practical approaches to patient advocacy barriers. http:// tinyurl.com/kns7qdh (accessed 5 January 2015)
Health and Social Care Information Centre (HSCIC) (2013) NHS Written Complaints Data Released. www.hscic.gov.uk/article/3414/NHS- written-complaints-data-released (accessed 5 January 2015)
Jugessur T, Iles IK (2009) Advocacy in mental health nursing: an integrative review of the literature. J Psychiatr Ment Health Nurs 16(2): 187–95. doi: 10.1111/j.1365-2850.2008.01315.x
Leadership-Central.com (2013) Burns’s Transformational Leadership Theory. http:// tinyurl.com/kdggteq (accessed 5 January 2015)
Nursing and Midwifery Council (NMC) (2008) The Code. www.nmc-uk.org/Publications/ Standards/The-code/Introduction/ (accessed 5 January 2015)
Schwartz L (2002) Is there an advocate in the
house? The role of health care professionals in patient advocacy. J Med Ethics 28(1): 37–40
Teasdale K (1998) Advocacy in Health Care. Blackwell Science, Oxford
Tomajan K (2012) Advocating for Nurses and Nursing. http://tinyurl.com/o4frhns. (accessed 5 January 2015)
Vallis M, McHugh S (2005) Illness Behaviour: Challenging The Medical Model. www. humanehealthcare.com/Article.asp?art_id=173 (accessed 5 January 2015)
Williams E (2014) Leadership Styles in Nursing Management. http://work.chron.com/leadership- styles-nursing-management-16070.html
Wood D (2010) The Nurse’s Role as Patient Advocate. http://tinyurl.com/7h3xg2d (accessed 5 January 2015)
Box 4. Proposals for future development
As a result of this assignment, two main proposals will be presented, which attempt to clarify the need for advocacy to be considered as an integral part of leadership within the healthcare setting.
First, education on the issues involved in advocacy needs to be implemented. The legal and moral areas around this field need to be clarified and presented in the education of all staff within the organisation. This could take the form of workshops, which could explore the legal implications and the ethics involved, as well as the risks which potentially could arise. In addition, training could be included as part of the induction process and/or mandatory training schemes.
Second, the role of an ‘official’ advocate could be introduced within an organisation whereby the position was validated and supported by the Trust leaders to act as a ‘port of call’ for all staff to raise issues (in confidence) which the advocate would then investigate and take action, if deemed necessary. It could thereby eliminating the risks now associated with advocacy and simultaneously reduce errors and complaints arising from these incidents. The official advocate could have the power to intervene in situations where an individual might lack the authority to do so.
These proposals would greatly improve the quality of an organisation by allowing free communication and proactive skills to reduce the incidence of error and to champion high-quality care for patients while acknowledging the ‘voices’ of all staff who work within the organisation on behalf of their patients.
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