Journal of Nursing Management, 2004, 12, 1–7
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KARIEN JOOSTE
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Leadership: a new perspective DLitt et Phil (Unisa)
J O O S T E K . (2004) Journal of Nursing Management 12, 1–7 Leadership: a new perspective
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Aim This overview article aimed at outlining the image of an effective futureorientated 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 leadership 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.
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Correspondence Karien Jooste Department of Nursing Rand Afrikaans University PO Box 100477 Moreletaplaza Pretoria 0167 South Africa E-mail:
[email protected]
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Associate Professor, Department of Nursing, Rand Afrikaans University, South Africa
Keywords: behaviour, influence, leadership, transformation
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Accepted for publication: 23 October 2003
Introduction
It was not until the early 19th century that leadership as a concept first appeared as a word in the English language (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 1
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Conceptual framework
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• How should I use influence to obtain the organizational 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 question 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:
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Problem statement
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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.
and its institutions. Things are changing at an astonishing pace in the health care environment and challenges 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. 1 Leaders should know how to use em(power)ment, authority and influence in meeting the new challenges in leadership in current health services. Some of the following are questions that leaders often ask themselves and are examples of their uncertainties:
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definitions is chosen to describe the difference between management and leadership: Ôlegitimate power and control vs. empowerment and changeÕ. 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 development 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).
Throughout the history, there have been calls for leadership. Today, it is more important than ever in society
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Past
Authority
Power
Factors influencing the leader
Figure 1 Conceptual framework.
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The arch of leadership
Influence
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 dimension.
ÔBegin with the end in mindÕ 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
Future
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Possible solutions
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 ª 2004 Blackwell Publishing Ltd, Journal of Nursing Management, 12, 1–7
Leadership: a new perspective
Factors in current health services that demand changes and challenges
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In South Africa, white governmental papers (Department of public service and administration 1997) for transforming health service delivery, focus on among others, the decentralization of responsibility, accountability, 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
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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 methods 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 position 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 professionalization (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 perspective 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-directed focus of the neo-human relations, and the hardnosed, profit-focused themes of the 1980s (Sofarelli & Brown 1998, p. 202). Nelson Mandela changed the rules of the political game, from revolution to democracy, 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
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distinguishing upper, middle and lower level leaders are 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, assessing past impacts and current reality, job suitability, strategic human resource systems to address the future. Future functional level leaders should undergo transformation from implementers to aggressive entrepreneurs in running cost units. Those at middle level management are slowly starting to move away from their previous role as administrative controller to supportive 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, politics and market expectations that can influence health services.
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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 ÔgoodÕ. 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 patientsÕ 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. ª 2004 Blackwell Publishing Ltd, Journal of Nursing Management, 12, 1–7
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The arch of leadership
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Clarity
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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 compelling 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 followers; • 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.
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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 leader, the other to identify and solve problems in the health management sector (Figure 2). The leader has an enormous role to play in influencing 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 solving framework for leaders the following questions could be asked to identify reasons for and address any problematic scenario with followers:
Answers to these questions could help to determine reasons for problems in the work place.
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capacity to motivate, persuade, appreciate, understand and negotiate. These dimensions of influence are critical 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 appropriate care namely (1) to model by example, (2) to build caring relationships and (3) to mentor by instruction 2 (Lambert & Nugert 1999, p. 174).
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• 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?
Figure 2 The arch of leadership.
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The leader is responsible for communication and should check for clarity of communication, she should not assume, and should involve all followers in decisionmaking and setting standards, for more commitment. Less involvement leads to less commitment. How does your leader looks like? Is she/he competent, qualified, 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 people 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 ª 2004 Blackwell Publishing Ltd, Journal of Nursing Management, 12, 1–7
Leadership: a new perspective
Inspiring a shared vision. Enabling others to act. Challenging the process. Modelling the way. Encouraging the heart.
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Transformational leadership is an empowering leadership style and one which is highly suited to the profession of nursing, characterized as it is as being caring and highly ethical (Sofarelli & Brown 1998, p. 202). The ability to effectively use a transformational leadership style in health care will become increasingly critical as we approach the 21st century. Five of the fundamental practices in an effective leadership style should be pointed out:
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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 committed to this vision and should empower others with that vision (Lambert & Nugert 1999, p. 174).
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provides a practical process for: increasing self awareness, uncovering assumptions and beliefs which limit our effectiveness, becoming autonomous individuals acting from our values and purpose; using our awareness and inner will to realize our deepest resources and selfleading potentiality. ÔNothing changes without personal transformationÕ. 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). ÔTo become an effective leader is the ultimate act of free will … becoming a leader is synonymous with becoming yourself.Õ (Sofarelli & Brown 1998, p. 202).
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Price
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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 clients/patients (Mullins et al. 2001, p. 123). This promotes 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. ª 2004 Blackwell Publishing Ltd, Journal of Nursing Management, 12, 1–7
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:
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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 organizational growth-directed change has become a core competence in the changing health care environment. 5
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strength, confidence, negotiation skills, knowledge management and willingness to form strategic alliances. I believe the key to nurturing these attributes is solidarity. 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 organizations will be.
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• Leaders should be proactive and see the present as a springboard to achieve future aims. • Skill management is essential in assessing competencies and skills of followers to determine and plan for changes in individual and team performances. • Build a global perspective through short-term international 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, acceptance 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.
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As nurses, we are never far from change; it is a hallmark of our profession. One of the new challenges of 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 leadership for change programme – one of many programmes 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 leaders who are able to be strategic in their thinking and facilitative in their style. In a changing health care system there seems to be a need to devise new ways to approach its management.
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Modelling the way Effective leaders should create a friendly environment, which supports collaboration, enthusiasm and commitment from staff. Leaders are people who get others to perform at consistently high standards – voluntarily. In these times of scarce resources and long hour working 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.
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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 influence. You have to recognize that to keep on being acknowledged as a leader, you have to keep earning it.
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.
Future solutions
Conclusion
Key attributes of modern nurse leaders are vision, strategic thinking ability, change management skills,
With the above mentioned solutions in mind, the nurse leader in the current health care environment of
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• 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 communication 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 protected 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.
Chapman J.A. (2001) The work of leaders in new organisational contexts. The Journal of Management Development 20 (1), 55–68. Charlton G. (2000) Human Habits of Highly Effective Organisations. The Human Race. Van Schaik, Cape Town. Davis J. & Cushing A. (1999) Nursing leadership in the US 1950s–1970s: a discourse analysis. International history of Nursing Journal 5 (1), 12–18. Department of Health (1997) National PatientsÕ Rights Charter. Pretoria, South Africa. Department of Health. Health Summit (2001) Background Papers: Quality of Care, Public–Private Interactions, HIV/ Aids? STI’s and TB & Human resources. Pretoria, South Africa. Department of public service and administration (1997) White Paper on Transforming Public Service Delivery (Batho Pele White Paper). Government Gazette No 18340. October 1997. Notice 1459 of 1997. Pretoria, South Africa. Ehlen K.J. & Sprenger G. (1998) Ethics and decision making in healthcare. Journal of Healthcare Management 43 (3), 219– 221. England D. (2002) Inner leadership – personal transformation. Industrial and Commercial Training 34 (1), 21–27. Lambert V.A. & Nugert K.E. (1999) Leadership style for facilitating the integration of culturally appropriate health care. Seminars for nurse leaders 7 (4), 172–178. McMurray M. (2001) Guest editorial: leadership for change. Australian Journal of Advanced Nursing 18 (3), 6–7. Mullins J., Lineham M. & Walsh J.S. (2001) People-centred management policies: a new approach in the Irish public service. Journal of European Industrial Thinking 25 (2/3/4/), 116– 125. Oddou G., Mendenhall M.E. & Ritchie J.B. (2000) Leveraging travel as a tool for global leadership development. Human Resource Management 39 (2, 3), 159–172. Quible Z.K. (2001) Administrative Office Management. An Introduction, 7th edn. Prentice Hall, NJ, USA. Sofarelli D. & Brown D. (1998) The need for nursing leadership in uncertain times. Journal of Nursing Management 6, 201– 207.
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South Africa, should maintain the following principles:
References
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Apps J.W. (1994) Leadership for the Emerging Age. Transforming Practice in Adult and Continuing Education. Jossey-Bass, San Francisco.
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