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MUSCULOSKELETAL CARE Musculoskelet. Care 4(1): 3847 (2006) Published online in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/msc.17

Professional issue

Leadership in health care

Susan Oliver MSc Nurse Consultant Rheumatology, Litchdon Medical Centre, Devon

Introduction
The National Health Service (NHS) has to provide a dynamic and responsive health care system with a workforce that can cope with frequent organizational change. To achieve this, the NHS must have clinicians who can demonstrate leadership skills and act as role models at all levels of health care provision. The outdated health care service that works on strong paternalistic and controlling principles is in effect dead. The changes in the culture of the NHS have been driven by numerous factors including changes in society, and the decentralization of health care services. Others factors include the failing of the NHS to tackle system failures such as those identified by the Bristol enquiry and challenges in implementing complex and ever increasing changes within the health care system. Let whoever is in charge keep this simple question in her head (not how can I always do this right thing myself, but) how can I provide for this right thing to always be done. Florence Nightingale (1969) Florence Nightingales words are interesting because she had clearly recognized the important concept of leadership by influencing the delivery of high quality care through delegation and empowerment. Donnelly (2003) states that achieving good leadership is more of a journey than a destination and is easy to recognize in action. Yet it is difficult to define the important characteristics of a good leader. A wealth of literature discusses different types of leadership and whether individuals are born natural leaders with intrinsic personality traits or whether they can be taught the key qualities required of an effective leader (Hawkins and Thornton, 2002; Austin et al., 2003). To be an effective leader requires a complex mix of attributes, behaviours and skills but most of all it requires an ability to reflect upon and evaluate yourself. The aim of this article is to provide the reader with an overview of some of the key concepts in leadership. This article will briefly discuss:
Copyright 2006 John Wiley & Sons, Ltd Musculoskelet. Care 4: 3847 (2006) DOI: 10.1002/msc

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TABLE 1. Suggested reading list Adair J (1998) Leadership Skills: Management Shapers. London: Chartered Institute of Personnel and Development. Adair J (2002). Inspiring Leadership. London: Thorogood. Austin S, Brewer M, Donnelly G, Fitzpatrick MA, Harberson G, Hunt PS, Morris M (2003). Five keys to successful nursing management. In GF Donnelly (Ed). Why Leadership is Important to Nursing. Springhouse, PA: Lippincott, Williams and Wilkins. Handy C (1991). Gods of Management: The changing work of organizations. New York: Oxford University Press. Hawkins E, Thornton C (Eds.) (2002). Six steps to effective management: Managing and Leading Innovation in Health Care. London: Bailliere Tindall. Isles V, Sutherland K (2001). Managing Change in the NHS. Organisational change. A Review for health care managers, professionals and researchers. (available from www.sdo.lshtm.ac.uk/pdf/changemanagement_review.pdf.) Kanungo RN, Mendonca M (1996). Ethical Dimensions of Leadership. Thousand Oaks, CA: Sage Publications. Soothill K, Mackay L, Webb C (Eds.) (1995). Interprofessional relations in healthcare. London: Edward Arnold.

Why leadership skills are important in the provision of health care. How to become an effective leader. How to work with teams.

The article will identify areas for further reading particularly in relation to managing organizational and cultural change and the challenges that can be faced working with people to implement change. It is beyond the scope of this article to provide a comprehensive overview of discussions related to the theories of leadership styles. Suggested further reading can be found in Table 1.

An important characteristic of a good leader is the ability to explore personal and team motives/beliefs in accomplishing a change or perceived vision of success. As part of this process true leadership requires the ability to critically appraise the team process and outcomes on the path to achieving a shared goal. Leadership requires constant fine tuning of self as well as reflection on the individual needs and characteristics of the team. Clinicians should have an insight into leadership styles and responsibilities in order to gain a deeper understanding of the attributes required of being, or supporting, leaders within the organization. The word leader has developed from the root meaning of a path, road or course of a ship at sea: according to Adair (1997) it is a journey word. It also implies
Copyright 2006 John Wiley & Sons, Ltd Musculoskelet.Care 4: 3847 (2006) DOI: 10.1002/msc

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What is leadership?

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TABLE 2. Leadership roles in health care Teaching Inspiring confidence Empowering Improving performance supporting reflection/clinical supervision Rewarding and recognizing individual contributions Recognizing the needs of the service from clinically based environment Leading and developing services implementing change Supporting the organization and, when necessary, providing a bridge between senior management and team members/employees in informing, supporting and developing national agreed initiatives/government initiatives

authority or power that is used appropriately for the common goals of the organization or group. Empowered leaders are key to organizational development. Some of the key roles are set out in Table 2. The NHS is subject to constant organizational change. One important difference in recent years has been the formal recognition of the role that nurses and allied health care professionals can play in effective change and as such become leaders within the organization (Department of Health, 2000).

Leadership in the NHS

Leadership is identified as an essential role within new nursing and allied health care professional consultant posts. It is no longer tenable for clinicians to avoid recognizing the importance of effective leadership in the current health care environment (Ewens, 2002). There is an increasing recognition that the wide-ranging changes necessary within the NHS cannot be implemented using a dictatorial management style that enforces change using a top down approach. In the past leadership models have often followed that of industry where managers have a responsibility to demonstrate leadership qualities within the managerial role. Leadership was seen purely as a management role yet it is acknowledged now that leaders can be recognized or nominated from within their team for specific tasks and may not necessarily have a role of recognized authority within the organization. Clinicians must have leadership expertise in all settings to implement change based upon good clinical decision making and around a patient-centred approach to care (Cooper, 2003). This is reflected in programmes such as the Leading an Empowered Organization (LEO) Programmes and the government funding to implement successful leadership training for nurses (Cooper, 2003; King, 2002).
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Improving leadership within the organization should enable a more effective implementation and ownership of changes but also retain staff, reduce stress, and improve job satisfaction and career advancement (Beech, 2002; Department of Health, 2005).

What is a leader?
A significant amount of analysis and theoretical discussion continues in the quest to attribute certain styles or characteristics to successful leadership (Cook, 2001). Adair (1998) confidently states that it is possible to become an effective leader not by teaching but by the individuals personal wish (or motivation) to acquire the expertise. A leader is an individual who is able to demonstrate a specific set of role behaviours to influence the attitudes and behaviours of others. It is usually a group phenomenon. Two specific aspects of being a leader are: 1. 2. The individual attributes or styles needed to be an effective leader. The organizational skills required to manage the process of change. The process of change will be discussed in the section on change management.

Leadership styles
Leadership styles are often discussed based upon behaviours used to influence change. Terms used to describe leadership styles include: Transactional or autocratic (Burns, 1978). This might have been called in the past the top down approach or autocratic leadership.

Renaissance or modern (Cook, 1999). Renaissance leadership has some similarities to what used to be previously termed a charismatic style. Renaissance leadership requires the effective use of power, influence and the ability to network to ensure key decision makers support changes. They can be encapsulated in leaders such Winston Churchill and John F Kennedy. Connective. There are similarities between both transformational and renaissance styles (Ewens, 2002) although this type of leadership is less likely to delegate in a
Copyright 2006 John Wiley & Sons, Ltd Musculoskelet. Care 4: 3847 (2006) DOI: 10.1002/msc

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Transformational/interactional (Burns, 1978). Transformational leadership is aligned to democratic forms of leadership. This involves leaders and followers engaged in a common aim. It is a leadership style based upon embracing change and encouraging innovation.

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way that empowers the workforce. The focus is that of building collaborative structures and networks to effect change. According to the Royal College of Nursing (2003), leaders in the modern NHS are expected to: 1. 2. 3. 4. Improve the quality of patient care. Influence improvements in the health of the population. Promote the NHS as being well led, well managed and accountable. Lead on strategies to motivate and develop NHS staff.

How does a clinical leader lead?

The role of leadership and how changes are implemented can be considered in a multiplicity of ways but a basic analysis would be that of addressing: 1. 2. 3. 4. The The The The leadership qualities and styles required for a specific task/project. needs of the individuals. needs of the team. needs of the organization/patient group.

The leadership qualities and styles required for a specific task/project

The level of trust and authority that a leader holds within the organization or team is crucial to the implementation of any project. Leaders can only lead if there is consensus in the workforce they wish to inspire and work with. That is they may be nominated as leader and may have the title. However, to be able to use their authority to effect change, the team (or individuals) must recognize and support the leaders and the authority they hold. Leaders have a key role as change agents and role models. Change agents can be described as requiring seven skills to manage change effectively (Dale et al., 2002). These are: 1. 2. The ability to work independently, without the power, sanction and support of the management hierarchy. The skills of an effective collaborator, able to compete in ways that enhance rather than destroy co-operation.
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3. 4. 5. 6.

The ability to develop high trust relationships, based on high ethical standards. Self-confidence, tempered with humility. Respect for the process of change, as well as the content. The ability to work across business functions and units, to be multi-faceted and ambidextrous. (Quoted from Dale et al., 2002, citing Kanter, 1989).

Working as a facilitator of change, the most effective approach is to develop a clear understanding of the task or project, as well as planning and briefing needs. At times, some leaders may include the team in the planning and briefing stages (Transformational style). Although, depending upon the change required, the project or task may require an inspirational/influencing presentation to those that are to work and support the proposed change (Renaissance style). Leadership responsibilities include awareness of ones own abilities (strengths and weaknesses), level of authority, the needs of the patient group, the needs of the individual employees and the team.

The needs of the individuals

All teams are made up of individuals with their own personal beliefs, attitudes and expectations. These behaviours will also influence their respect for authority, their perceptions of self-esteem and value within the organization. In turn these cannot fail but to affect their ability or wish to accept or support change (Handy, 1993). As health care professionals, the needs of the individual and theories such as Maslows hierarchy of need are intrinsic to work undertaken in clinical care (Maslow, 1943). However, it is important that these basic needs are also recognized and valued when considering individual members of a team in the work environment. Beattie (1995) identifies specific difficulties of change within health care and the possible shifting of professional boundaries aligning behaviours to those of tribalism. Historically, nurses and allied health care professionals have established work habits and attitudes that have been controlled by an authoritarian style of leadership. In the new era of empowerment for allied health care professionals motivation levels will rely on the ability and opportunities for individuals or teams to expand their skills and recognize opportunities to develop.

The needs of the team

A team is a complex mix of people with individual personalities, cultural beliefs and behaviours who work together with the overall aim of achieving a common
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goal. Working together as a team is a dynamic and ever changing process; it is, in no way, a constant phenomenon. Teams will be subject to constant transition depending upon various changes in group dynamics, changes of roles, responsibilities and other external influences. Many inadequate team performances are related to poor leadership (Ovretveit, 1993). A leader remains in an effective position of authority by consensual agreement of the followers (the team). Instances can be recalled when change or leadership authority are challenged or sabotaged by an individual team member or collectively by a team. This sabotage can be undertaken in a range of ways. Some individuals have a lower tolerance of change and will find change threatening (Dawson, 2003). However, it is not always appropriate to consider that the team or individual has failed if one or the other is resistant to change. It may be the fault of the leadership approach to implementation or attributed to a wide range of anxieties that affect the teams perspective on ownership or the task (See Table 3). As a leader it is important to recognize the best way of providing support that achieves the common goals of the team. There are a number of problem solving tools used to aid individual and team working. Some useful models can be found in the reading list (Table 1). Team development is said to consist of five stages. Forming This usually happens at a time of change (e.g. new team member). The team is more cautious, evaluating and looking for guidance from the leader. Storming Frustration and anger may present with clashes of individual perspectives and interest in the outcome of projects or planned changes. There is a high potential for conflict. Morale and job satisfaction may be affected. Norming Team members become more sensitive to others needs. Attempt should be made to achieve harmony where the aims of the team or project begin to be recognized and considered. Performing Team members may communicate openly, they work well together and are motivated. They can handle disagreements and progress with the aims of the team. Adjourning The team may reflect on completed tasks/projects and recognize the need for review of new plans or goals required.

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TABLE 3. Possible response to change Response to proposal Denial or non-compliance May be demonstrated by

Failure to understand process, ignorance of decisions Hope that changes will not be sustained it will all go away/seen it before Work outside recognizing role/framework Grudging compliance Voice hopes for failure Interpret to the letter all aspects of new proposal/ potential change Demonstrate apathy Anger Why is this being forced upon me? Challenges decision making and refuses to take part/ownership of the process Sabotage of consensual decision making process or failure to work with new process Negotiating Attempts to find another route to avoid undertaking task or taking part in decision making process Negotiates unrealistic needs to achieve task/ project planning Expresses emotional distress Catastrophising Sees an organisation threat or sinister motive (e.g. redeployment) Acceptance/commitment/ownership Recognises the need to change Identifies ways to adapt to new model/proposed project Enthusiastic for change

Note: Some individual will go through various transitions (e.g. from denial to negotiating to acceptance) before making a stance on the proposal/change

Organizations need to invest in their potential change agents. They also need to demonstrate a shared philosophy of learning. Empowered leadership must include organizing effective change. Leaders need to demonstrate to the organization clarity of purpose and outcome when implementing a clinical change in practice. Adair (1997) sets out a model for leaders implementing change. These include: 1. Planning: Consider whether planning should be undertaken individually or as part of the process with the team members. 2. Defining the task: Focus on an objective that is SMART (specific, measurable, achievable, realistic and timely).
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3. 4. 5. 6. 7. 8.

Briefing: Communicate objectives and plans in a focused and effective manner. Controlling: Control the effective use of resources, time and effort in implementing the change. Evaluating: Use clear realistic objectives that are based on the patient and/or organizational needs. Motivating: Inspire the team and others with a vested interest or anxieties. Organizing: Use systematic planning and structuring or re-structuring according to the needs of the project. Providing an example: Provide an example as a role model.

Change management
Change management is a term used to describe and support theoretical constructs to aid leaders working with individuals and teams facing change. The Modernisation Agency (National Health Service, 2005) has developed a wide range of useful booklets that provide practical support to practitioners implementing change and wishing to develop their leadership skills, the information is also available on the website (www.modern.nhs.uk). Iles and Sutherland (2001) also provide a detailed review of change management within the NHS and include examples of models to support leaders in change management. Change is a stressful process within an organization and individuals or teams can perceive change as a threat and a retrograde step. This can result in a range of challenges.

Conclusions
This overview of leadership focusing on change management identifies issues for nurses and allied health care professionals undertaking new roles and responsibilities in the changing NHS. It is by no means definitive and it is hoped that this article has provided a springboard for additional reading into the complex and yet rewarding aspects of being an effective leader.

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References
Adair J (1997). Effective Leadership Masterclass London: MacMillan. Adair J (1998) Leadership Skills: Management Shapers. London: Chartered Institute of Personnel and Development. Austin S, Brewer M, Donnelly G, Fitzpatrick MA, Harberson G, Hunt PS, Morris M (2003). Five keys to successful nursing management. In GF Donnelly (Ed). Why Leadership is Important to Nursing. Springhouse, PA: Lippincott, Williams and Wilkins. Copyright 2006 John Wiley & Sons, Ltd Musculoskelet. Care 4: 3847 (2006) DOI: 10.1002/msc

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Correspondence should be sent to Susan Oliver, 7 Trafalgar Lawn, Barnstaple, North Devon EX32 4JB. E-mail: susan.oliver@bigfoot.com Received August 2005 Accepted September 2005

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Musculoskelet. Care 4: 3847 (2006) DOI: 10.1002/msc

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Beattie A (1995). War and peace among the health tribes. In K Soothill, L MacKay, C Webb (Eds). Interprofessional Relations in Health Care (pp. 1126). London: Edward Arnold. Beech M (2002). Leaders or managers: The drive for effective leadership. Nursing Standard 16(30): 356. Burns JM (1978). Leadership. New York: Harper and Row. Cook M (1999). Improving care requires leadership in nursing. Nurse Education Today 19: 30612. Cook MJ (2001). The renaissance of clinical leadership. International Nursing Review 48(1): 3846. Cooper SJ (2003). An evaluation of the leading an Empowered Organisation Programme. Nursing Standard 17(24): 339. Dale C, Gardner J, Philogene S (2002). Overcoming barriers to change: case of Ashworth Hospital. In E Howkins, C Thornton (Eds). Six Steps to Effective Management; Managing and Leading Innovation in Health Care. London: Balliere Tindall. Dawson P (2003). Understanding Organisational Change: The Contemporary Experience of People at Work. London: Sage Publications. Department of Health (2000). The NHS Plan. London: Department of Health. Department of Health (2005). Supporting People with Long-Term Conditions London: Department of Health. Donnelly GF (2003). Why Leadership is important to nursing. In S Austin, M Brewer, G Donnelly, MA Fitzpatrick, G Harberson, PS Hunt, M Morris (Eds). Five Steps to Successful Nursing Management. Springhouse, PA: Lippincott, Williams and Wilkins. Ewens A (2002). The nature and purpose of leadership. In E Hawkins, C Thornton (Eds). Six Steps to Effective Management: Managing and Leading Innovation in Health Care (Ch. 4). London: Balliere Tindall. Handy C. (1993). Understanding Organisations (4th edn). London: Penguin. Hawkins E, Thornton C (2002). Six Steps to Effective Management: Managing and Leading Innovation in Health Care. London: Balliere Tindall. Iles V, Sutherland K (2001). Organisational Change. London: National Co-ordinating Centre for NHS Service Delivery and Organisation Research and Development. Kanter RM (1989). When Giants Learn to Dance. London: Unwin. King R (2002). Leadership in the NHS: Leading at all levels. Nursing Management 8(9): 2627. Maslow A (1943). A theory of human motivation. Psychological Review 50: 37096. National Health Service Modernisation Agency (2005). Improvement Leaders Guides. London: Department of Health. Nightingale F (1969). Notes on Nursing. What it is, and What it is not. London: Constable Company. Ovretveit J (1993). Co-ordinating Community Care: Multi-disciplinary Teams and Care Management. Buckingham: Open University Press. Royal College of Nursing (2003). Clinical Governance: An RCN Resource Guide. London: Royal College of Nursing.