Developing personal leadership behaviour

There are four key components to leadership behaviour:

Communication

Becoming a clinical leader is a time of great personal vulnerability. The leader’s knowledge, ability to organize and sustain direction, and skills in supporting others will all come under scrutiny before followers decide to adopt the leader’s vision. Effective communication is fundamental to gaining acceptance as a leader. Most ED nurses have experienced a shift where the nurse in charge keeps information about patient progress to him- or herself and does not keep staff informed of activity. This results in a withdrawal from the situation; nurses continue to function under direction, but they have no ownership of the activity and offer little support to the leader. Conversely, where communication is good and ideas are welcomed from other nurses, staff work as a team, supporting each other and the leader. The success relies on the ability to communicate effectively with other staff members. This means the leader is able to give direction and feedback to staff, but also can receive feedback, air ideas and develop strategy (Box 36.5).

Empowerment

Empowerment of individuals or a team can be a lengthy process; it is sometimes difficult to imagine this taking place in a busy ED when decision-making is necessarily rapid. The clinical leader needs to work periodically with nurses on an individual basis. She/he needs to understand and appreciate the nurse’s contribution, give constructive feedback and invest in the nurse’s individual development. This way when rapid decisions do need to be made, the followers are more likely to trust their leader and accept and support the action proposed.

Empowerment does not mean a lack of managerial control. The clinical leader must set boundaries on what are acceptable standards and behaviours and what are unacceptable. These must be communicated to others in the clinical environment and should remain constant. This way the team is free to participate in decision-making within a preset structure. For most people, boundaries provide a sense of stability and security. This can be particularly important when trying to maintain a departmental direction and vision. Leadership, however, is as much about risk-taking as it is about control. The effective leader will allow her team to make decisions that may be inappropriate or less than efficient (Bowles & Bowles 1999). The risk that should be considered, balanced and judged is whether the consequences of the staff making the wrong decision will be catastrophic. If this is likely then the leader would be foolish not to make a decision and pass it on; if it will not be then it may be worth allowing others to make the choice and let them glory in their success or learn from their lesson, depending on how things turn out. It might be easier as a leader to just take control and make the decisions; there is little risk of things going wrong, particularly in a busy ED. This fails, however, to empower the team. This lack of empowerment and overly controlling approach can lead to disenfranchisement of staff from the organizational process of their department, simply turning up at work to do their job; or worse the team become so disempowered that staff become unable to make even the most basic and simple of decisions. Every leader must remember that if there is constant downward management there will be constant upward referral. This does nothing to develop the skills of others and is exhausting for the leader. The challenge for the leader is one of balance; in order to empower and develop staff they must feel trusted, capable and supported. In order to achieve this, the leader must feel comfortable with the degree of risk he/she is taking.

Team-building

The ability to build and sustain a team is fundamental to being an effective leader. Part of the role of the leader is to draw people together, create common goals and encourage a sense of collaboration. This way a team can be formed that will face challenges together. This is best demonstrated by a well-run resuscitation – the team comes together, each member has a role, and a comprehensive package of care is given.

These teams last only for a short while. In building a team that is expected to work closely for a sustained period, such as a project group within a department, the leader must have an understanding of group dynamics. An effective team is one where there is diversity among the team members and the collective qualities those individuals bring offer a richness to the breadth of skills the team has at its disposal to achieve its goals. Effective leaders will look at their team and understand the differences between the individuals, celebrate these differences, and use them to the benefit of the service and the patients.

There are a number of systems available to analyse the personality profiles of individuals. It can be helpful to undertake such analysis in order to appreciate where the strengths lie within a team (Dolan 2011). By understanding this, the allocation of tasks can be made based upon people’s strengths, so ensuring the best outcome. The effective leader, however, will also use such understanding to identify where an individual’s weaknesses lie and sometimes allocate tasks to stretch and develop skills. This can be an uncomfortable experience for the individual that may result in resistance to the leader. The leader must, therefore, ensure that such development is backed up with support, reassurance and positive feedback.

A crucial factor in team-building is the function of the leader. To be successful, this person must remain part of the team, giving direction and support to the other team members. The leader must be secure enough in her/his own knowledge to encourage and utilize the abilities and knowledge of other team members without being threatened. It is important for leaders to recognize their own limitations, but recognition is not sufficient. Declaration of one’s own limitations can often encourage loyalty and affiliation to the leader by the followers. This must be undertaken positively and with care and judgement. Listening effectively to the views and opinions of others, while acknowledging one’s own short-comings, can lead to better decisions and a stronger team (Caplin-Davies 2000).

Political savvy

As a professional group, nurses are often less aware of how to manage organizational politics than other professional groups in healthcare (Nelson & Gordon 2006). This can have a detrimental effect on leadership ability. The principles of influence are the same regardless of the target audience, so whether the Chief Executive, Director of Nursing or Healthcare Assistant is the person to be influenced, the following principles apply.

Clinical leaders should use charm in the same way many medical colleagues do; it will engage others, make them want to talk, and more importantly listen to others’ views (Box 36.6).

As trust grows they will provide the clinical leader with information that increases their political intelligence, but also trust the leader’s views and ideas, give the benefit of the doubt because that leader is a known and trusted entity, and as credibility grows other professionals and Trust directors will want to work with the leader who has charmed them because they now know her, trust her/him and rate her/him. That alone makes the clinical leader’s job a whole lot easier.

Clinical leaders should see organizational meetings as an opportunity, not an ordeal to be avoided with the slightest excuse. They are where issues are discussed and decisions are made and if the clinical leader is not there, her/his opinion is lost: worse, her/his power of influence is diminished. Instead clinical leaders should be political, plan for the meeting, read the agenda, and decide in advance what subject’s impact on their clinical area. Prior to the meeting identify natural allies, and discuss issues beforehand, identify critics and have answers for their criticisms. On the day of the meeting arrive early, try to sit facing the chairperson as it is easier to get heard, and watch listeners as well as speakers, as they often give away much information about their stance on the discussion. The clinical leader should have prepared what she/he wants to say, and be clear and concise, avoiding any complex clinical analogies, which may lose the attention of non-clinicians. Finally the leader should stay on message responding, not reacting, to others comments. It is often worth practising this technique in meetings with little risk first, but it quickly becomes a habit. Other professional groups have practised in this way for a long while, and nurse leaders are disadvantaged if they do not engage in this process.

Leadership is fundamentally about influence; it is worth thinking about the impact clinical leaders make as individuals to ensure it is the impact they want to make (Armstrong 2012).

Principles to support clinical supervision

The Nursing and Midwifery Council (2002) supports the concept of clinical supervision, however it has stopped short of identifying any particular model of delivery to allow for local adaptation. It does stipulate a set of guiding principles that should be used (Box 36.7).

For its introduction to be successful in any clinical environment, it is essential for participants to share a common understanding of their interpretation of clinical supervision. One approach to this is for emergency nurses to explore the many activities and skills in nursing work, including:

These activities all involve interaction with others, such as patients and their relatives or friends, and are not without personal risk. In emergency care, the patient’s stay is relatively short and the onus is on the nurse to develop a therapeutic relationship quickly, but how do nurses maintain this relationship when someone is off sick, the shift is busy or the relative has complained about the ever-increasing waiting times?

Types of supervision

Clinical supervision must be clearly separated from issues relating to pay, promotion or discipline. Only then can a trusting relationship be fostered. Several ways of addressing supervision have emerged. These include:

Peer supervision means the supervisor and supervisee are involved in similar clinical work, and possibly face similar challenges. The advantages are increased awareness, potentially greater trust and a relationship that is less threatening to the supervisee. The disadvantage is that without effort and commitment from both parties, the activity can become purely one of support and not development. Group and network supervision have been developed in some areas of healthcare, particularly in community settings. This involves a group of similar professionals sharing experiences and developing their practice using one another. For this to be successful, a large degree of trust and commitment is needed from participants. It does have disadvantages in that some members of the group can remain non-participative or dominate activity. It is perhaps organizationally easier to facilitate than one-to-one supervision. Whichever method of supervision is adopted, it is essential that the clinical supervisor remains clinically challenging. The success of clinical supervision relies on its perceived value to the department (Jones 2006); therefore agreeing the aims and process before implementation is imperative. Bishop (1994) identifies three overall aims that act as a bedrock for supervision activities:

To achieve these objectives, clinical supervision should be seen as a continuum along with mentorship and preceptorship. A mentor helps to develop clinical competence by guiding a nurse through learning a new skill, such as cannulation. A preceptor helps the nurse gain confidence in that role. A clinical supervisor aids professional development from acquisition of new skills. But for clinical supervision to be successful it is important to consider the impact of the nurse as a whole and not as a technician.

The philosophical approach to clinical supervision does not have to be complicated. Proctor (1986) suggested a simple tripartite approach to supervision (Fig. 36.1). The formative role is one of education, supplementing the supervisee’s knowledge and facilitating growth. The restorative aspect relies on support, exploring anxieties or critical incidents and allowing the supervisee to resolve stress. The normative function is one of quality control, looking at actual practice and challenging methods to maintain high standards of patient care.

The success of clinical supervision relies on its perceived value to the department and staff commitment. The activities of clinical supervision revolve around the provision of regular space for reflection on the content and process of work (Fig. 36.2). Its functions are to develop the understanding and skills of the supervisee, to ensure quality nursing care and to provide space to explore and express distress about work. Done effectively this will result in the supervisee feeling valued and validated both as a person and as a nurse, as she/he is able to receive feedback and therefore gain new perspectives on her/his work. This empowers the nurse to plan and utilize personal resources and become proactive and innovative. Clinical supervision should not be a forum for self-congratulation or self-destruction, nor should it be personal therapy. The supervisor can facilitate this by observation of practice, encouraging retrospective reflection and participation in evaluating outcomes (RCN 2000).

Getting clinical supervision

Clinical supervision is not without personal risk, because the nurse is being asked to expose anxieties or perceived areas of weakness to a close colleague. Trust and confidentiality are therefore pivotal to a successful relationship. The nurse has a responsibility to seek supervision actively by going into a meeting with identified areas for support. She/he must ask for help in these areas and not rely on the supervisor to work it out. For supervision to succeed, the nurse needs to be able to share her/his feelings and be open to feedback, monitoring any tendencies to defend practice, but also monitoring what feedback is useful. Perhaps most important to the success of the relationship is the ability to be creative about clinical practice.

Self-awareness helps to minimize the impact of any blocks the nurse may have towards supervision, such as negative past experiences, inhibition, misunderstandings or relationship problems such as personality clashes. Much of this can be overcome if the nurse being supervised has a choice of who acts as supervisor. In making this choice it is important that the supervisee chooses a supervisor based on that person’s ability to challenge and develop nursing practice and not because of popularity with the supervisee. This person is most likely to be another nurse from the same or a similar specialty. The supervisor needs to apply clinical knowledge in a manner that promotes innovation, is constructive and creative, and facilitates the professional growth of the supervisee. It is not enough to be more senior or more experienced; the supervisor also needs advanced skills in listening, giving positive and negative feedback, facilitating reflection and defusing distress.

Before clinical supervision is established in a department, its ground rules should be identified and agreed by participants (Simms 1993); for example, it should be agreed that any unacceptable breach of the Code of Professional Conduct (Nursing and Midwifery Council 2008) may need to be taken outside the supervisory relationship (Box 36.8).

In addition to these, some practical considerations such as the frequency and length of meetings, criteria for supervisors and termination routes if sessions become destructive should all be agreed. A robust audit tool is useful to measure quantitative data about activity such as the frequency and duration of supervision sessions. Evidence of its value to nurses is largely subjective, but potential benefits are outlined in Box 36.9.

There remains much debate about the real value of clinical supervision. Shanley & Stevenson (2006) argue that it is potentially hazardous in its current form, and models need to become more sophisticated if they are to be successful. Despite the ongoing concern in acute and primary care, clinical supervision has been successful in mental health nursing for many years.

Clinical supervision is a complex activity; it facilitates the development of clinical practice and supports the provision of quality patient care. Perhaps most importantly, clinical supervision provides a forum for innovation and creativity to flourish. Its implementation has been hampered by misunderstanding of its function, not aided by the inference of its title ‘supervision’. It is, however, a real opportunity for nurses to develop their nursing practice further, challenge professional boundaries and celebrate the value of nursing.

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