Lynda Holt

Chapter Contents

Introduction

This chapter takes a broad look at leadership, a principle of organizational development that has been debated and studied for over 50 years. During this time the theories have changed considerably (Huczynski & Buchanan 2003, Bass & Bass 2008, Lang & Rybnikova 2012); however, one thing has remained consistent, human behaviour is a fundamental part of leadership. It is also clear that in an increasingly political healthcare environment strong clinical leadership is essential for effective patient care, and for nurses’ well-being. This chapter will look at some aspects of leadership behaviour and identify the key components of effective clinical leadership as well as some of the principles of clinical supervision.

What is leadership?

Leadership is a much debated term with many conflicting theories, definitions and qualities to describe successful leaders (Wade-Grimm 2010). Most people recognize a good leader, but it is often harder to identify why that individual is a good leader. It does, however, differ from management in that specific status or organizational position is not necessary for an individual to be a leader. So, if position is not the key factor, what is? Skills are important, but not necessarily the ones that may be expected. For example, management skills, attention to detail, organization, intelligence and planning are not consistent among great leaders (Owen 2005). The same inconsistencies exist when considering styles of leadership. Where consensus does exist it is around a collection of behaviours that together can create a leader; these include honesty and integrity, the ability to motivate others, vision, decisiveness, confidence and intuition. In short, leadership is the ability to influence others without threat or coercion (Huczynski & Buchanan 2003).

In healthcare, the profile and priority given to effective leadership has grown slowly, but its importance continues to increase, along with the evidence base showing how powerful effective leadership can be (Young-Ritchie et al. 2010). Effective leadership should not be confused with good management; the two often co-exist, but can also come from two different sources, as the behaviours demonstrated by leaders are not absolutely necessary for effective management.

Management can be seen as the organizational and technical tasks that have to be achieved in order to ensure the fluid delivery of services. Management is head-driven, rational and pragmatic. Leadership can be seen as the inspiration of others, the skills employed, often subtly, to galvanize a group of staff to commit to deliver a quality service. Leadership is heart-driven, emotive and enthusing. The most effective environments have both, and both leaders and managers are most effective when able to use a range of behaviours and skill from each domain, depending on circumstances.

Clinical leadership

Leadership skills are essential in any clinical environment, and the nature of Emergency Department (ED) work is such that priorities and pace can change dramatically over a very short period, with a potential for staff to feel threatened by the perceived chaos. To maintain a safe, effective service to patients the clinical leader needs to foster an environment where care delivery has some structure, staff have guidance and security, therefore trust can develop (Jonas et al. 2011). These rapidly changing high-pressured clinical areas are the environments where leadership and management are mostly likely to intertwine. It is not uncommon for the management role to become dominant, resulting in both perceived leaders and their clinical staff feeling disempowered and demoralized with their work. For clinical leadership to be successful, and not just clinical management, an overarching environment where individuals feel empowered and able to develop relies on access to information, power, opportunity and resources (Upenieks 2003). It is only when individuals feel empowered that they can truly lead change, take risks and create the innovation needed to develop clinical care.

The challenge for those leading care on a day-to-day basis in emergency care environments can seem daunting alongside the practical tasks of managing the workload, but often what is required is conscious application of principles used every day. Stanley (2006) discusses the value of congruent leadership as a basis for developing clinical care and describes clinical leaders as individuals who are experts in their field, positive clinical role models and good communicators. They are followed because they can translate what they believe about nursing into good clinical care. This is in fact a simple phenomenon; congruent leaders are successful because their values and beliefs and their actions match up; as a result they are credible.

Effective clinical leaders can adapt congruence theory to enhance their current practice. It creates a bridge between the necessary management role and the desired leadership role. The most important component in creating congruence is passion; this comes from trusting, valuing and believing in what you are doing (Thompson 2000).

Congruent leadership can be summed up as leading from the heart, trusting your instincts, and valuing your knowledge and beliefs (Box 36.1).

Step 1: how you feel It is no accident this is step one, and in the clinical environment nurses do this all the time; they get a feel for when a patient is ‘going off’ or when they should be wary or feel threatened by some patients and not others displaying similar behaviour. This can be explained as intuition, sixth sense, or tacit or expert knowledge (Benner 1984, Benner et al. 2009). The key is to trust these feelings and act in congruence with them; they are based on both experience and intrinsic beliefs. Leadership behaviour will appear natural and confident, fostering trust and motivation to comply, as opposed to ignoring ‘feelings’, which can have the reverse effect on leadership behaviour, leaving the leader and the followers feeling anxious and lacking in confidence.

Step 2: walk the talk This is about personal congruence, the leader’s values and purpose, but most of all their ability to take responsibility for their own thoughts, behaviours and actions, whatever the outcome. So when things do not go to plan, for example, blood results get lost, the leader takes responsibility for the appropriate delegation of that task, discusses the incident with those involved, and does not just pass on blame but follows through with any necessary action to prevent a repeat.

Step 3: constantly interact Most information in the clinical environment is gained through face-to-face interaction and observation; a leader remote from this cannot lead with passion and congruence. It is also worth remembering that individuals’ experiences are different, and therefore their understanding and interpretation of situations may be different too. Interaction ensures the leader understands the reality for others in the clinical area they are leading.

Step 4: build trust This comes from demonstrated consistency in the leader’s behaviour, from equity towards all staff and integrity. Being a role model in the clinical area helps to build trust.

Step 5: lead by example Again the leader’s behaviour determines their success; the role should be carried out with passion, purpose and commitment, instilling confidence and enhancing motivation in followers.

Step 6: resolve conflict Conflict should not be left to fester, it grows and poisons. Most clinical teams rely heavily on each other to be effective, therefore the leader needs to step in and address conflict rapidly even when it is uncomfortable to do so.

Step 7: select followers A clinical team is no different to any other team, it needs complementary skills and differing personalities to work, so when selecting new members consideration should be given to what the team needs rather than selecting those in the leader’s mould. People with genuine passion for their role usually have a natural energy which spills into the team. They are worth looking out for even if they do not yet have all the skills needed.

Garbett (1995) described leaders as people who have a vision; they make things happen, and at the same time they strengthen and support their followers, inspiring them to trust the leader. These appear to be the core qualities needed to lead the clinical team in ED.