This paper will provide an analysis of leadership and its importance in the provision of healthcare. Key leadership issues related to the individual, healthcare teams, and health services will be discussed along with their overall impact on individuals and health services. This analysis will be supported by personal experience and contemporary leadership theory as a means of demonstrating alignment with the overall analysis.
Leadership has long been identified as a relationship between those who desire leadership roles and those who choose to follow, both being required for effective leadership to occur, with its role across all health systems considered crucial. The ability to influence and motivate individuals or groups to agree on what needs to be done and the approach required to achieve it is a fundamental aspect of good leadership. With health systems being large and complex organizations that undergo relentless change across a variety of mediums and health service levels, constant evolution to adjust to epidemiological, demographic, and societal changes is required. Over the coming years, the healthcare system in Australia is set to face numerous complex and interrelated challenges in providing high-quality, cost-effective care in the future. Some of these challenges include constantly changing systems, an aging population worsened by chronic disease, increasing healthcare costs, technological advances, and the need to improve access and equity to healthcare services. Additionally, the political, economic, social, and environmental demands go on to create complexities on a global scale with the current workforce worldwide consisting of mixed generations and varying attitudes, beliefs, work ethics, and expectations.
On all levels, including local, state, national, and international, barriers exist, which impede effective leadership. The ACN (2015) identifies the importance of maintaining nurse leadership positions at appropriate levels within an organization and organizations supporting the nurse unit manager, middle management, and the executive leadership team to maintain influence and visibility. It is considered imperative that health leadership is central to the identification of priorities, whilst providing strategic direction within the health system and working to create commitment across the sector as a means to addressing priorities for improvement to be made. Additionally, building skilled and capable workforces, including responding to skill shortages in key areas such as physicians, nursing, and allied health and keeping up with salary increases, further heightened barriers to effective leadership. Flexibility and enthusiasm are required to ensure successful leadership.
With nursing recognized as a dynamic and challenging profession within the healthcare system, leaders with engagement and inspiration are highly sought after to help guide its future trajectory, and they are needed now more than ever before. Such qualities will endeavor to influence and impact the quality of care, patient safety, and the development of effective and efficient systems (Roussel, 2019) in addition to care that is culturally sensitive and patient-centered. However, in today's ever-changing and demanding healthcare environment, identifying and developing nurse leaders continues to be one of the greatest challenges faced by the nursing profession.
The development of leadership has long been identified as an area requiring review to ensure the provision of high-quality, safe, cost-effective, and compassionate care. In today’s healthcare climate, leaders continue to face competing demands. For example, nurse unit managers consider a disparity between the authority they hold and their actual influence within an organization, potentially impacting their ability to effectively lead. Furthermore, Garling (2008, p.19), authored the Special Commission of Inquiry into Acute Care Services in NSW Public Hospitals, exemplifying the administrative burden placed upon nurse unit managers. It raised concern that more than half their time was spent on administrative tasks and non-clinical responsibilities, removing them from clinical leadership, mentoring, communicating within the team, and supervising patient care. Additionally, the Francis Report (2013) was commissioned by the NHS as a result of systemic failures. Here, it was identified that the priority of leadership within healthcare was imperative to positive patient outcomes and that without it patient care would be compromised. It further highlighted the contribution of leadership style, level of supervision, and communication methods to the overall importance allocated to patient safety. In my current role as a nurse unit manager of a small team of community nurses, I have been required to optimize time management to ensure a balance is maintained between clinical and administrative requirements. As such, I have also found significant benefits to ensuring I maintain regularity with performing clinical tasks both as an independent clinician, but also jointly within my team. This provides an opportunity for clinical supervision and mentoring to also occur whilst striving to model the way.
Significant pressure is placed upon nurse leaders to improve cost and the patient experience all whilst striving to achieve positive staff and patient outcomes. Healthcare leaders from around the world have formed multiple initiatives focusing on patients’ rights. Nowadays, the overarching term for this is patient experience, transitioning from patients’ rights to encompassing patient advocacy, patient satisfaction, and service excellence. Great lengths have been taken within my workplace from lower management up to executive level, in a bid to engage staff in patient feedback. The leadership style along with supervisor engagement and communication systems are now considered several of many organizational influences in determining the importance allocated to safety. Fostering leadership at every level creates a commitment to share a culture of safety with the patient remaining central to changes in care delivery, and also develops the capacity to develop future leaders.
Effective leadership is considered essential in minimizing bureaucracy and stimulating curious and creative thinking by modeling action and experimenting with innovative ways to achieve optimal outcomes. As a result of solution finding and implementation, healthcare systems require effective and collaborative leadership to ensure high-quality, cost-effective, and patient-centered healthcare, as positive leadership is applicable for both staff and patient development.
A multitude of essential skills are required for effective nursing leadership. Soloman (2017) identifies these skills as “complex problem solving, critical thinking, creativity, people management, coordinating with others, emotional intelligence, judgment and decision-making, service orientation, negotiation and cognitive flexibility”. To begin, leaders need to allocate resources such as time, attention, listening and feedback, look to remove potential barriers and work towards starting meaningful conversations, with quality remaining the goal for any healthcare leader. Since starting as a new manager only recently, I soon realized the importance of the above-mentioned. In particular, flexibility, negotiation, meaningful conversations, and feedback. It became clear, the nurses on my team were seeking autonomy and shared decision-making about service development and provision. I had seen this as a window of opportunity to embrace and promote positive workplace morale, critical thinking, and working towards limiting potential barriers.
Over time, leadership styles have constantly changed and evolved. Historically, autocratic and directive leadership were considered essential to ensure orders were made and followed. Despite resulting in less consultation and more rapid implementation, this form of leadership’s effect has become ineffective after misuse. In modern times, leaders need to be capable of being highly adaptive and collaborative with their colleagues to ensure goals are met, whilst shifting the lens away from the doing of the leader to being a leader.
Contemporary leadership includes four theories that align with current practice, including transactional, transformational, situational, and authentic leadership. Transactional leadership is a style whereby power and control are exerted in an effort to achieve behaviors from the followers, however, is not considered effective in meeting targets. This style provides a clear delineation between leaders and followers, whilst utilizing rewards and punishments as a means of motivating followers. Meanwhile, the transformational leadership style is becoming a global approach to healthcare delivery, demonstrating strong links to organizational commitment through the application of the ‘four I’s’ – idealized influence, inspirational motivation, intellectual stimulation, and individualized consideration. This style is proactive, portraying vision and influence whilst relying on key leadership traits including charisma, consideration, and inspiration, resulting in increased follower satisfaction and overall commitment to the organization. The literature relating to nursing leadership has recognized transformational leadership as the preferred style for leading nursing through a forever-changing healthcare climate.
Furthermore, situational leadership is broadly recognized with its key feature affording the leader the ability to modify their own style to meet the situation at hand. Here, the leader is required to model the way, with these actions stimulating enthusiasm in the followers.
Finally, authentic leadership focuses on behavior consistent with transparency, ethics, and the open sharing of information required to make decisions, in addition to accepting input from followers. It combines knowledge, self-concept, and self-regulation. This style of leadership is congruent with influencing workplace relationships and behaviors by role-modeling positive interactions and establishing policies on conduct within the workplace. Although a relatively new leadership theory, there have not yet been any significant criticisms that have arisen. Malila, Lunkka, and Suhonen (2018) identify that this style of leadership is often seen as superior, with international studies supporting multiple positive flow-on effects as a result of this style. However, further evaluations are required involving all disciplines within the healthcare system to better gauge its full impact across situations and cultures, in particular the quality of patient care and the work environment.
Additionally, Kouzes and Posner (2018) have identified the ‘five practices of exemplary leadership’, which are considered instrumental in engaging leaders and creating change within organizations and coincide with the above-mentioned styles. These include modeling the way, inspiring a shared vision, challenging the process, enabling others to act, and encouraging the heart. It is considered the leader’s role in modeling action and introducing innovative and creative ways to make improvements resulting in improved patient outcomes. Furthermore, this supports the notion that leadership is about behavior, not personality.
Leadership is recognized as fundamental in healthcare and considered crucial for its shaping into the future. The identification and development of effective leaders remains one of the greatest challenges worldwide. A focus on developing positive leaders will equip them with the right skill set to grow, with the ability to influence and achieve excellence in person-centered care, reduce costs, and motivate and inspire their team. To ensure the accomplishment of set objectives, leadership requires constant re-assessment. Over time, leadership theories have evolved, with greater emphasis now on role modeling and the leader leading the way, as opposed to a top-down, autocratic approach. In turn, collaborative and shared leadership is delivered, empowering and motivating individuals and teams to apply critical thinking and an innovative approach to ensuring optimal outcomes for staff, patients, and organizations.
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