Theories of Leadership in Healthcare Settings

INTRODUCTION

Leadership

Defining leadership is a complex task, while many scholars and intellectuals have given meaning to this word, still people find another connotation or gives more meaning to it as time goes by. In the book Leadership Theory and Practice written by Peter Northouse, he defines ‘Leadership as a process whereby an individual influences a group of individuals to achieve a common goal’ (Northouse, 2016). Leadership has four main components: (1) it is a process, (2) involves influence, (3) transpires in groups and (4) includes shared goals. It involves not only the leader but also its members as active participants in the process and must be accessible to everyone. Leadership involves influence rather than coercion and takes the group, not just the leader but also the members by persuading the whole organization to realize their mutual purpose or goals. Though many leadership theories and models have been developed overtime, the concept of leadership is relatively new in Healthcare sector and since most of leadership theories were based on business setting, an intellectual adaptation of these theories must be critically chosen to be effective in healthcare. Healthcare is not the same as running a business that manufactures products, it involves human beings and the complexities in dealing and treating them individually. One may improve the techniques, practices and even the system but might lose the whole purpose of healthcare. Healthcare leadership looks into the complex components of the organization such as the multidisciplinary staff, various departments and different medical professionals and give them support so that they will go in harmony and move as a whole towards the wellbeing of the patients (LG Bolman, 2003). Leadership in healthcare focus on the connection with patients and quality which also may be referred to as clinical leadership. Clinical leadership focuses on enabling evidence-based practice and delivering patient outcomes. This assignment will examine some of the leadership theories that may be applied to healthcare setting and how they can help in combating the challenges that arises.

LEADERSHIP CHALLENGES IN HEALTHCARE ORGANIZATIONS

• Challenge of Multicultural and Diversity 

People
are becoming more interconnected as what can we observed in schools and
organisations, communities are far more global because of globalisation or the interdependence among nations, which started
during the World War II. The challenges that globalisation brings does not
exempt leadership as a function. Today, leaders has to faced many challenges
like understanding cultural difference, what leadership style to use for a
multinational organisation and how to lead a culturally diverse group. Leading
a multicultural organisation takes into account an approach that must cater
various cultures such as Asian, American, African, European and Middle Eastern
or can also be by race, ethnicity, gender and age. It must also address
diversity or the existence of different cultures or ethnicities within the
organisation. In healthcare setting it is a challenge for leadership because
one must understand, accept and value people’s differences, avoid ethnocentrism
(tendency for the individual to give priority to their own group above others) and
prejudice (largely fixed belief towards an individual). Take for example in a
big hospital, it’s hard for an Asian leader to lead an American nurse because
one may think that the other is superior in terms of ethnicity. According to a
recent research, the fast-changing demography and economies of our growing
multicultural world and the long-standing disparities in the health status of
people from culturally diverse backgrounds have challenged healthcare providers
and organizations to consider cultural diversity as a priority (Bacote, 2003).

• Challenge of Education & Leadership
  Development

When
a leader leaves, the organisation will be in chaos if there is only one person
who knows how to lead. In the environment where there is only one who decides
on everything for everyone and no space or chance for others to contribute in
the decision-making because they are not trained to do so, like in the UK, they
see the need for current development on leadership programmes in the NHS that gives
priority to the distributed nature of leadership instead of individualistic
approach which has become obsolete this time. There is a need to provide
training and education to more individuals in every level so that many will
have the skills and competencies that they might use when the situation calls
for it (Fulop and Day, 2010). Healthcare
organisations should also provide training for their staff so that they will be
skilled and competent to deliver care. Leadership development and education
must start from the pre-registration period of the individuals or when they are
still students, that they must fully understand their professional boundaries
and must be practice-based rather than just theoretical in nature and will not
stop there but will be an essential continuation when they are already
practicing the profession. Healthcare is a complex environment that require a
set of skills and knowledge too broad to be possessed by any one individual
that makes the stress level of leadership too high.

• Challenge of High Turnover of Staff

With
the growing demand for providing excellent healthcare delivery, healthcare
providers are faced with many challenges, high turnover rates of staff is one
of these especially nurses. Nursing is a very demanding profession and when
they are not lead effectively may result to burnout and attrition. Healthcare
organisations sometimes ask too highly from nurses but neglect them and don’t
give such importance to them and don’t see their value in the organisation.
Staff nurses may feel dissatisfied and may feel toxic that would lead to a poor
performance or poor quality in their care delivery to patients, in turn
patients are also affected. According to a study conducted, an estimated 30-50%
of fresh graduate nurses, decide on either to change positions or leave nursing
totally within their first three years of clinical practice. When nurses leave,
the overall patient quality care is affected because of the loss of expertise
and it will be costly for the organisation to loose expert nurses (Belsky, 2016).

• Challenge of Bullying in the Organisation

Workplace
bullying among healthcare workers has become a persistent phenomenon. According
to Rowell, today, bullying in the workplace has predominantly increased and is
four times more rampant in the health and community care sectors than issues on
sexual harassment (Rowell, 2005). Both nurses and physicians are
occasionally victims of hostility in the workplace. Bullying can be define by
its social manifestations, such as aggressive behaviour (e.g. intimidation, harassment, victimization, aggression, emotional
abuse, and psychological harassment or mistreatment) that mainly occurs in
interpersonal interactions in the workplace. On the same note, the intention,
frequency, duration, apparent imbalance and misuse of power between the
perpetrator and target, inadequate support, and the inability of the target to
defend himself from such aggression, as well as having to cope with negative
and constant social interactions, physical or verbal harassing, insulting comments,
and intense pressure must be take into consideration when we speak of bullying.
The impact of bullying does not only affects the victim’s health and but also
the morale in the workplace which in turn affects the organisation’s productivity
as a whole. Like when a new nurse started his first day in the hospital, he has
this ideal perception of clinical setting but he will realize that he has to adapt
the kind of clinical set-up that is already going on and if he will not abide
by it, he will encounter difficulties with the senior staff.

• Challenge of Role Ambiguity  and Work Overload

According
to a research done in Australia (Chang and Hancock, 2003), a new nursing
graduate first few months in the profession are the most challenging and most
stressful. Role ambiguity was the most prominent part of role stress in the
first few months, while role overload was prevalent source of stress after 10
months. Role ambiguity occurs
when professionals are unclear or uncertain about a certain role in their workplace, it arises when the definition of
the job is vague or not clearly define. While role overload is a situation in
which there is no enough time in which to carry out all of the projected role
functions. This challenges arise when leaders do not effectively delegate task
to the staff. For example, in a ward, new nurses will mostly be doing most of
the jobs to the extent that they don’t have enough time even for a quick break
while their seniors are chatting and their alibi is that they want the newbies
to learn the hard way so they will be better in the future but sometimes it’s
too much.

LEADERSHIP THEORIES AND MODELS     

• Cultural Leadership

Learned
beliefs, rules, values, symbols, norms, and traditions that are mutual to a
group of people is called culture and it is dynamic in nature. It is these
shared collective qualities that make them distinct from others. In short,
culture is the way of life, customs, and script of a group of people (Gudykunst, Ting-Toomey, 1988). Due to globalisation,
the world became flat and most of the time, it is evident that we can see many
cultures mixed together in one organization especially in multinational
companies and also in healthcare settings, so understanding different cultures
are needed for the leaders to be able to be effective in leading. Cultural
leadership requires three interactive components such as cognitive, motivational,
and behavioural or the capability to generate actions needed. This type of
leadership style needs the understanding of one’s own cultural biases and
preferences, which is the first step to understand that individuals in other
cultures might also have different preferences, just like everyone else.

In
a hospital where nurses are composed of different ethnicities, it is best that
a leader must have a clear understanding of their diverse cultures in order to
lead the organisation because different cultures have different ideas about
what they want from their leaders. This will help the leaders in communicating
effectively across geographical and cultural boundaries. This leadership style
can address the challenge of multicultural
and diversity, by having an essential understanding on cultural
differences, leaders can become more empathic and accurate in their
communications with others that have different cultures. Information on culture
and leadership has also been applied in very practical ways like designing new
employee orientation programs, conduct programs in relocation training, and
improve global team effectiveness. These examples clearly indicate the wide
range of applications for research on culture and leadership in the workplace. Integration
of skills in culturally competent care meets six aims for healthcare excellence
that is safe, effective, patient-centred, timely, efficient and equitable that
all care providers truly understand the patient individually while taking into
account cultural knowledge, differences and preferences.

• Transformational Leadership

James
McGregor Burns, a political sociologist tried to see the relationship between
the roles of leadership and followership in order to better achieve their goals
and it’s not about power after all. Transformational is different and better than
that of transactional leadership because the latter focuses on an exchange
dimension wherein the followers will be rewarded if they will do this and that,
like when a tutor gives high mark for students after completing a good
assignment. On the other hand, transformational leadership is a practice
wherein a person take part with others and creates connection that nurtures the
level of motivation and morality in both the leader and the members (Northouse, 2016). Transformational
leader not only focuses on making today better but also the future. They have a
clear vision that is well-communicated with all the members and at the same
time inspires them to achieve their goals through their integrity and authentic
commitment to the mission and not for their personal gratification. They also
exhibits an advanced mind-set by investing time and effort to attain personal
and professional development together as an organization. Creativity is also
encourage to develop new ideas through allowing measured risks to build a
culture of innovation and continuous transformation for the better. Transformational
leaders are vision driven and must be a shared one to be truly effective.

In healthcare setting, transformational leadership has been mainly positive in the organization’s driving force for progressive change (Manley, 2000) and also for developing and empowering the team (Thyer, 2003). This leadership style enhances nurses’ creativity to bring about meaningful change. An example of this is the creation of clinical nursing consultants in the UK’s National Health Service. It supports the role of expert nurses as clinical leaders that will improve the quality of service and being more responsive and it also solves the shortages in junior doctors. It guarantees that nurses with the highest levels of clinical skills and practice will be at the forefront to the delivery of care. This ensures that the nurse consultants, as the leaders will have a great influence in care delivery strategies and spent most of their time in clinical environment. A concrete example of this, was the creation of Older Person’s Outreach and Support Team (OPOST) – a core team consisting of consultant nurse, senior elderly care nurses, senior elderly care occupational therapist, and superintendent physiotherapist, social worker, audit facilitator and team administrator, to improve the older people’s care management in an acute settings and the model of choice is transformational leadership. Everyone was articulated by the team’s vision and captures their hearts and minds about their objectives as a team and their specific roles in the group to avoid role ambiguity and to achieve their commitment in developing services for older people. Everyone is encourage to do what they seem beneficial to the client but taking full responsibility as well. It significantly reduces the length of confinement associated with complications by working and collaborating with the staff.

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Like
that of the OPOST setting, the core team members belong to different specialty
fields so when they go back to their professional groups they were treated as
outsiders and they are experiencing confidence crisis. Transformational Leadership
comes in when dealing with the challenges
in diversity, where leaders must motivate, inspire and remind the team the
importance of their role and what they are doing. After 9 months, team members
saw their achievements in the project and counted them as positive experiences
that will help the organisation change for the better and ultimately for the benefit
of the patients.

• CLINLAP and LEADLAP Model

Clinical Nursing Leadership Learning and
Action Process Model (CLINLAP)
is specifically used for nursing and midwifery or known as Leadership Learning and Action Process Model (LEADLAP) in a more
general perspective is a result of a 15-month Action Science Research Project
designed to specify the set of attitudes, skills and knowledge needed for the
46 District Nurse Team Leaders (DNTLs) to carry out their roles efficiently and
ways how to develop such characteristics (Jumaa, 1997).
The research outlined the core problems that clinical teams face are generally
circling around the goals, roles, processes and relationships and the viable
solutions would be having specified and agreed goals, explicit roles which
avoids ambiguity or confusion, clear processes and an environment that encourages
open relationships, be present in the education of health and social care, in
research, in practice and also in clinical environments (Moxon, 1993).
The Modernisation Agency (in the UK) launched in 2001, positively recognized
the roles of the professions and healthcare managers, specifically nurses, to
manage the organization and healthcare delivery more effectively and
efficiently according to the framework of clinical governance which has 3
aspects: setting quality standards, delivering quality standards and monitoring
quality standards (Department of Health, 1998).

In
a complex environment setting, as that of healthcare with many uncertainties
and dilemma which are present in a day to day occurrence, knowledge and
experience is the competitive advantage of the team so they need to educate and
update the skills of the whole organization and overcome the challenges of education and leadership
development in the long-run. The CLINLAP model as a whole is a “strategic clinical leadership process that
positions strategic learning as a force that drives the health and social care
organisations on a day to day basis, in the management of clinical nursing
goals; nursing roles; nursing processes; and nursing relationships (Jumaa, M.O. and Alleyne, J., 1998).” CLINLAP model
addresses the issue on role ambiguity
and work overload since this provides a clear strategy and specified goals
and how to deliver quality care to patients. Each member has explicit roles in
the group and they know the clinical process that needs to be followed in a
certain clinical scenario. It also encourages up to date education and training
for their staff to be highly competitive in practice.

Other Contemporary Models/Theories

• Servant
  Leadership

It
is an approach that focuses on the leader’s point of view of leadership and his
behaviours. Its emphasis is on the leader’s attentiveness to his followers’
concerns, showing empathy and nurturing the group. Followers’ always come first
and servant leaders must empower them so they will develop their full
potentials as individuals. And also, these leaders are considered ethical, who
serve in ways that seek the greater good of the organisation and the society as
a whole. To summarize this model, one can remember the 3 components that
consists servant leadership these are antecedent conditions, servant leader
behaviours, and outcomes. The primary focus of the model is on the 7
behaviours, servant leaders must have (conceptualizing,
emotional healing, putting followers first, helping followers grow and succeed,
behaving ethically, empowering, and creating value for the community) that
mainly influenced by one’s context and cultures, the leader’s attributes, and
the followers receptivity to servant leadership style. Improvement at
individual, organisational and societal levels will be observed if individuals
will take part in servant leadership. It is similar to transformational and
authentic leadership at some point but altruism at its centrality makes it
unique.

Others
argued that servant leadership may be the best model for a healthcare setting
for the reason that the team’s strength, trust development and serving the
needs of others are its main focused as a model. Servant leaders help people
develop individuals and let them flourish to attain their full potential as a
person and as a professional. This kind of leadership show genuine concern for
others and put their interests first. A
high turnover of staff which is a major threat in healthcare organisations
is a result of staff burnout in their jobs and servant leadership style may
help in facing this challenge. A significant study showed that this kind of
leadership promotes psychological well-being of nurses because it can decrease
emotional exhaustion thus improving job performance and satisfaction that
decreases their intention to leave the organisation. Treating nurses as humans
with emotions and the tendency to be exhausted as well, is an important aspect
that servant leaders can address because they do not only care professionally
but also for the personal well-being of their followers. They support followers
to overcome their personal problems so their job will not be affected, they want
their followers to be whole so that they can build a community or a place when
everyone feel safe, valued and connected with others but are also encouraged to
express their individuality.

• Shared
  or Distributed Leadership

Shared
leadership is when members of the team assume leadership behaviours to
influence the team and to take full advantage of its effectiveness. Members
know when to step forward when situations arise, providing necessary
leadership, and then step back to let other members lead. This kind of
leadership has becoming important in different organisations today to allow
faster responses to complex issues. Also, team leaders make sure they delegate
sufficient autonomy and responsibility to all members of the team, involve them
in decision-making, and encourage to self-manage its performance to the extent
possible.

Healthcare
organizations have responded to the need for new leadership styles, and shared
leadership is one that can improve outcomes because it is highly practical in
this environment, as the nature of the healthcare environment requires much
collaboration (Merkens & Spencer, 1998). According to a
study (Konu & Viitanen, 2008), patient care
quality mostly depends on how well a group of diverse medical and administrative
experts work together and shared leadership can create uniform decision-making
and define responsibilities but it must be an ongoing process that requires
continuous assessment and evaluation in order to be responsive to the ever-changing
healthcare environment. A study showed that nonmedical staff favoured shared
leadership than clinicians, but both groups were generally satisfied with the
shared leadership model, according to them it seems to provide nurse
empowerment and promotes good nurse-physician relationships (Steinert, Goebel & Rieger, 2006). Shared leadership
may give a solution for education and
leadership development challenge since one of its benefits is that it
promotes an inclusive decision-making process and emphasize on participative
styles of leadership, where members take on leadership tasks for which they are
good at and where they are most motivated in accomplishing, thus gives the
organisation the luxury of wealth of talent of all the members. Take for
example a group of doctors, shared leadership enhances doctors’ engagement in
the decision-making process and add to the improvement of cost-effective
systems of delivery and are likely to be important drivers in the process of implementing
policy reforms at local level such as services redesigning and resources
shifting from acute to primary care.

• Emotional Intelligence

In
the 20^th century, intelligence quotient (IQ) which measures one’s
cognitive ability and intellect became the gold standard to test one’s ability
but many argued that IQ is not the sole basis to gauge one’s capability because
there’s the existence of many types of intelligence. Thus, emotional
intelligence come to being. It is the combination of abilities in personal,
emotional and social aspects that influence a person’s ability to become
successful in coping with the demands and pressures of his environment (Reuven, 1992). Let us look at the
five-competency model of emotional intelligence according to Goleman’s
description that includes: (1) self-awareness:
understanding your emotions that will guide you confidently in decision-making,
(2) self-regulation: handling
emotions well that it will not interfere with work and be able to recover from
emotional distress, (3) motivation:
perseverance even in times of frustrations, (4) empathy: can sense another’s feelings and understand people that
cultivates rapport despite diversity, and (5) social skills: smooth interaction that comes from negotiating
differences.

In
any organisation, challenges of bullying
in any form may take place, thus having EI, prepares an individual on how to process
and handles such conditions. It will help the person to cope with these
ill-behaviours around him and how to address such so that it will not affect
his personal life and also his job. A person with EI knows how to negotiate
differences in a win to win situation. If for example, a senior nurse is mean
to her junior nurse, the junior must show her skills to her senior in a way
that the former will see that the latter knows what she is doing and will not
be intimidated by her but will use this scenario to prove her value and worth
in the organisation. One must persevere in trying times and not just give up
because there is challenges everywhere, it just depends on how you handle it.

CONCLUSION

Leadership
still is a word that is hard to give a specific meaning that is why the search
and research about this topic is still on-going especially in healthcare
environment because leadership is essential to transform and in pursuing
excellence in the delivery of care. With the many books, journals, research
paper and other sources I have read, an individual that assumes leadership in
healthcare must have the personal qualities, may be innate or acquired through
time that aids the person to lead and set the direction for the organisation in
order to deliver care in an excellent way. The heart of all healthcare
organisations is the patient, giving them the highest quality care possible and
an effective leadership is fundamental in meeting that ultimate goal. There are
many models and theories about leadership but the choice of style depends on
the organisation and the leaders because what may be effective to one, may not
be effective to the other. Though there is no gold standard for leadership
style in healthcare, for me, transformational leadership stands out. Its
assumptions are very ideal but it is in application that it became difficult.
Many have tried, but many also failed because leadership, just like in this
literature cannot stand alone by the presence of the leader but also with the
support and cooperation of the members. Change is something that must be
mutually wanted to be attainable but there will always be a reluctant to
change, so the challenge still lies on the leader on how to inspire and motivate
the whole organisations so they can all attain the change they want and need
for the organisation. The most important for leadership is trust, a leader must
have trust in himself and his abilities, trust with his followers, trust with
their shared vision or goal. For the healthcare sector, whatever leadership
style you will select for your organisation, may it be servant,
transformational, cultural, CLINLAP or shared leadership, the success lies
within the leader and his followers because there is no perfect theories or
model, it’s the people who wants to make it work, succeeds.

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