Leadership Styles in Clinical Management

Our discussion will revolve around two forms of leadership patterns - mainly the transactional and the transformational styles of leadership. The differences between transactional and transformational leadership styles were first given by Weber (1947, in Turner, 1998) who suggested that transactional leadership is based on control on the basis of knowledge and hierarchical power and transactional leaders aim to negotiate and bargain to achieve higher efficiency. In case of transformational leadership, the leader is a charismatic personality who seeks to change or transform ordinary people with his qualities and seeks to change ways of thinking by using novel ideas within the organisation.

Hendel et al(2005)examined the relationship between leadership styles and the choice of strategy in conflict management among nurse managers. The study identified conflict mode choices of head nurses in general hospitals as nurses deal with conflicts on a daily basis and have to implement effective choice of conflict management mode to deal with the complicated situations. The authors point out that the choice of conflict management mode is largely associated with managerial effectiveness of the nurses. It is largely understood that the ability to manage conflict situations creatively to result in constructive and effective outcomes is a standard requirement in nursing practice.

The most common conflict management strategy was an emphasis on compromise and more than half of the nurses studied admitted to using only one mode of conflict management. Transformational leadership was found to be more popular and widely used than transactional style of leadership and the style of leadership also affected the conflict strategy selected. In case of mental health and psychiatric patients, conflict management and management of violent behaviours in patients are the major challenges. Thus the study mainly argued that conflict handling mode in head nurses is largely associated with the style of leadership and the overall conflict management approach that was based on compromise.

The role of personality in transactional and transformational leadership has been examined by Bono and Judge (2004). Their study was based on meta-analysis of the relationship between personality and ratings on transformational and transactional leadership behaviours. The five factor model was used in the study and personality traits were related to 3 dimensions of transformational leadership namely idealized influence-inspirational motivation or charisma, intellectual stimulation, and individualised consideration and also to the 3 dimensions of transactional leadership namely contingent reward, management by exception-active and passive leadership. Extraversion as a major personality trait has been found to be the most consistent

correlate of transformational leadership and even charisma was closely related to this style of leadership. Leadership styles also affect performance and not just personality patterns and behaviours. The overall performance of a unit has been critically examined by Bass et al (2003) assessing both transformational and transactional leadership styles. The authors ask how leadership styles and ratings from operating units can predict the subsequent performance of these units that operate under high stress and even considerable uncertainty. In this study, the predictive relationships for transformational and transactional leadership styles for ratings of unit potency, cohesion and performance levels were calculated. The results indicated that both the leadership styles positively predicted unit performance suggesting that transactional and transformational styles of leadership may be both effective for improving performance of an entire nursing or clinical unit

Conclusion:In this study we discussed various approaches to transformational and transactional leadership styles and behaviours and in the course of the discussion we showed the different views and perceptions on leadership styles. In general most of the studies discussed here suggest that transformational leadership is preferred and is the more positive form of leadership as it emphasises on individual power and charisma to change the surroundings and the situation. Transactional leadership on the other hand is comparatively easier form of leadership as it is not dependent on any unique personality pattern but is largely dependent on how an individual uses the situations to bring out efficient and positive consequences. However as Bono's studies suggest both the leadership styles may be equally related to personality patterns with openness and agreeableness being important traits of a transformational leader. Most studies discussed here seems to point out that leadership styles are closely related to change management, quality of care, work relations, job satisfaction and overall nursing practice. This is also true in all other areas and services, including mental health wards where violence management of patients is a major challenge for head nurses. There are however few exceptional studies examined here that seem to argue that organisational effectiveness have little, no or uncertain relationship with leadership styles.

 

Nursing Leadership Theories:

Quantum, Transformational, and Dynamic Leader-Follower Relationship Model

While there are several theories of nursing leadership, it’s important to review those most applicable to the new nurse. The three theories that can be best practiced as a new nurse are quantum leadership, transformational leadership and the dynamic leader-follower relationship model. These three theories are appealing specifically for their embrace of leadership at all levels. Five years ago Porter-O’Grady (1997) observed, "Leaders issue from a number of places in the system and play as divergent a role as their places in the system require" (p. 18). Porter-O’Grady (1997, 1999) opened up a new process of thinking about leadership by noting how the changing healthcare system required new leadership characteristics and roles. He observed that knowledge of technology has changed the traditional hierarchy of leadership. Traditionally, worker knowledge rose vertically as the worker moved up the chain of command. Typically, knowledge bases increase as position increases. Now leadership and the knowledge associated with it has shifted. As new nurses enter the profession with ever expanding skills, "Technology has made possible this growth in the horizontal connections…" (Porter-O’Grady, 1997, p. 17). Staff nurses at the bedside 24 hours a day, seven days a week are on the front lines and have a distinct power to influence sustainable outcomes and productivity. They are, in fact, at the first level of decision-making. By permitting some autonomy in their decision-making however slight, we lay the foundation of leadership. New nurses decide appropriate times to call a physician, choose applicable care plans and pertinent interventions. These early autonomous steps form the building blocks of leadership. We can effectively train nurses in this manner by evaluating their decisions with corresponding patient outcomes. To motivate leadership from the bottom up, mangers can "develop staff self-direction rather than giving direction" (Porter-O’Grady, 1999, p. 41). Again, these simple steps facilitate new nurses’ enhancement of their own leadership skills.

Transformational leadership merges ideals of leaders and followers (Sullivan & Decker, 2001). Its focus is to unite both manager and employee to pursue a greater good and "encourages others to exercise leadership"(p. 57). Transformational leadership can readily pertain to situations common among new nurses. Sofarelli & Brown (1998) favor the transformational leadership style and find it empowering. Transformational leadership promotes change and suites the extremely dynamic health care system. Its focus on change can be directly applicable to nursing. New nurses are in a unique position of evaluating end results of both new and old policies and procedures. Using transformational leadership, managers can motivate new nurses to submit feedback on how well unit specific procedures are carried out and implemented. The key is to actively listen and institute pertinent suggestions that not only promote client outcomes,

but also again help to build a base of leadership with the new nurse. Not everyone can take direct action on issues directing affecting patient care by sitting in on an advisory meeting or voting on proposed legislation. Transformational leadership provides new nurses with a method of taking an active and participatory role in policy within a new nurse’s jurisdiction and power.

A third nursing leadership theory that can be readily used by new nurses is modeled after Ida J. Orlando’s nursing model. Orlando’s middle-range theory concentrates on the process nurses’ use to identify a patient’s distress and immediate needs. It specifically draws on cues in the interpersonal process to reach those objectives. Using Orlando’s theory as a backdrop, Laurent (2000) proposes a dynamic leader-follower relationship model. The theory is that the leader and follower exchanges are dynamic. Both parties are vital to the success of the unit. "The leader provides direction to the employee, not control, allowing for maximum participation by the employee or a dynamic relationship" (Laurent, 2000, p.87). This type of interaction between manager and new nurse can instill motivation and commitment. At the time new nurses are finding their niche, they can simultaneously develop basic leadership principles facilitated by interaction with established nursing leaders.

Clinical and Leadership Proficiency

Central to the theme of new nurses as leaders is the fact that effective leaders are also proficient clinically. New nurses can incorporate leadership fundamentals while developing competency in their profession. However, not all authors subscribe to the notion that clinical proficiency and leadership are congruous. In exploring the Synergy model Kerfoot (2001) contends, "A leader cannot provide direct care. The leaders obligation is to create the environment in which good people can provide good care" (p. 101). Many leadership studies and professional opinions, including mine, disagree. In fact in the United Kingdom, a "lack of consensus on nursing leadership has led to leadership development programmes [sic] for nurses which have emphasized the development of corporate and political skills, often to the detriment of nursing knowledge" (Antrobus & Kitson, 1999, p.751).

Naturally, some will relinquish the title of leader and would rather follow. That is necessary for the system to operate. Leaders in the lower rungs have less responsibility, but still can act as a leader. This is leadership in training. Leadership within the confines of their position or authority. The fact is that while new nurses provide the majority of care and spend the majority of time with a patient, they are clearly not at the same power-level/structure as physicians or administrators. Few new nurses have input on major decisions affecting an organization. What new nurses can do is propose improvements to the existing status quo. They can submit new scheduling options, take the lead in presenting in service training or consult on retention and recruitment issues.

USING NURSING HISTORY TO EDUCATE FOR LEADERSHIP

SANDRA B, LEWENSON

In 1934 the comitte on the Grading of Nursing Schools recommended in its final report to nursing educators, “it is important that all student admitted to school of nursing in the future be of a professional type, capable of leadership. The expectation that nursing would assume leadership roles meant that professional preparation include the skills necessary for the student to become nurses and for all nurses to become a leader.

It provides insight into leadership principle and skills only when we seek to learn these lessons. Today nursing history is integrated in the nursing curricula. For the most part, students and faculty have a smattering of knowledge of the historical antecedents to nursing practice, education and research. Lack of substantive knowledge about nursing history often leads educators and practioners to ignore the study of how leaders in the past dealt with the issues they faced or the strategies they used while building the profession. By studying the leadership strategies of the pioneers of the profession, students and practicing nurses can begin to understand the skills required to make change and to reflect on nursing history.