8.1 Introduction

This chapter will explore the importance of values‐based approaches to nursing leadership. The relationship between professional values and approaches to leadership will be addressed and how this can influence others in areas such as role modelling and experience. How nursing leadership is perceived is introduced along with considerations for the importance of values‐based nursing leadership for power balance and social justice.

Nurses and professional healthcare practitioners align themselves to the professional values of their chosen profession and indeed, with regulation, comes the expectation and requirement that those values will be central to the decision‐making and actions carried out in their day‐to‐day practice. We know that when considering self‐leadership, student nurses look to mentors and role models and their experience of leadership can have an impact on how they view leadership (James et al. 2022). Bruner (1986) explains that in communities of practice where values, knowledge and cultures are shared, such as nursing, “critical events” or experiences which alter perceptions can have a profound impact. James (2020) explored “critical events,” experiences of leadership which impact individuals, both in a positive and negative way, and shape views of leadership. When a nurse leader demonstrates professional values in practice, as Stanley (2019) outlines in the development of the congruent leadership theory, it is clear that the attributes align to nursing principles such as treating everyone with dignity and respect and demonstrating integrity. However, it is also evident that instances of incivility and bullying are also an issue in nursing with studies suggesting it is 10–15% higher in nursing than in other occupations (Hunt and Marini 2012). Clearly these actions are not aligned to the professional values of nursing and pose a danger to less experienced nurses, in establishing incivility as an accepted practice on which to base professional behaviours.

Demonstrations of incivility and bullying have been linked to oppressed groups, lacking in self‐esteem and power (Roberts 2015; Mikaelian and Stanley 2016; James and Bennett 2022a). As individuals within such a group nurse leaders may also be susceptible to such behaviour, directing frustrations on their own peers. Therefore, within this chapter we consider what can be done to ensure leadership in nursing remains values based and to ensure incivility is not tolerated. When faced with challenges of power and conflict, how can leaders maintain professional integrity and ensure their actions and behaviours remain aligned.

8.2 Change and Values

Open your arms to change but don’t let go of your values.

Dalai Lama (2000)

We discussed in Chapter 5 how leaders can influence change and innovation. Here we deal with change on an individual level. As people develop and gain experience, they may change in their thinking and approach to things. That is perhaps a natural progression of our human development. Learning comes from errors and mistakes, from others (role models) and from gaining different experiences and learning. These are known as:

• tacit knowledge: gained from personal experience,
  
• explicit knowledge: knowledge which is documented, easy to share and write down, and
  
• implicit knowledge: application of explicit knowledge such as transferable skills.

All of these types of learning and development are important for nurse leaders to progress and develop. However, because of the complexities, hierarchies and cultural structures of healthcare organisations, the values and learning can be forgotten or swayed, which can result in failures of leadership (James and Bennett 2022b). Rather than empower colleagues and the profession, disempowerment and self‐destruction can be the result, causing damage to the fragility of nursing’s strength as a profession of integrity. When individual leaders lose sight of core values and become distracted or indeed perhaps feel powerless against more powerful influencers, cultures of negativity and neglect can flourish. When leadership fails to be values focused, human focused, transparent in its decision‐making, open to questioning and self‐reflective. Negative cultures and ultimately unsafe environments can emerge, as documented in recent examples in the United Kingdom, such as the Francis Report (2013) and more recently in the Ockenden Review (2022).

Kaiser (2017) found that behaviours of nursing leaders that resulted in adverse impacts on staff were:

• not encouraging staff to be involved in decision‐making,
  
• being distant and remote and lacking in relationship forming with staff,
  
• being controlling and authoritarian,
  
• not being visible and present in clinical areas and
  
• not encouraging staff to be involved in wider decisions.

Leaders who do not address incivility or allow competitiveness and adversarial attitudes do not address the issues of drift from professional values, and it is suggested that when staff perceive a lack of response and action to incivility, it can become the accepted and normalised behaviour (Clark et al. 2013). While we attribute leadership as being possible for all nurses, with no attachment to position or role, it must be acknowledged that in our healthcare systems, leadership can be associated with position and progression, or climbing the career ladder. In some situations, this results in distancing from clinical practice to a focus on management. This personal change can perhaps induce a feeling of remoteness from the clinical day‐to‐day professional challenges of providing quality patient care and move to complex management decision‐making of higher level and macro‐organisation needs. It is clear from the reports mentioned earlier, a constant reminder that the nature and principles of nursing are for the benefit of patients. So keeping professional values at the fore are a priority for nurse leaders whatever positional role they acquire and managing incivility and negative cultures are important to maintain these.

Kelly et al. (2023) in their study of Executive Nurse Directors (these are nurses who hold strategic‐ and operational‐level leadership in hospitals in the United Kingdom, other titles are used globally) found that while they are expected to be visible and present in clinical areas and to staff, some felt low self‐esteem and professionally vulnerable. Therefore, career progression to high‐level leadership and management roles can perhaps be distancing and challenging. Maintaining professional values and clearly communicating these to others means nurse leaders may thrive at any positional level and importantly set the culture and expectations of respect for patients and colleagues, transparency and openness of responsibility, being patient centred and knowledgeable, and demonstrating values‐based professionalism within their organisations.

8.3 Facing the Challenges and Balancing Power

Whether leaders are clinically positioned or at executive level, the relevance of power will often be of consequence as both politics and power are central to the provision and delivery of healthcare globally. Whether through national or local policy, nurses must be aware of and manage the influence of these forces as they can directly impact the allocation of resources, the effectiveness of provision and the equity of healthcare. Locally, we know that power balances inhabit our workplaces, our professions and our teams, and they can be positive and negative influences. Being aware of these can help navigate the challenging situations and decision‐making a nurse leader may be faced with and provide a broader view of what the issues really are (James and Bennett 2022a). It is helpful to know that there are different types of power sources which Yoder‐Wise (2015) explores and provides examples such as:

• Resource power – controlling of allocation of resources and budgets, promotion opportunities, reward and withholding reward.
  
• Information power – having access to information or knowledge and controlling the sharing or withholding.
  
• Expert power – from knowledge or expertise that has value.
  
• Coercive power – the generation of fear by threat.
  
• Charismatic power – the ability to be accepted by others and connection with others in authority.
  
• Legitimate power – having a titled position which provides authority.
  
• Reward power – the ability to grant awards or reward which is valued by others.

Being aware of these types of power enables us to realise it is not negative or indeed positive in itself, rather how it used and to what purpose. As a nurse leader it is possible to apply the use of power to great effect when the purpose and desired outcome is aligned to professional values.

Unfortunately, within large organisations, people may well feel powerlessness, or lack of control, over their work environment. Nurse leaders who wish others and their teams to thrive can enable feelings of power by engaging them in decision‐making, seeking out their opinions and views and acting on these in a demonstrative way, placing value on their insights (James and Bennett 2022a).

Nurse leaders are considered as influencing, whether it is about decisions about patient care or within a team discussion, or indeed wider. Using influence involves managing power, and how you apply this will depend on your values, on your professional approach, on your leadership approach and on your determination and conviction. It may be that you need to advocate for a patient, are involved in a discussion of resource priorities or are advocating for another member of staff. The way you apply your influencing power is something that takes time and experience to master, but being aware of where values feature in this is important. When values leave the equation, power can be used negatively or for pure personal gain.

Consider the following types of influencing styles (Stanley et al. 2023), and how you might apply these with your own approach to leadership while keeping your professional values at the centre:

• Assertive persuasion – influencing through the weight of your argument, a logical approach using reasoning.
  
• Reward and punishment – use of bargaining, incentivising and reward for compliance, while withdrawing these in an attempt to control, or as punishment for non‐compliance.
  
• Participation and trust – instilling trust through engagement, listening and transparency about own vulnerabilities.
  
• Common vision – agreeing on a collective vision for the future with clear communication and conviction to enable buy in from others.
  
• Common values – the leader may demonstrate their values through actions, associations with professions and symbolism. A congruent leader may align to this as actions convey their values base.