INTRODUCTION

Both the Australian and UK health care systems are increasingly being politically driven and led. Nurses have possibly been slow to realise the important role they have to play in leading health care provision and influencing the future. Perhaps nurses have also found it difficult to influence policy development. Much of this can be attributed to a weakness in nursing leadership at all levels (Pearson & Borbasi 1996). In this chapter we explore the idea of leading, motivating and supporting colleagues in nursing practice in a world of accelerated change. Faced with the current state of affairs in health care—high acuity and throughput, diverse skill mixes, diminishing budgets, limited resources and increasing consumer expectation—one could argue that the need for leading, motivating and supporting colleagues in a nurse’s professional life has never been greater. Indeed, it has been stated that ‘the activities of the professional nurse … have more to do with managing the delivery of care rather than actually providing that care’ (Norman 1997, p.4), and that if they are to succeed, twenty-first century registered nurses require unprecedented management and leadership skills (Cherry 2002, p.353; Jones & Cheek 2003).

We know that management is a different concept to leadership. Ideally, however, a good manager should be a good leader and vice versa (Cherry 2002). However, as many have no doubt experienced, this is not always the case. In this chapter we concentrate on the notion of leadership as opposed to management, because it is the leaders who have such a large influence in producing the culture within which management takes place, and it is the workplace environment/culture (the ‘system’) that so often makes or breaks success. We also explore the concept of constant change, bearing in mind the words of Mann (2002, p.68) who states, ‘[I]n a previous time drastic upheavals in the health care industry happened once a generation, what is different today is the speed of change’. Such pace then makes for an unstable environment.

Essentially we will explore where we are now and where we are headed in the short term, and look to the longer term future. Through leadership, motivation and support what we hope to achieve is increased voice and visibility for nursing. What do leadership, mentorship and support actually mean in a world of relentless change?

LEADERSHIP

Traditionally, leadership has been construed as the possession of a set of qualities that makes a person a leader, including the notion of providing direction with extreme daring under conditions of duress. It was thought that leaders were born to lead. Such ideas rest on behaviourist assumptions of leadership. Other mental models developed over the years include relationship and activity/task theories and the influence that leaders hold in transforming the actions of others (Ospina & Schall 2001). However, these theories are criticised because they are perceived as inappropriate to a twentyfirst century post-industrial society where different attributes in the workplace have become important. Sought-after qualities now include greater collaboration, common good, client orientation, pluralism in structures and participation, consensus-oriented policy-making, among others (Rost 1993). Newer theories on leadership focus on process. Increasingly there has been recognition of the need to develop leaders, and the tools to assist in that development have never been greater. There is an incredible amount of literature on the topic of leadership and, increasingly, mentorship. Numerous individuals and consortiums are putting themselves forward as leadership gurus. Life coaches are emerging. A search of the Internet reveals masses of information and that there is significant money to be made in the field.

There can be no doubt that good leadership skills have become a marketable commodity. Effective and strong leadership is afforded increasing attention because in a number of professional and political arenas, gifted leaders are perceived as a rarity (Nicholson 2002). Perhaps this situation is a result of the age in which we now live. Described as a ‘capricious new decade’, a newspaper article tells us to ‘get ready for a new breed’ of leaders and proceeds to describe these individuals as being ‘capable of effectively managing strategic and operational challenges in an environment of increased stakeholder scrutiny and dramatic and unpredictable change’ (Advertiser, 4 January 2003, p.3). However, in the next sentence we are told that the task of producing such leaders is a huge challenge and building leadership capacity does not happen overnight.

Obviously, there is a sense of urgency in producing the talent pool necessary for twenty-first century leadership. Mackay (1999, p.40) points out that when people are experiencing insecurity and uncertainty, as they often do in times of change, they look for ‘strength and vision at the top’. He points out that a ‘leadership vacuum’ (p.132) is potentially a very serious state of affairs for any organisation/community.

Research into finding new ways to understand leadership is also burgeoning. In the United States, for example, academic researchers Ospina and Schall are studying how Americans conceptualise leadership (Louv 2002). In their research, they explore the concept of leadership as both a process and a social construct. Ospina and Schall (2001) take a constructivist view, believing it a useful means of understanding leadership. They see leadership as a process of meaning/sense-making that occurs among groups of people with a common purpose—communities of practice in order to bring about change. It is a collective, shared process that is social, contextual, interactive, sensitive, ‘embodied and concrete’. Championing the group’s vision may be a shared or rotated activity, or undertaken by one individual or the group as a whole. Seeing leadership as something that is already out there in communities as a collective, social and embedded constituent, takes away from the need for the ‘heroic’ leadership that society laments to be presently so lacking (Ospina & Schall 2001, p.4).

It seems that the general thrust of ‘alternative’ visions of leadership (Louv 2002) implies we should be looking for it in places other than those where it has traditionally been found. Indeed, in a previous paper, Gaston (Borbasi & Gaston 2002) suggested the need to look to new avenues for nursing leadership and that more often than not, these would be found in practice-related positions rather than administration or education, as in the past.

It can be seen that collaborative concepts of leadership are emerging as the way forward and leadership through groups, rather than leaders as individuals, is becoming the acceptable model (Louv 2002). Engagement in symbiotic relationships in order to progress change is recognised as something that happens in communities and is to be encouraged and expanded upon (Gardner in Louv 2002). Leadership groups are exhorted to ‘find each other’ and work together in order to sustain change (Gardner cited in Louv 2002).

Of interest to nurses is the later work of Ospina et al. (2002) that uses the same constructivist framework to examine the ways in which practitioners and academics can work together to generate knowledge on leadership. The researchers perceive the existence of a gap between nursing research literature and the way in which that information can be usefully applied in practice. Their study involves a combination of ethnography, narrative inquiry and cooperative inquiry, which means the coresearchers will be working alongside practitioners, participating in the leadership experience. The data generated will be grounded in practice and therefore useful and relevant in informing practice.

Of course, while Ospina and Schall write from the sphere of public management and policy, much of what anyone has to say about leadership is potentially of use to a practice-based discipline such as nursing. However, whatever the theory, it would appear that the enduring essence of good leadership is embedded in the capacity for articulating a vision and rallying others around it (Champy 2002, p.114). In the late 1990s, Mackay (1999) noted that the leadership traits most desired at the time appeared to be ‘passion, enthusiasm’ and ‘a zest for having a go’ (p.142). Both sound remarkably similar. He also observed that society’s demand for strong leadership grows in direct proportion to the lack of collective confidence felt by that community. As a result, he states it is an ‘unusually difficult time to be a leader in Australia’ (1999 p.138). For nursing, the situation is no different.

LEADERSHIP AND NURSING

Change is taking place all of the time. We have all experienced the changes that occur daily in our lives. The biotechnical revolution; biomedical research restructuring as it is, human life, together with an ageing population; economic rationalisation and other key trends have moved us into a new era. In such an era, organisations have had to rethink and reorganise the way in which health care delivery is structured (Fukuyama 2002; Kerfoot 2001; Mann 2002).

Leadership in nursing is about leadership for nursing, as well as leading nurses. As a recent article in The New England Journal of Medicine reported, we now have a growing body of evidence that shows nurses make a significant contribution to health outcomes (Needleman et al. 2002). It is important, therefore, to be reminded that the impact of leadership is influenced by the culture of the work environment, the nature of the workforce and the educational background or level of workers (Jones & Cheek 2003). Therefore, just as nurses have the potential to be impacted upon by a leader and their style of leadership, nurses can also make an impact on leadership in their environment and practice domain per se (Firth 2001; Hein 1998; Lett 1999; Mahoney 2001). To ensure that nurses are retained in the workforce, key issues must be examined from within a professional discourse. That is, leadership requires a balance within and between the nexus of industrial and professional concerns to manage and drive change in order to facilitate practice and better health outcomes for communities and individuals.

McMillan et al. (2002) suggests that three major influences have framed how leadership in western nursing has developed. These are the emergence of nursing as a discrete area of professional practice, the influence of feminism on nursing, and the commitment to providing evidence-based practice across the health care sector (McMillan et al. 2002, p.4). We would add to that, population health as a driving force behind health care reform (Generational Health Review 2002/2003) and the burgeoning impact of violence in the workplace, now argued as a public health issue by the World Health Organisation (2002). The culture of tolerance to violence and negativity within a nursing workplace requires strong leadership, vision and the capacity to step beyond the accepted norm that ‘it goes with the job’, thus giving credence to the insidious and often latent emotional damage caused to nurses (Turney 2002, p.134–48)(for further detail see Chapter 9). Vision to recognise and then act is imperative for nurse leaders of the twenty-first century, especially in a climate where national reviews (Heath 2002, p.193; Senate Community Affairs Committee 2002) recommend that workplaces should recognise and support the development of future nurse leaders rather than continue with an outdated ethos of tall poppy slaying and neglect. Staff satisfaction is seen as a priority of the organisation because dissatisfaction with work life seems endemic in nursing (McMillan et al. 2002) and has been strongly implicated in the loss of nurses from the workforce.

We know that nursing is being transformed with a different set of expectations to that of even five years ago. Registered nurses are not necessarily going to be handson nurses for very long in their careers. With the advent of patient care assistants and their ilk, the move is away from the basic nursing care of activities of daily living, and the registered nurse is carrying out much more higher order work, especially as the role expands to advanced practice. Today’s nursing graduates are expected to be change agents, case managers, care brokers. In short, the profession is currently breaking through barriers and pushing boundaries as never before.

To add to the complexity, society is different today. Younger Australians (known as ‘Generation Xs’) have grown up to ‘expect change’ and accept the uncertainty of tomorrow. As a result, they are reluctant to commit themselves to aspects of life as readily as the previous generation and often do not place the same value on having work (Mackay 1999, p.117). Attracting talented youth to the job of nursing requires a cultural shift, evident in the frenetic vying that goes on for graduate nurses at a time of severe shortages. The traditional traits of fear and apathy in the workforce as a result of a ‘military’ model of leadership (Oakley & Krug 1991), common to many organisations not that long ago (some of you may remember the days of hospital training), are rapidly fading. Mackay (1999) points out that ‘the rising generation of young Australians are likely to be the sharpest, most assertive, most sceptical and most demanding employees we’ve ever seen’ (p.119). These trends pose enormous challenges to those nurse managers who work in outdated, heavily bureaucratic health care systems that appear to youth as decidedly unattractive places of work. Having multigenerational employees, including Generation Xs, means there is a requirement for ‘open discussion of how generational differences influence attitudes towards work and organizations’ (Kupperschmidt 2000, p.65). Indeed, it has been shown that health care institutions are the slowest to embrace many of the ideas inherent in contemporary leadership models (Malone 2001).

Gaston recalls her experience of the way nurses traditionally behaved in such an oppressive system:

We have all experienced ‘the system’ to a greater or lesser extent, but essentially what it has meant is that relatively few nurses in the past were considered great leaders, and leadership, even in the current, more enlightened climate, is perceived as wanting (Borbasi & Gaston 2002; Pearson & Borbasi 1996). That is not to say that leadership does not occur—many nurses lead daily within their practice roles. However, given the size of the nursing workforce in relation to other health professions, not many are involved in high-level leadership across multi-disciplinary groups that have political, policy and decision-making powers. Indeed, the issue for nurses has been an entrenched reluctance to accept that leadership is inextricably bound to the use of power and that it involves influencing others in the achievement of certain ends (Malone 2001). The Report on the Senate Inquiry into Nursing (2002) notes the problems with nurses’ inadequate representation on decision-making boards and calls for their ‘appointment to and meaningful participation in management’ (Recommendation 57). Additionally, it recommends that nurses be provided with appropriate education and training to support them in leadership roles (Recommendation 58).

At an international level, the World Health Organisation, at its 54th Assembly held in May 2001, also recognised the need to involve nurses in decision-making processes and urged member states to, among other things: ‘[f]urther the development of their health systems to pursue health sector reform by involving nurses and midwives in the framing, planning and implementation of health policy at all levels.’

So, what does all of this mean for the provision of effective nursing leadership? Basically, at the moment, because of the breakneck speed of change and the fact that much of it is groundbreaking by nature, in some practice areas there are limited numbers of individuals capable of acting as role models or leaders (Clare et al. 2002). Moreover, because the health system is so highly stretched and understaffed, beginning practitioners are expected to ‘hit the ground running’, yet are provided with very little support or direction in doing so. Consequently, many are burnt out within five years and leave the profession to pursue new avenues of work. Also of note is the movement of those nurses who do hold executive leadership positions but who are lured to take up non-nursing leadership positions. This is an expanding phenomenon and one that Malone (2001) sees has advantages and disadvantages. On the one hand, by giving voice to nursing in other arenas, nurses in non-nursing leadership positions have the potential to further the cause/s of nursing. Yet, on the other hand, there are those who would ‘wipe the presence of nursing from their career portfolio’ and in doing so, reinforce the stereotypes of ‘low status and mobility’ attributed to the profession (p.297). Malone (2001, p.295) believes nurses in non-nursing leadership positions function at the ‘living edge’ of nursing and are to be nurtured, not shunned.

Just as nurses are taking on new roles, so too leadership requires different skills in the ‘new world of health care’ (Kerfoot 2001, p.292). According to Kerfoot (2001), successful leaders in a rapidly changing health care environment need to be able to access and therefore keep abreast of knowledge relevant to practice and to understand the implications of new found knowledge. They should be capable of entering debate surrounding issues that stem from that knowledge; for example, the human genome project. Leaders need to be consumer savvy, experts at information technology and how to use it in working with patients, have fiscal expertise, know how to manage and model change, be sensitive to diversity, have the ability to empower those with whom they work, coordinate multi-disciplinary teams, and be capable of creating work environments in which employees flourish and where consumers feel physically, socially, mentally and spiritually nurtured (Kerfoot 2001, p.291–2).

That is a tall order and one that might send many a nurse into rapid retreat. In fact, cutting-edge thinking in leadership might criticise such theorising for its lack of application to the complexity of today’s practice. For example, Nicholson (2002) states that in many cases, people enmeshed in the real world of practice do not have the capacities to be a leader or, if they do, the organisation determines otherwise. Nicholson (2002) stands against the idea that anyone, given the right set of circumstances (e.g. supportive promotion), can become a leader. Drawing on work stemming from evolutionary psychology, he describes three broad bands of people in the workplace—confident and competent people, who want to be at the top in their profession; the complete opposite, that is, people who might otherwise be good employees but would never be considered leadership material; and finally, those who fall somewhere in between. Given the right circumstances, this third group might just emerge as leaders. He goes on to point out that in many cases, due to the nature of the complex modern environments we have created, organisations often end up with ‘ill-suited leaders’ (p.34). Nicholson’s treatise is that human nature, encoded as it is through evolutionary genetics and equipping us for survival and reproduction, has changed only marginally since we abandoned hunter-gathering as a way of life. He argues that the modern workstyles we are expected to adopt may ‘be out of synch with how our brains are wired for leadership’ (p.32). Human nature is much more difficult to change than the other things within our environment. He calls for management strategies that work ‘with’ rather than ‘against’ the grain of human nature (p.32). For example, many hyper-competitive business cultures reward ‘street fighter dominance’ and take on a ‘slash and burn’ mentality, rewarding those leaders with strong power needs who know the business but who have pitiful people skills (p.36). However, ignoring basic human needs and a sense of community in the workplace rarely works. By the same token, bureaucracies where leadership positions tend to be based on seniority or longevity in the workplace or qualifications—and hence, where leadership is predictable—seldom produce inspirational leadership (p.37). Modern psychology suggests that even with drive and vision, unless individuals are rewarded for their efforts, their capacity to achieve is limited. We would question how much of nursing leadership is reward driven rather than penalty-focused?

Nicholson (2002) advocates a new type of leadership for a new age, a move from the traditional ‘alpha-male model of leadership’ to one of a ‘clan-type model’ better suited to our ancestral communitarian make-up (p.39). While ‘dominance and achievement’ remain important characteristics, individuals also need to be able to communicate, innovate and work in a team (pp.39–40). Furthermore, because such characteristics may not be inherent within one individual but may be found in two or more people, the concept of ‘multiple power-sharing leadership’ is advocated (p.40). Different environments call for different leadership styles. Gender is an influencing factor but so too is the notion that leaders are able to change their behaviour from situation to situation (Vroom & Jago 1998). Thus leadership groups offer greater potential for the diverse environments of health care.

In today’s work environment, if organisations are to endure then leadership needs to occur at all levels within it (Ray 1999). Ray, writing about ‘organisational change leadership’, sees the emergence and subsequent disappearance of various approaches to leadership as evolutionary. Participative management, quality of work life, quality circles, employee involvement, self-directed work teams, and total quality management have all been fashionable approaches to leadership at one stage or other (Ray 1999, p.5). Ray’s treatise is ‘facilitative leadership’, where ‘all work is accomplished through relationships’ (p.12) and the leader is an ‘enabler of change’, using influence as opposed to direct power to bring work to fruition (p.25). Relationship-building is therefore important, together with coaching and learning, where information is openly shared. Moreover, the leader adopts a problem-solving approach to work, and action planning and implementation tracking provide clear pictures of how the job at hand is to be accomplished (p.12).

McMillan et al. (2002) suggest that nursing leaders ‘are those who cause us to rethink the concepts we have of what it means to be a nurse; to research, to educate and to manage and consider how we enact nursing roles’(p.5). These authors go on to add that all nurses who engage in thinking about nursing have the potential to participate in synergistic leadership in the profession (p.5). Indeed, one could argue that such thinking nurses are also scholars of nursing. Nurses have arrived at a point from which they can engage in scholarly discussion, critique and voice their concerns knowing they have evidence upon which to draw, clinical expertise which they can describe and drive, and the credibility among their peers to do so. Boyer (1990, p.16) provides us with a framework in which to understand the nurse as a professional scholar. A scholar, he describes, is one who is able to step back from his or her practice, look for connections, build bridges between theory, practice and research, and communicate knowledge effectively. A scholar is also one who can respond effectively to critique, who acknowledges the valuable role critique plays in uncovering alternate connections and bridges than was first thought. He or she is also prepared to foster and lead new ideas. However, a scholarly nurse, to be fully effective, cannot ‘work continuously in isolation’ (p.80). Boyer contends that ‘even as individual creativity is recognised and affirmed’; the complex social, economic and political problems of our time require an integrative team approach, a community of scholars with a vision for the future of nursing and health care (p.80). The question arises, who then are such a community of scholars, the leaders in nursing, and by what criteria do they get recognised?

Fundamentally, nursing is a clinical activity. Career pathways in the past have not facilitated keeping nursing expertise and leadership at the clinical interface. There is a need to recognise and value clinical practice and clinical leadership, and to help individuals—that is, all nurses—to develop effective leadership skills (Mahoney 2001, p.269). Collective/shared/relational leadership appears to be the key and certainly sounds promising for nursing. Nevertheless, it should be remembered that no single leadership theory is rated better than any other, and, in many cases, using a combination of approaches is more effective (Cherry 2002). The ability to bring humour into aspects of work, as well as fun and lightheartedness is an advantage (Champy 2002; Ray 1999). What has become clear, however, is that in any modern recipe for creating a sound leadership base, seeking out and establishing mentoring relationships is a key component to success (Malone 2001).