INTRODUCTION

Although it is recognised that diversity exists in nursing service delivery in the community, we have selected one nursing organisation as a case study for this chapter. In the section to follow we will give the leadership perspectives used for managing health services in the community. The content of this chapter is informed by the practice of four people working in a community health service. Together they comprise the fields of research, nursing executive (clinical leadership), education and human resource management. The organisation for the case study is Royal District Nursing Service (RDNS, SA Inc). RDNS is a service health care service organisation that seeks to offer a quality nursing service, primarily to the population of Adelaide, South Australia, and the greater Adelaide suburban area.

LEADERSHIP AND MANAGEMENT

Early leadership research focused on personal traits such as intelligence, appearance and energy, closely followed by research that tends to favour functionalist, that is, behavioural approaches. Influenced by research in North America, attention then shifted to contingency approaches such as Hersey and Blanchard’s situational theory (Daft 1997). Leadership concepts have shifted to include charismatic, interactive, transactional and transformational styles. Debates in the current literature reflect the debates surrounding leadership and management (Collins & McLaughlin 1996; Daft 1997; Ellyard 1998; McKenna 1999), and the debatable point is whether they are the same or different. It is clear that managing and managers can be viewed from several perspectives. We take the position that it is paramount to understand and respect that there are many ways to lead and manage.

The awareness of differences in leadership styles and preferences is crucial in the establishment of organisational relationships. Each of the four authors will offer their perspective on nursing leadership and management, and while they hold a diversity of theoretical views on this topic, their work is shaped by the Ottawa Charter principles. Translation of the principles to guide leadership and management are as follows:

The ability to advocate a clear political commitment to health and equity in all sectors will assist in building healthy public policy. One strategy derived from this statement is that service delivery is based on the identified needs of the community.

The ability to speak to the health of the workforce in the awareness that working conditions are safe, stimulating, satisfying and enjoyable. This results in creating a supportive environment for all staff in the organisation. Situational management is one such strategy.

Being able to generate empowering ideals through developing ownership and control over nursing practice. Professional autonomy is recognised as self-directed, self-regulated, competent, and strives for evidenced-based nursing practice. Professional autonomy strengthens the action of a community workforce. Transformational leadership is participative and congruent with this principle.

Being able to support personal and social development through the provision of human resources and education. Developing personal skills assists with the development of lifelong learning strategies.

The ability to see the broader pictures in health so that the service is sensitive and respects diverse cultural needs. It may be necessary to reorient or expand the health service mandate to meet identified population diversity.

It is argued here that the Ottawa Charter principles are useful for guiding leadership and management in a community organisation. In the preparation, maintenance and further development of a community nursing service, these principles can underpin action.

SHARED COMMON VISION

Although health services differ in community settings, there are certain common factors that are beginning to influence their evolution. As argued, one of the influences is the philosophical framework of the Ottawa Charter for Health Promotion (1986). Leaders in the community can lead through articulating a vision, guided by primary care principles from the Ottawa Charter. Central to this community service organisation is the delivery of primary health care. Primary health care can be two things: a level of service provision or a philosophical approach to health care. We argue that it is both. Although this chapter deals specifically with a nursing service, it is understood that the way primary health care is ideally organised is within an integrated team and supported by a community network that includes not only the health care workers and service providers but also the community as partner. The principles of primary health care are health education and promotion, early identification of disease, working with entire families rather than the individual. These activities closely reflect community nursing practice. However, primary health care also incorporates a wider definition of health to include social health. It corresponds with a move from a biomedical model to a social model for health, and includes wider social and political reform. The way in which a community service can transform itself to include the wider primary health care definition is through its leadership. Preparation of nurses to lead health reforms is one of the tasks of managers and leaders in the community.

INTERACTIVE LEADERSHIP: A RESEARCHER’S PERSPECTIVE

RDNS has a dedicated research unit with team members who are doctorally prepared nurses. The aims of the research unit are to respond to research questions arising from practice, the organisation or the community; to enhance RDNS research capability; to develop a focused, well-recognised research program; and to make a difference to practice and in the wider community. The research strategies we utilise are interactive; that is, we rely on working with clients and community nurses to foster the research agenda. We use collaborative approaches such as participatory action research and fourth-generation evaluation. Research activity is driven by the belief that the nursing service exists so that it can provide quality nursing care to clients and the wider community. On a practical level, the professional code guiding an individual nurse’s practice means that the nurse is accountable for her or his practice. This requires the use of the latest available knowledge or ‘evidence-based practice’. Is quality providing the best evidence on which to base practice? What is best practice for leg ulcer wound management? What is the best way to facilitate diabetes self-care management? Driven by such questions, research-finding utilisation completes the 360-degree circle. However, the organisation must have a structure for the dissemination of research findings and their incorporation into daily practice.

Clients and the wider community need to know that nursing practice is ideally based on evidence. Indeed evidence-based practice is a precursor to another concept relevant to nursing—clinical governance. There is no doubt nursing leaders and managers would agree that the clinical needs of patients/clients and services based on identified community needs should shape the administrative framework for their delivery. Their role is to create an environment that supports services driven by need. Not only should evidence-based clinical practice be good management practice, but also every decision managers make should be based on the best evidence available. Accomplishing this means finding the best available evidence relating to a particular decision. To successfully complete this task the decision-maker requires a number of research skills. These are:

to define criteria such as effectiveness, safety and acceptability that relates not only to service delivery but the larger social health agenda, e.g. health promotion;

to find key resources, e.g. current articles on the effectiveness, safety and acceptability of new nursing practices/service delivery;

to assess the quality of the evidence; and

to assess whether results of research papers are applicable to the local context.

Research activity

In trying to enhance the research capabilities of staff, researchers respond not only to questions from practice but need to involve staff in the actual research process. We cannot underestimate that critical, systematic reading of research papers requires some research knowledge and understanding. Participation in research endeavours is the key ingredient, followed closely by further educational preparation. Such preparation will indirectly lead to better prepared staff who are able to discern what constitutes best possible evidence. The role for community leaders is to provide an educative and supportive framework in the quest for evidence and to assist in the preparation of its practitioners.

One important research activity is establishing community need. Here it is argued that delivery should be based on the identified needs of the community. It is necessary for the RDNS to formally identify, on a regular basis, the gaps in its service—and to subsequently adjust service delivery based upon the needs identified that pertain to the service gap. Synonymous with this aim is the identification of what groups of persons are accessing RDNS services in proportion to their representation within the general population of the community served—and to ascertain the reasons for any disparity. The community can be viewed as (a) a structure or locale; (b) the people; and (c) the social systems. A complete assessment involves a careful look at each component to begin to identify needs for health policy, health program development, health issues and service provision. These data provide evidence for decision-makers within organisations, in the wider political arena and towards healthy public policy.

Evaluation of service is the third research activity. As congruent with the RDNS ethos, vision, mission and strategic plan, and as expected by pertinent accrediting and funding organisations, this service is required to regularly evaluate not only the effectiveness of the service it provides, but also to what extent community needs are met.

So, who are the clients of this community service? The majority (75 per cent) of the clientele are people living with a chronic illness. In 1997 nurse clinicians, together with researchers, commenced a series of collaborative group research projects with people who live with chronic illness. The research questions arose from the practice of nurses who recognised that most of their clients lived with chronic illness but had varied self-management approaches that ranged from effective to deficient. Our research interest has focused on how community nurses can assist people living with chronic conditions to live well. We have applied the principles of participatory action research (Stringer 1996). We envisaged a community-based action research program that sought to change the social and personal dynamics of the research situation and enhance the lives of all those who participated. One other important justification for us to use a participatory action research approach is that the principles are closely aligned to the primary health care concepts of collaboration and empowerment. Primary health care emphasises the participation of people in the planning and development of their own health care—an important foundation for evidence-based community nursing practice.

How can community action be strengthened?

Managing and leadership in the context of the emerging research agenda is interactive, concerned with consensus building, inclusiveness and participation (Hill 1994; Rosener 1990). Although this may reflect a personal style, its success is contingent on others in the organisation and their willingness to appreciate cultural diversity in management.

TOWARDS TRANSFORMATIONAL LEADERSHIP: A CLINICAL NURSE’S PERSPECTIVE

The style of leadership that is most appealing to my case is transformational, as it most closely resembles the participatory ideals of the Ottawa Charter (Alexander 1998; Howell 2000; Trofino 2000; Trott & Windsor 1999). Traditional management functions are described as planning, organising, leading and controlling (McKenna 1999). The point raised here is that while transformation is an appealing notion in terms of bringing about innovation and change, it means a slow transition from traditional management functions towards collaborative management. One of the reasons for its appeal is that research demonstrates that increased participation in management leads to increased job satisfaction and increased retention of nurses (Trott & Windsor 1999). The development towards a participative model is a slow, methodical process. However, if we are to achieve a health system that strengthens the action of a community (nursing workforce), participation is central.

As the clinical director of the service, the application of the Ottawa Charter referring to strengthening community action means creating a safe and stimulating organisational context for nurses to practise autonomously in the ‘field’. In this sense, the term community is applied to a community of district nurses. It means striving together for a vision fostering the belief that the profession is self-directed, self-regulated, competent and aims to base its practice on the best possible evidence.

While the generic RDNS consists of 400 employees, the ‘field’ workforce consists predominantly of 350 registered nurses, who visit people at home or at clinics. The services comprise nursing specialty areas such as wound management, diabetes, continence, HIV AIDS and disability, and includes health programs for homeless people. Contrasting acute care heath systems, nursing services are mobile (each nurse has a vehicle) and the environment (people’s homes) is uncontrolled.

The transformational style of leadership is defined by four key behaviours. It is based on the work of Howell (2000):