INTRODUCTION

This chapter explores the norms that leadership takes in the contemporary nursing context and the usefulness of traditional hierarchical ‘top down’ leadership in current health care contexts. It then goes on to explore other theories of leadership that have the capacity to build ethical, effective, creative and harmonious workplaces. The issue of trust is significant to nursing leadership and governance, as it underpins the development of respect for individual contributions to organisational practices.

THE AUSTRALIAN NURSING CONTEXT

In the last two decades the context of nursing practice has increased in complexity, pace and workload levels; there are shortages of skilled nurses, diminishing discipline boundaries and increasing managerialism. Moreover, the acuity of patients in general wards and nursing homes is increasing, and there is an imperative towards discharge of patients to the community as early as possible (DETYA 2001). Of specific interest too is the mode of delivery of health care and conditions of practice in the nursing workplace that are shaped by corporate neo-liberal values and measurement of progress and profit. Also of concern are equity issues in resource allocation for patient care and processes of inclusion and exclusion of nurses within health care teams and decision-making bodies.

Since the Reid (1994) review of nurse education in Australia, subsequent to the transfer of registered nurse education into the higher education sector in 1993, a number of national reviews and research studies have been conducted into aspects of nurse education and practice, and into workforce issues of supply and demand. Three recent reviews of issues in nursing education and practice in Australia have demonstrated what many previous nursing workforce reports confirmed; that is, the changing context of nursing and the increasing complexity of health care since the early 1980s (Clare et al. 2002; DETYA 2001; Heath 2002). Of significance are two particular areas identified in many of the reports reviewed in these recent studies.

First, is the need for ‘family friendly and flexible work environments’ because nurses report ‘dissatisfaction with conditions of work—shift-work, frequent changes, overloads, lack of appreciation by superiors and colleagues, lack of child care’ (Clare et al. 2002; DETYA 2001; Heath 2002). Second, is the issue of workforce strategies related to the difficulties in recruitment and retention of qualified nurses, specifically the cohort of registered nurses who leave the profession. Evidence confirms that pay levels are not the prime reason for qualified nurses leaving the workplace, but rather nurses report unacceptable levels of ‘poor management practice and a general lack of appreciation’ (Clare et al. 2002; DETYA 2001, p.7; Heath 2002).

Of specific concern is the number of nurses who leave the profession during their first year of employment, apparently due to unreasonable expectations by employers (Clare et al. 2002; DETYA 2001; Heath 2002). These are significant moral and professional issues for health care decision-makers to urgently consider. It seems incongruous that nurses feel they are not respected and valued in the workplace, because these elements of caring are purported to form the basis of nurse/patient relationships. Also of concern are the numerous reports reviewed in the recent research (Clare et al. 2002) which all failed to address crucial issues of leadership development, management and interpersonal relations (see, for example, Gerrish 2000; Greenwood 2000; Hart & Rotem 1995; Hegney et al. 1997).

CORPORATE VALUES OF NEO-LIBERALISM AND MANAGERIALISM

Contemporary heath care systems are characterised by modern managerial theories and practices. Managerialism is predicated on the assumption that markets should control society and governments should minimise their involvement in public services. In capitalist societies there has been a burgeoning of privatisation of public services in recent years, with claims of better services for consumers or customers. Corporate managerialism has been promoted globally as a set of values informing the management strategy of organisations since the early 1980s. Human productivity in these systems is viewed as a ‘commodity’ and the ‘organisation’s financial accountability is the criterion to measure performance’ (Rees 1995, p.16). Corporate managerialism has resulted in profound changes in the health sector through greater efficiency, maximising productivity, cost cutting and increasing profits. The goal for managers is to manage people efficiently to meet organisational productivity and financial targets, with little scope for active participation in these decisions by workers. In more developed countries, health care systems are predicated upon neo-liberal capitalist values of competition, individual success and the consequent changes in public health policies. In this regard, we contend there is a crucial agenda for nursing leadership to meld political activism and organisational reform.

Nursing recognises that the life options and opportunity for people to enjoy an authentic existence free from unequal economic, gender or racial oppression, is dependent on access to health sustaining resources and social change (Stevens 1989). Moreover, Moccia (1988, p.32) stated ‘social conditions, therefore, call for nurses’ attention if caring work is to be allowed, recognised, acknowledge, and valued’. With the increasing attrition of registered nurses from the Australian (and worldwide) workforce, health administrators are beginning to acknowledge nurses who take this standpoint (see for example, Aiken et al. 2002).

VALUES SHAPING THE CURRENT HEALTH CARE CONTEXT

The nursing workplace has not escaped unscathed amid market-driven trends. Corporate language and markers of efficiency and outcomes call for a keen focus on rules and regulations, protocols and procedures, necessitating regular surveillance regimes. These systems have been widely embraced by administrators in nursing workplaces to ensure regularity and to manage risk. However, these limited corporate measures of efficiency and fiscal outcomes have often clashed with sets of values that underpin caring and other ‘invisible’ nursing work, because such measures lack the capacity to comprehensively and accurately account for the processes of nursing.

As a consequence of managerialism in the health sector, research from the 1960s to the present day demonstrates that nurses report moral constraint and distress in caring for patients, where workplace structures and measurements of efficiency and progress are shaped by managerialism and neo-liberalist policies (Clare et al. 2002; Corley 1995; Heath 2002; Hiraki 1998; Hutchinson 1990; Ketefian 1985, 1981; Komesaroff 1999; Liaschenko 1993, 1998; Menzies 1960; Rodney & Starzomski 1993; Starzomski & Rodney 1997; Varcoe 1998; Varcoe & Rodney 2002; Wilkinson 1988, 1989). When a society is defined in economic terms, economic indicators primarily measure success and productivity, with little consideration of the social and environmental costs. Such an approach diminishes trust, social relationships and reciprocity.

We suggest nursing leadership is crucial because the leader is a ‘driver’ in the process of embedding concepts into policy and core organisational culture, rather than such concepts simply existing as unfulfilled statements in annual reports. Clearly, trust is fundamental in this long-term process. That being the case, what constitutes profit in broader social and ecological terms needs to be redefined, rather than defined in purely fiscal outcomes. For example, what constitutes social profit could be conceptualized in terms of the health levels of individuals and populations, and in work practice and relationships among nurses. These advances are predicated on the assumptions that trust and cooperation may work better than competition and that building social networks and reducing environmental degradation is as important as the aggregation of financial capital.

LEADERSHIP STYLES

Traditional leadership styles can be characterised as being based on hierarchical structures, commands, coercion and control activities such as constant surveillance of staff and checking systems for monitoring performance, risk, production and output. Porter-O’Grady (1996, p.6) noted ‘vertical integration in organisations relates to the essentials of control’. To meet the challenges of leadership in health care in the twenty-first century, Porter-O’Grady (2001, p.182) asserted, ‘much profound and personal transformation must be undertaken if good leadership is to continue and effective results are to be obtained’.

In view of the pressures being exerted from the external environment and the critical re-visioning of organisations, research suggests that senior management needs to establish a flexible and adaptive infrastructure that should assist contemporary and complex organisations to reach optimum levels of performance (Appelbaum et al. 1998). These authors conclude that the largest barrier to ‘change’ is not changes to technologies and work processes but those involving people. People usually want to understand changes in direction and how the changes will affect their working lives. Ray, Turkel and Marino (2002) argue that ‘a loss of trust underscores employees’ decreased loyalty to hospital organisations and herald their increasing disillusionment’ with nursing education, practice and management of health care. Employees and the public need to trust the ability of managers to move the organisation in new directions without decreasing people’s ability to derive satisfaction from their employment or from the services they receive.

Traditional leadership styles are not designed to be responsive or inclusive, and therefore do not necessarily build trust or collective valuing in teams and groups (Handy 1997; Porter-O’Grady 1997). However, models of shared governance are predicated on collaborative leadership, open communication and transparency (Blumgart 1997). Antrobus and Kitson (1999, p.746) claim ‘effective nursing leadership currently is a vehicle through which both nursing practice and health policy can be influenced and shaped’. Leaders need to have the flexibility to ‘live in permanent transition, to accommodate ambiguity, and to mentor and facilitate others in their struggle to redefine and renew themselves and their new roles’ (Porter-O’Grady 1997, p. viii). This leadership style is based on mutual respect and recognition of contributions that all workers make to the whole organisation (Trofino 1995). Many nursing leaders are caught between the need to support traditional hierarchical management styles expected in organisations and the need to demonstrate more current attributes of leadership, as explained above. This dichotomy may mean that leaders can espouse one set of values about the direction and style of the organisation, while at the same time exhibiting behaviours that are inconsistent with them. In other words, actions and behaviours are manifestations of a different value-set to those espoused to colleagues and workers. This leads to a lack of trust in the organisation, which results in low levels of motivation, harmful conflict and waste of all types (see 12 Key Principles of Business Excellence, Australian Quality Council, 2000, for further explanation).