Transformational & Charismatic Leadership in Health Care

Title Transformational and Charismatic Leadership in Health Care

Sub-Title A critical critical examination examination of the role of transform transformationa ationall and charismati charismaticc leadership leadership in developing developing health care services which are responsive to change and thus more likely to meet the needs of   patients, clients, other users, and those involved in the delivery of such services.

Abstract This essay begins with an articulation of origins and developmen ts of transformational leadership theor theory y and and whil whilst st supp suppor orti ting ng the the asse assert rtio ion n that that char charis isma ma is an impo import rtant ant compon componen entt of  transformational leadership behaviour argues that it is not in itself a defining feature. The cascading effect of transformational leadership is explored in relation to contemporary research  both within the US and UK and utilised utilised to articulate articulate the relationship relationship between transactional transactional and transformational behaviours within health care settings which constitute an optimum change  profile. The nature of vision and charisma within within the health care setting are critically evaluated along with the relationship between transformational leadership and key outcomes such as felt auto autono nomy my,, job job sati satisf sfac acti tion, on, low low staf stafff turn turnov over er,, serv servic icee quali quality ty and and the the achie achieve veme ment nt of  organisational (cultural) change.

Key Words Transf Transform ormati ational onal Leader Leadershi ship, p, Transa Transacti ctional onal Leader Leadershi ship, p, Full Full Range Range Leader Leadershi ship p Model, Model, Charisma, Charisma, Idealised Idealised Influence, Influence, Inspirati Inspirational onal Motivatio Motivation, n, Intellectu Intellectual al Stimulati Stimulation, on, Individual Individual Consideration, Contingent Reward, Management by Exception, Laissez-Faire, Empowerment, Innovation, Innovation, Creativity Creativity,, System System Perspectiv Perspective, e, Patient Patient Directed Directed Health Health Outcomes, Outcomes, Complexity Complexity,, Comple Complexit xity y of Need, Need, Human Human Relati Relations ons,, Nursin Nursing g Proces Process, s, Redesi Redesign gn of Workin Working g Practi Practices ces,, Process Redesign, Vision, Risk Taking, Management of Attention, Management of Meaning,

Manage Managemen mentt of Trust, Trust, Manage Managemen mentt of Self, Self, Buildi Building ng Relati Relations onship hips, s, Teamwo Teamwork, rk, Physic Physician ian Integration, Sharing Experiences, Learning Organisation, Work Satisfaction, Job Satisfaction, Staff Staff Turnover, Turnover, Occupational Occupational Health, Health, Cascading Cascading Phenomenon, Phenomenon, Leadership Leadership Practices Practices Inventory, Inventory, LPI, Nursing Development Units, NDUs, NHS.

The concept of transformational leadership is described in a seminal work by the political  Leadership (1978). In his work, Burns attempts to sociologist James MacGregor Burns entitled entitled Leadership to link the roles of leadership leadership and followershi followership. p. He describes describes leaders as those people people who tap the motives of followers.

Transactional leadership occurs when leaders set up relationships with followers that are based on an exch exchan ange ge for for some some reso resour urce ce valu valued ed by the the foll follow ower ers. s.

Inte Intera ract ctio ions ns betw betwee een n the the

transactional leader and the followers appear to be episodic, short-lived and limited to that one  particular transaction. A transactional leader balances the demands of the organisation and the requirements of the people within the organisation.

Transformational leadership is much more complex and happens when people are engaged together in such a way that leaders and followers encourage one another to increase levels of  motivation motivation and morality. morality. In such situations situations the aspirations aspirations of leaders and followers merge to  become one, (Bass, 1998).

(Northhouse, 2001; McKenna, 2000) distinguishes between two types of leadership Similarly, (Northhouse,

styles:

“Transactional leadership refers to the bulk of leadership models, which focus on the exchange that occurs occurs between between leaders and their follower followers. s. Managers Managers who offer promotion to employees who surpass their goals are exhibiting transactional leadership. The exchange dimension of transactional leadership is very common and can be observed at many levels in the organisation." (Northhouse P, 2001, p. 132)

"In transf transform ormati ationa onall leader leadershi ship p the emphas emphasis is is on people people of vision vision who are creative, innovative, and capable of getting others to share their dreams while  playing down self-interest; and who are able to cooperate with others in reshaping the strate strategie giess and tactic tacticss of the organi organisat sation ion…in …in respons responsee to a fast-c fast-chang hanging ing world (Tichy & Devanna, 1986 )… to these qualities could be added the pursuit

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of high standards, standards, taking taking calculated calculated risks, risks, challenging challenging and changing changing the existing compan company y struct structure ure,, with with even even the potent potential ial for the displa display y (when (when conside considered red appropriate) of directive tendencies. (Bass, 1990)” (McKenna, 2000, p.383)

Bass (1985, 1998) provides a more expanded and refined theory of transformational leadership

which develops the work of Burns (1978) and House (1977) , by giving far more attention to the  behaviour and needs of followers than had previously been given. Bass (1985, 1998) argued that the principles of transformational leadership could be equally applied to situations where the outcomes were not positive than those where the opposite was true and describing transactional and transformational leadership as a singe continuum rather than mutually independent continua. Bass (1985, 1998) identifies the main characteristics of transformational leadership as; charisma

idealised influence, intellectual stimulation and consideration of the emotional needs of each follower, (Hunt, 1996) .

Transformational Leadership

Transformational Leadership Continuum Transactional Leadership Laissez-fair Leadership

Idealised Influence Contingent Reward Non-transactional (non-leadership) (Charisma) Management By Inspirational Exception (Active) Motivation Management By Intellectual Exception (Passive) Stimulation Individual Consideration [Source: Adapted from Northouse P, 2001, p.136; Bass B, 1998, p.7-9 ] In develo developin ping g his model model of transf transform ormati ational onal leader leadershi ship p Bass built upon earlie earlier  r  Bass (1985) (1985) built House’s (1977) (1977) model charis charismat matic ic litera literatur turee and it is not surpri surprisin sing g that that House’s model of charism charismati aticc

leadership is often mistakenly identified as an archetype of transformational leadership. Weber (1947) describes charisma as a special personality characteristic that gives a person superhuman

or exceptional powers and is reserved for a few, is of divine origin, and results in the person  being treated as a leader. In addition to displaying certain personality characteristics, charismatic leaders also demonstrate specific types of behaviours: they are strong role models for the beliefs and values they want their followers to adopt,

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they appear competent to their followers, they articulate ideological goals which have moral overtones, they they commun communicat icatee high high expect expectati ations ons for follow followers ers,, and they they exhibit exhibit confide confidence nce in follow follower’ er’ss abili abilitie tiess to meet these these expect expectati ations ons..

The impact impact of this behaviour behaviour is to

increase followers’ sense of competence and self-efficacy, which in turn increases their   performance, they arouse task-relevant motives in followers that may include affiliation, power or  esteem. Charismatic Leadership Characteristics Personality Characteristics Behaviours Effects on Followers Dominant Sets strong role model Trust in leader’s ideology Desire to influence Shows competence Belief similarity between leader and follower 

Confident Strong Values

Articulates goals Communicates high expectations Expresses confidence Arouses motives

Unquestioning acceptance Affection towards leader 

Obedience Identification with leader  Emotional involvement Heightened goals Increased confidence [Source: Adapted from Northouse, 2001, p.133; Hunt 1996, p.189-190 ] Hunt (1996) provides a clear synopsis of the differences between Bass’s (1985) theory of 

transformational leadership and the earlier work of (Burns, 1978; House, 1977 ): Bass (1985) emphasised an expansion of the followers’ portfolio of needs and wants with

a firm focus on the need for growth, development and self-actualisation, Bass (1985) allowed for positive and negative transformations, that is transformations

that lead to organisational failure or ethically undesirable outcomes, transformational nal and transactio transactional nal Bass (1985) (1985) unlike Burn Burnss (1978) (1978) does not view transformatio leadership as opposite ends of the same continuum, but views transformational leadership as higher order (extraordinary) leadership which goes beyond the transactions found in everyday management, Bass (1985) considers that transformational leadership consists of four factors; idealised

influence (or charisma), individual consideration, inspirational motivation and intellectual

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stimulation. Thus charisma is an important element of transformational leadership but unlike House’s (1977) theory is not considered to be sufficient in itslef, considers rs that that transa transacti ctional onal leader leadershi ship p behavio behaviours urs are based based on two Bass (1985) (1985) conside dimensions namely, contingent reward and management-by-exception. Contem Contempor porary ary health health care care settin settings gs are charact characteri erised sed by discont discontinu inuous ous change, change, increa increased sed expectations from all service users, increased professional accountability and political pressure for efficiency incorporating standardised easily measurable outcomes, technologically driven change, an ageing population and an increase focus on the role of management and leadership within clinical practice. practice. Thus, despite the conceptual and operational liabilities liabilities often associated with charismatic and transformational paradigms these have become increasingly attractive to researchers and practitioners within health care and n ursing contexts.

(Brown & Sofarelli, 1998 ) cite (Davidhizar R, 1993 ) in arguing that in today's changing and chaotic health care arena the nurse leader needs to utilise the qualities of transformational leadership which focus on people and solving solving problems in an ever-changing environment. They go on to state state that that transf transform ormati ationa onall nursin nursing g leader leadershi ship p active actively ly embrac embraces es and encoura encourages ges innovation and change and provides the skills necessary for the profession to:

"… stretch its boundaries and be innovative in the way in which problems are viewed and solved. This will become increasingly increasingly more important as nurses nurses leave the traditional hospital setting setting and expand their practises into into the community. The ability to find innovative solutions, to extend beyond their boundaries of comfort, and to test new ways of doing old things, will move nursing further into the centre of the arena of the new health care services." (Brown D & Sofarelli D, 1998, p.203)

Trofino, Trofino, (1995) claims that transformational leadership provides a mechanism for developing a

holistic, (bio-psycho-social), systemic perspective, which empowers nurses to make optimum use of the enabling technologies to move “beyond even patient-centred health care to patient directed health outcomes.” (Trofino, 1995, p.42 )

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Davidhizar ar R, 1993) cite (Davidhiz citess the the work work of  Barker (1991) in arguing arguing that; transformationa transformationall

leadership in health care settings place less emphasis on hierarchical structures, logical decision making and that rationality becomes less prominent, and that “this transition is appropriate as the world has has become become a far more more complex complex place” (Davidhizar R, 1993, p.675 ). Hence, scientific approaches to leadership, (and presumably medically, scientifically orientated models of health care), which do not take into account the complexity of individual need and the contingent relationship of an ever changing environment are not likely to provide conceptual or practical frameworks which underpin everyday actions. Davidhizar (1993) citing Barker (1991) argues:

“The new transformational paradigm is characterised by mutuality and affiliation, acknowledging acknowledging complexity complexity and ambiguity, ambiguity, co-operation co-operation verses competition, competition, and emphas emphasis is on human human relati relations ons,, proces processs versus versus task, task, accept acceptanc ancee of feelin feelings, gs, netw networ orki king ng vers verses es hier hierar archy chy,, and and reco recogni gniti tion on of the the value value of intu intuit itio ion.” n.” (Davidhizar R, 1993, p.675 ).

According to Davidhizar (1993) the techniques of transformational leadership can enable nurse leaders to design work environments, which satisfy the needs of their followers and enhance the quality quality of care given to patients. patients. She makes the important important point that transformati transformational onal leaders combine a focus on nursing process (‘nursing heritage’) with redesigning the working practices (proce (process ss redesi redesign) gn) and the wider wider environ environmen mentt in order order to facili facilitat tatee team team workin working g and the achievements of followers.

What is interesting about Davidhizar’s (1993) framework for transformational leadership in nursing is the emphasis and importance she places on charisma (idealised influence) almost to the exclusion of other transformational dimensions, and the lack of any guidance on how, (or  indeed indeed if it is necess necessary ary), ), for nurse nurse leader leaderss to combin combinee transf transform ormati ationa onall and transa transacti ctional onal dimensions of leadership behaviour to achieve optimum influence. Davidhizar (1993) however, does does not not atte attemp mptt to prov provid idee a deta detail iled ed defin definit itio ion n of char charis isma ma beyo beyond nd labe labell llin ing g it as a “management quality that can empower employees and facilitate co-operation, creativity and innovation” (Davidhizar R, 1993, p.675 ).

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Davidhizar ar R, 1993) charismati According to (Davidhiz charismaticc leadership leadership can ‘backfire’ ‘backfire’ in the following following

conditions:

-

Goals of the leaders are contrary to needs of the society: society: when followers and leaders are   bound by values which are not beneficial to society (and presumably patients) then such leadership can be regarded as unethical as its effects are likely to be non-beneficial. n on-beneficial.

-  Emotions become irrational: when emotional commitment to the leader becomes so intense that a wider sense of rationality rationality becomes lost. At which point followers will will have developed either a dependent or counter-dependent relationship with the leader to the exclusion of all other influences. -  Leader is judged by exceptional standards: in such situation the strong desire amongst followers to achieve personal identity with the leader may lead to unacceptable levels of  emotional and physical stress as followers attempt to emulate their leader’s exceptional  behaviour.

However, positive influences of charisma in transformational leadership are identified as:

-

Self-esteem:

having having a posit positive ive self-r self-rega egard rd is an import important ant person personal al charac character terist istic ic of 

leadership, leadership, which is projected projected onto followers. followers.

Charismat Charismatic ic leaders are confident, confident, highly

enthus enthusias iastic tic and have have a high high sense sense of self-wor self-worth. th.

These These charact characteri eristi stics cs are importan importantt

determinants of influence as subordinates (followers) are unlikely to follow a leader who appea appears rs lack lackin ing g in self self-c -conf onfid iden ence ce,, pers persona onall abil abilit ity y or has has litt little le under underst stand andin ing g of  organisational goals and the wider environmental influences.

-  Focus on People: Within the nursing profession the ability to relate to others members of the team who are likely to possess high levels of interpersonal skills themselves is an important determinant determinant of effective leadership/ leadership/influ influence. ence. This is especially especially important important given that the ability to sustain and develop human relationships is an integral component of effective   practice. practice. The charismatic/tr charismatic/transfor ansformatio mational nal nursing leader ensures that relationships relationships with

Transformational & Charismatic Leadership in Health Care

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colleagues are used to foster participation in problem solving and decision-making as a basis for sustaining commitment to shared goals.

“Focus on people is one characteristic of charismatic charismatic leadership. In other words, the leader who utilises a charismatic approach is orientated to people and visibly focuses on human needs of followers. When subordinates present a concern, the leader conducts an assessment to find the basis for concern.” (Davidhizar R, 1993, p.677).

-

Vision: having a vision is an essential component of leadership for a leader who seeks to lead lead with with charism charisma. a.

Having Having a vision vision for the develo developme pment nt of practi practice, ce, the ward/d ward/dept ept,,

organisation, patient/clients and other stakeholders involves “knowing where the department, unit or organisation is heading and how society will be served” (Davidhizar R, 1993, p.678). A vision allows followers to reflect on the current state, identify its shortcomings and  become committed to a desirable future state, which is attainable and predicated on known  professional/ideological values.

“A visi vision on allo allows ws indi indivi vidu dual alss to see see beyo beyond nd the the tedi tedium um of thei theirr pres presen entt  predicament and to rise above the the tedium of day-day events. A vision [if shared]   pulls people together in collective purpose and provides stimulation for extra effort.” (Davidhizar R, 1993, p.678 ).

An Australian Australian perspective perspective on transforma transformational tional nursing leadership leadership provided provided by Sofarel Sofarelli li & Brown (1998) citing (Davidhizar R, 1993 ) argues that:

“Transformational leadership is a style which is ideally suited to the present climate of change because it actively embraces and encourages innovation and change. A transformat transformational ional leader [by encouragin encouraging g and supporting supporting reasonable reasonable risk taking] will provide the skills for the profession to stretch its boundaries and Sofarelli &  be innovative in the way in which problems are are viewed an solved.” solved.” (Sofarelli Brown, 1998, p.203)

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In defining the nature of transformational leadership within a nursing, health care setting they cite the work of  (Bennis 1986, 1990; Bennis & Nanus, 1985; McDaniel, 1997) in describing four leadership competencies which they view as central to the provision of transformational leadership in nursing/health care settings:

Management of Attention: management of attention is demonstrated by leaders who are able to determine from events, patterns and relationships around them, what is relevant for the future and then communicate this to followers. followers. (Sofarelli & Brown, 1998) cite McBride (1994) who states that “transformational leaders are those who have the ability to find meaning in piecemeal actions and to make those connections for others so they can see the macro level while dealing with the micro micro level” level” (McBride, 1994, p.284 ). Within Within contemporary contemporary health health care systems systems the the transformational nursing leader will be constantly scanning their environment in order to use relevant information in the formation and development of their vision.

“The “The tran transf sfor orma mati tiona onall leade leaderr will will ensu ensure re that that thei theirr foll follow ower erss have have all all the the information that is required to work towards the shared vision, and will give them the knowledge knowledge and suppor supportt to enable them to develo develop p the skills skills requir required ed to analyse the information for themselves and to make decisions based upon that information. [Thus, developing their followers followers ability to become transformational leaders in their own right].” (Sofarelli & Brown, 1998, p.204 )

The management of meaning meaning is an essential essential prerequisite prerequisite of individual individual,, team and organisatio organisational nal learning, as organisations strive through learning to achieve a symbiotic relationship with their  environments so that they are able to shape the environment as much as being shaped by in.

Management of Meaning: transformational leaders give meaning to their actions and those of the organisation primarily through expressing their vision and modelling behaviours commensurate with that vision. (Sofarelli (Sofarelli & Brown, 1998) cite research by Dunham & Klafehn (1990, 1995) into the transform transformationa ationall nature nature of leadership leadership provided provided by nursing nursing executives, executives, in arguing arguing that a

Transformational & Charismatic Leadership in Health Care

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vision is a personal attribute and in order to align followers and the organisation to their vision transformational nursing leaders must posses powerful communication skills.

“To “To be effe effect ctiv ive, e, a lead leader er must must fulf fulfil il many many funct functio ions ns,, but one of the the most most important is the management of meaning and the effective articulation of their  dreams to their followers in order to inspire them to accept and be committed to the vision. vision. Effect Effective ive transfor transformat mation ional al leader leaderss are able to create create a vision vision and effectively communicate that vision to those people they lead, and throughout the organisati organisation. on.

This required required powerful powerful and persuasive persuasive communication communication skills.” skills.”

(Sofarelli & Brown, 1998, p.204 )

(Sofare arguin ing g that that Sofarell llii & Br Brow own, n, 1998 1998 ) cite the work of  Ke Kets ts de Viri Viries es (198 (1989) 9) in argu transformational leaders use language, ceremonies and symbols in order to reinforce the meaning of their vision, they also know how and when to make use of humour, irony and colloquial language language which enhances meaning meaning for their their followers. followers. They go on to argue, based on the work  of Dunham & Klafehn (1990) that a vision is not for the sole purpose of adding meaning to the leader-follower relationship; effective transformational leaders can use a vision to revitalise a whole organisation by giving people a meaning, purpose and a sense of higher value in their  work.

Management of Trust: is essential as leaders cannot empower with trust and trust is essential in the transformat transformational ional process. process. Trust is communicate communicated d to followers followers in many different different ways but one of the most important important is through through leadership leadership visibility. visibility. Followers Followers are not likely likely to trust a leader who is often absent (behind closed doors), not prepared to do their share of the work, avoi avoids ds

deve devellopi oping

int inter-p er-per erssonal onal

rel relatio ations nshi hips ps

wit with

fol follower owers, s,

does does

not not

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commitments/promises and who does not model behaviour commensurate with their vision. The successful development of trust is the foundation of transformational leadership in nursing as the interrelationships that nurses develop with fellow professionals, patients/clients and the wider  community is built on an ethos of care and trust.

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“Leaders must fulfil their commitments, keep promises, stay on course, live what they say and be supportive when necessary; they need to be seen by people as credible and trustworthy. (Kouzes & Posner, 1987) wrote that trust was at the centre centre of human human relati relations onship hipss and essent essential ial for organi organisat sation ional al effect effective ivenes ness. s. Leaders within organisations can communicate trust to others by providing and environment in which trust can develop.” (Sofarelli & Brown, 1998, p.205 )

Management of Self: transformational leaders have a high personal self-regard, built on high levels of self-awareness and self-esteem. They are able to communicate this to others and their  interrelationships with followers will as a consequence be built on positive reinforcement whilst encouraging encouraging reasonab reasonable le risk taking. taking. They cite cite Bennis (1986) who states that “leaders know themselves, they know what they are good at and they nurture those skills and competencies” (Bennis, 1986, p.86) Transformational nursing leaders value learning, the gaining gaining of knowledge and the encouraging of others to view mistakes as an opportunity to learn and recognise that there is no such thing as failure. failure. They cite Kouzes & Posner (1987) who believe that:

“..the “..the selfself-conf confide idence nce that that except exception ional al leader leaderss gain gain through through learni learning ng about about themse themselve lves; s; their their skills skills,, prejud prejudice ices, s, talent talentss and shortc shortcomi omings ngs .. [thei [their] r] self  self  confidence develops as [they] build on strengths and overcome weaknesses.” (Kouzes & Posner, 1987, p.277 )

Sofarelli & Brown (1998) argue that transformational leadership is ideally suited In conclusion Sofarelli

to context of nursing, not least because it actively embraces change and innovation within an ethical framework which complements values and b eliefs of the profession.

“A transformational nursing leader will not only be able to achieve this [change]  but will also provide the skills and desires for other professionals to stretch their   boundaries and become innovative in the way that they view problems and their  soluti solutions ons….t ….the he abilit ability y to find find innovat innovative ive soluti solutions ons;; to extend extend beyond beyond their  their    boundaries of comfort; and to test new ways of doing old things will move

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nursing further into the centre of the arena of the new health care services.” (Sofarelli & Brown, 1998, p. 206 )

They go on to argue that whilst traditional management skills, which emphasise transactional components of leadership are an important and necessary dimensions of nursing leadership, it is only when these are combined with transformational dimensions will nurses be able to deliver  the type of change and innovation so essential essential to today’s health care organisations. organisations. (Sofarelli & Brown, 1998) cite Beyers (1995) in arguing that nurses are in an ideal position to influence

change within the health care settings, given that the profession is present in all context and that nurses that nurse have a expert power base and a good, (holistic), insight into health problems; “this places them in an ideal position to identify problems, to make recommendations and implement new models of care” (Sofarelli & Brown, 1998, p. 206 )

Dixon (1999) makes the important point that within today’s health care environments which are

characterised by “discontinuity leading to a fundamental shift in the ways in which patient care is delivered” (Dixon, (Dixon, 1999, 1999, p.17) p.17).

She She goes goes on to arg argue ue that that with within in such such an an envir environm onmen entt

organisations need to balance so called soft issues of human relations with harder issues of   budget management. Key to such cultural change is the “metamorphosis of the the leader’s ability to to  put into action transformational leadership behaviours and characteristics” (Dixon, 1999, p.17 ).

“Leaders must posses the ability to help organisational players commit to what the organisati organisation on stands for and how work is conducted. conducted. This is the foundation foundation of  change. Without this, this, transformation transformation is doomed to failure. Other key behaviours include include meaningful meaningful clear, clear, consistent consistent communication communication through through multiple multiple forms, forms, acting with integrity and being authentic; and treating people with respect and dignity. dignity. These behaviours behaviours engender engender the trust building building so central to teamwork. teamwork. Finally creating opportunities for innovation and risk taking provides the fuel that  propels the organisation to a new level of effectiveness.” (Dixon, 1999, p.17)

(Dixon, 1999) argues that:

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-

 Building  Building relationships: relationships: by ensuring ensuring visibili visibility ty on shifts, shifts, active active listening, listening, challenging challenging traditional viewpoints whilst providing support required to explore new behaviours – new ways of working,

-

Creating a shared vision for the future: which emphasise a positive view of the future whilst recognising the importance of professional values,

-

 Developing a strategy for implementing the vision: involving all organisational members at all levels levels focuss focussing ing on core core values values such such as the recognit recognition ion of expert expert resour resources ces,, conscientio conscientiousness usness,, will/can-d will/can-do o attitude, attitude, sensitivit sensitivity y to internal internal and external external customer  customer  needs, and creative thinking,

-

 Recognising the value of teamwork:

-

 Developing a physician integration strategy:

-

Communicating and sharing experiences:

-

Creating a learning Organisation:

-

 Recognising Results Achieved:

In a survey by McDaniel & Wolf (1992) to determine the dimensions of leadership that result in Bass & Avolio Avolio’s ’s (1985) (1985), Multi-Funct low turnove turnoverr and work work satisf satisfact action ion,, utili utilisin sing g Bass Multi-Functional ional--

Leadership Questionnaire and Job Satisfaction Questionnaire from an earlier study by Hinshaw (1987) aimed aimed at develo developin ping g ‘innov ‘innovati ative ve retent retention ion strate strategie giess for nursin nursing g staff’ staff’,, in a nursin nursing g

department comprising of 1 nurse executive (NCEO), 11 middle level administrators and 77 registered nurses was able to validate the following hypotheses: Hypothesis 1: Leader self-assessment scores will be higher (p>0.05) than those of the respective followers; Hypoth Hypothesi esiss 2: Leader Leader self-as self-asses sessme sment nt scores scores will will be higher higher than than the follow follower’ er’ss assessment of the leader  Hypothesis 3: (in a facility where leaders report a predominance of transformational  behaviour, (as illustrated by their transformational scores), staff nurse work satisfaction will be average or above and correlated to staff’s leader- other scores and Hypothesis 4: Staff turnover will be low.

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The results derived from the MFLQ were as follows: Transformational and Transactional Self Score of the Nursing Chief Executive Officer (NCEO) and Middle Administrators Factors NCEO Middle Administrators Transformational 3.4 3.0* Individual Consideration 3.1 2.7 Charisma 3.7 3.2 Intellectual Stimulation 3.3 3.0 Transactional 2.5 2.2 Management by Exception 2.5 2.0 Contingent Rewards 2.4 2.3 (McDaniel & Wolf, 1992, p.62) *Statistically Significant P < 0.05 Paired Scores Showing Self-Scores and Other Scores of NCEO, Middle Level Administrators, and RN Staff  Factors NCEO Self NCEO by Admin Self Admin by Admin RNs Transformational 3.4 2.6* 3.0 2.4* Individual Consideration 3.1 2.7 2.7 2.3 Charisma 3.7 2.3 3.2 2.7 Intellectual Stimulation 3.3 2.7 3.0 2.3

Transactional Management by Exception Contingent Rewards *Statistically Significant P < 0.05

2.5 2.5 2.4

2.0* 2.2 2.1 1.8 2.0 1.9 2.1 2.3 2.2 (McDaniel & Wolf, 1992, p.63)

The self-scores for the NCEO and Middle level administrators indicate that the nurse executives had consistently higher self-assessment scores across all factors compared with those of middle level administrators, (hypothesis 1). McDaniel and Wolf (1992) state that:

“The score validated the cascading cascading or shared shared [leadershi [leadership] p] phenomenon phenomenon and were comp compar arab able le with with thos thosee resu result ltss obta obtain ined ed at simi simila larr leve levels ls of nonnon-nu nurs rsee administr administrators ators and nurse executiv executives. es. As one moves down the hierarchy hierarchy,, it is anti antici cipat pated ed that that the the trans transfo form rmat atio ional nal scor scores es will will decr decreas easee slig slight htly ly,, with with a conco concomi mita tant nt empha emphasi siss on the the trans transact actio ional nal scor scorin ing g repr repres esen enti ting ng the the dail daily y management in an organisation.” (McDaniel & Wolf, 1992, p.62)

They go on to argue that the higher top echelon transformational scores suggested that more attention was given to leadership interventions which directly related to the transformational

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items on the MFLQ, such as developing an organisational vision or shared values of service delive delivery. ry. The declin declining ing transf transform ormati ational onal scores scores for middle middle grades grades may sugges suggestt that that “an increasing amount of attention would be given to the operational management of the service that  parallels the decline in administrative hierarchy.” (McDaniel & Wolf, 1992, p.62)

The paired scores show that the self-assessment scores of the administrators were higher than the scores given to them by the registered nurses, these differences are consistent across all factors and support hypothesis hypothesis 2. The transactional transactional scores of the administrators administrators and registered registered nurses were lower than the transformational scores which according to McDaniel & Wolf (1992) is a desirable finding.

“This This

sugg sugges ests ts

that that

whi while

thes hese

nurs nursee

adm admini inistra strato torrs

emph emphas asiise

the

tran transf sfor orma mati tiona onall comp compon onent entss of thei theirr work, work, they they also also build build on day day to day day management [predicated primarily on transactional dimensions of leadership] to encourage the nursing staff in their work and the accomplishment of their nursing goals. The transformational leader leader would support a vision vision of nursing and enhance the nursing staff to share that vision and to develop their perceptive positions.” (McDaniel & Wolf, 1992, p.63)

The results from the job satisfaction survey supported hypothesis 3, that given the high levels of  transformational leadership practised by the nurse administrators that job satisfaction among the nursing nursing staff would be average or above. Data collecting collecting relating relating to staff turnover turnover supported supported hypothesis 4.

Research by Morrison et al., (1997) investigating the relationship between leadership style and empowerment and its effect on job satisfaction amongst nursing staff in a regional medical centre in the USA, using Bass & Avolio’s (1995) MFLQ to measure leadership and leadership style, Warr’ Warr’ss et al., al., (1979 (1979)) Job Satisfact Spreizer’s (1995) psychological Satisfaction ion Questionnai Questionnaire re and Spreizer’s

empowerment instrument, returning 275 useable questionnaires from an initial sample of n=442; indicated that both transformational and transactional leadership were positively related to job satisfaction with correlations of 0.64 and 0.35 respectively, with only transformational leadership

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 being positively correlated to empowerment 0.26. The higher positive correlation between job satisfaction and transformational leadership compared with transactional leadership is argued by augmentation on concept which Morrison et al (1997) to provide evidence of the Bass’s (1985) augmentati (Dixo (Dixon n 1999; 1999; McDa McDanie niell & Wolf, Wolf, 1992) 1992) practi practical cally ly summar summarise ise in arguin arguing g that that effect effective ive

transformational leaders build on the transactions found in everyday management.

Correlation Matrix for Leadership Style, Empowerment and job Satisfaction Variable 1 2 3 4 Transformational Leadership Transactional Leadership 0.54* Empowerment 0.26* 0.08* Job Satisfaction 0.64* 0.35* 0.41* N= 275, *p < 0.05 [Source: Morrison et al, 1997, p.30]

Other studies by Laschinger & Havens (1997) , Laschinger, Wong, Macmahon & Kaufmann (1999) and McNeese-Smith McNeese-Smith (1997) indicate indicate a causal relationship relationship between between transforma transformational tional

leadership behaviour and perceptions of staff nurse empowerment, levels of occupational health and organisational effectiveness.

Research in the UK by Bowles & Bowles (2000) using Kouzes & Posner’s (1988, 1995) Leadership Practices Inventory (LPI) in a comparative study of transformational leadership in nursing development units (NDUs) and conventional clinical settings, using a sample of 70 nurses comprising of two equally sized sub-groups drawn from NDU and Non-NDU settings. The self-evaluations using using the LPI showed little difference difference between the sub-groups. sub-groups. However, the the data data indi indica cate ted d two two diff differ eren ence cess in whic which h lead leader ersh ship ip was was perc percei eive ved d by foll follow ower erss (observers/raters):

The observer (raters) score for non-NDU leaders were lower than those from NDU leaders across each of the five practices of exemplary leadership.

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The observ observer er (rater (raters) s) scores scores for non-ND non-NDU U leader leaderss are lower lower than than the leader leaders’ s’ selfselfevaluat evaluation ionss across across each of the five practices practices..

By contrast contrast observer observer scores scores for NDU

leaders were higher than the leaders’ self-evaluations on four out of the five practices.

Mean Self-evaluations for each of the five practices of exemplary leadership Role

Challenge the process

Inspire a shred Vision

Enable others to act

Model the way

Encourage the heart

NDU Leader Non-NDU Leader

24.14

23.14

25.29

24.14

25.29

Total Leadership Score 121.43

24

22.14

25.36

24.57

25.29

121.86

Mean observer evaluations for each of the five practices of exemplary leadership Role

Challenge the process

Inspire a shred Vision

Enable others to act

Model the way

Encourage the heart

NDU Leader Non-NDU Leader

25.71

25.25

25.64

24.71

25.21

Total Leadership Score 125.75

22.92

21.29

24.64

23.82

23.32

115.57

[Source: Bowles & Bowles, 2000, p.73] Bowles & Bowles (2000) state that

“NDU leaders were more highly evaluated by their observers than their non-NDU counterparts. They demonstrated a higher higher level of congruence between between their selfevaluat evaluation ionss and observ observer er evaluat evaluation ion and more more trans transfor format mation ional al leader leadershi ship p  behaviour than their counterparts.” (Bowles & Bowles, 2000, p.74 )

A review of a sample of 2,013 managers from the NHS identified a far more complex model set of behaviours than previous US research.

“The most obvious implications of these findings is the staggering complexity of  the role of leadersh leadership ip in the NHS.

Anothe Anotherr lesson lesson is that the transact transaction ional al

competencies of management, while crucial are simply not sufficient on their  own. […] what is clear is that existing us models of leadership do not encapsulate this complexity. complexity. Typically, they place and overwhelming emphasis on charisma charisma

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and vision: on leaders acting acting primarily primarily as the role model for their followers. followers. Is this the product of adopting research methodologies which focus solely on the view viewss of top top mana manager gers, s, or rese resear arche chers rs deve develo lopi ping ng model modelss from from thei theirr own own observations?” (Alimo-metcalfe, 2001, p.40 )

The qualities of leadership emerging as most important to staff to staff in NHS are characterised  by concern for others , followed by the ability to communicate and inspire. Qualities of Leadership Perceived by NHS Staff to be Most Important At the very ery top of the list of dim dimensi nsion for  Decisi Decisiven veness ess,, Determi Determinat nation ion,, Readin Readiness ess to leadership leadership came Genuine Concern for Others. take Reasonable Risks. Ability Ability to clarify clarify shared

This includes showing genuine interest in staff as individual individuals, s, seeing seeing the world world through through their eyes, valu valuin ing g thei theirr cont contri ribu buti tion ons, s, deve develo lopi ping ng thei their  r  strengths; coaching, mentoring and having positive expectations of what what staff can achieve. achieve. The others, in order of importance, were followers.

values values and a sense of directi direction. on. This This reflect reflects s a strong element element of engaging with with colleagues. This is another example of how the model differs from major US ones.

Inspi Inspirati rationa onall Commun Communica icator tor,, Networ Networker ker and Abil Abilit ity y to Draw Draw Peop People le Toge Togeth ther er with with a Achiever. This is essentially about communicating Shared Vision. This relates to having a clear vision the vision vision of the organ organisa isatio tion n with with passio passion n and commitme commitment. nt. Unlike Unlike US models of ‘visionar ‘visionary y and charismat charismatic’ ic’ leadership, leadership, it stresses stresses the need for  partne partnersh rship ip in engagi engaging ng and extens extensive ive range range of  inte intern rnal al and and exte extern rnal al inte intere rest sted ed parti parties es in the the process by actively networking with them, gaining their confidence and support through sensitivity to their varying varying needs. needs. It also about about celebrating celebrating the acco accomp mpli lish shme ment nts s of the the team team,, depar departm tmen entt or  organisation. Empowering Empowering others to lead A manage managerr who disp displa lays ys this this dime dimens nsio ion, n, trus trusts ts staf stafff to take take decisions/initiatives on important matter; delegates effective effectively ly and encourages encourages staff to develop develop their  their  leadership leadership by providing providing opportunities opportunities to them to take on increased responsibilities. Transparency. This his relat elates es to the the aspe aspect ct of  integrity which is about honesty and consistency in behaviour, but also reflects the attitude of placing the good of the organisation before personal gain. It also also invo involv lves es huma humani nity ty and and humi humili lity ty and and willingness to modify one’s views after listening to others. Accessibil Accessibility, ity, Approachab Approachabilit ility y and Flexibilit Flexibility y. This reflects a style which is not status-conscious, which places great importance on face-to-face, as opposed to distant leadership, and which attempts to ensure that staff at all levels feel comfortable and able to access the individual. .

and strategic direction in which the ‘leader’ actively engages various internal and external stakeholders in developing; drawing others together in achieving the vision. It encapsulates some some of the core values values and and atti attitu tude des s exho exhort rted ed by the the gove govern rnme ment nt’s ’s modernisation agenda.

Charisma. This This is conc concer erne ned d with with exce except ptio ional nal comm communi unica cati tion on skil skills ls,, abili ability ty to keep keep in clos close e contact with others, encouraging others to join in.

Encouraging Challenges to the Status Quo. This includes clarifying the long term corporate direction while encouraging others to challenge the status quo, quo, with with respec respectt to tradit tradition ions s and assump assumpti tions ons about what is being done, how problems are dealt with, and the quality of the service provided.

Supp Suppor orti ting ng

a

Deve Develo lopm pmen entt

Cult Cultur ure e.

This incl include udes s empow empower erin ing g indi indivi vidu dual als s to chal challe lenge nge tradition, take risks and express dissatisfaction. dissatisfaction. In so doing the person presents a powerful role model for leadership.

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Ability to Analyse and Think Creatively . This is

Managi Managing ng Change Change Sensit Sensitive ively ly and Skillf Skillfully ully.

sees as an essential dimension in the public sector  leader. It involves the capacity to deal with with a wide range of complex issues and the ability to utilise creativity in problem solving.

This includes being sensitive to the impact which changes in the external environment can have on the orga organi nisa sati tion on;; bein being g awar aware e of how how thes these e changes changes will will different differentiall ially y impact impact on parts of the organisation, being aware of the impact of one’s decisions, and having the wisdom to balance the need to change with some degree of stability.

(Source: Alimo-Metcalfe, 2001, p.41 ) According to Lindholm & Sivberg (2000) managers within health care generally and nursing in  particular are increasing the pressure on their subordinates from board level downwards to  provide skilled and competent leadership which will empower their staff to meet the challenges of providing patient/client focussed health care in the 21st century. Contemporary approaches to leadership Bass & Avolio (1985, 1990) , Burns (1978) , Kouzes & Posner (1987) , Tichy & present complex complex multi-dim multi-dimensio ensional nal DeVanna DeVanna (1986), Conger Conger & Kun Kunnun nungo go (1987, (1987, 1999) 1999)   present models of leadership which argue that change may be engendered though by combining the   judic judiciou iouss use of transf transform ormati ational onal behavio behaviours urs with with the less less freque frequent nt use of trans transact action ional al  behaviours.

Davidhizar (1993) and “Wit “W ith h rega regard rd to the the turb turbul ulent ent aren arenaa of heal health th care, care, Davidhizar Lafferty (1998) speak about utilising the qualities of transformational leadership,

whic which h focu focuse sess on probl problem em solv solvin ing g in a chang changin ing g envi enviro ronm nment ent as the the most most appropriate form of leadership. Burns (1978) , who produced an early conception of transformational leadership, argue that leaders and followers raise one another  to

higher

levels

of

motivation

and

morality

rooted

in

common

values values….. …..Tra Transa nsacti ctional onal leader leadershi ship p by contras contrastt is concern concerned ed with with day-to day-to-da -day y operations in an unchanged organisational system and has, according to Dunham more of the charac character terist istics ics of tradit tradition ional al leader leadershi ship p and & Klafehn Klafehn (1990) more management…d management…direct irected ed at organisati organisational onal maintenance… maintenance… Bass (1985) considers transform transformationa ationall leadership leadership and transactio transactional nal leadership leadership to be distinct distinct but not mutually exclusive processes, and declared that the same leader may use both types of leadership at different times.” (Lindholm & Sivberg , 2000, p.328)

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The key issues here is that the empowerment of nursing by leaders is likely to cascade down to the community, and an empowered community will then be able to choose cho ose [within environmental constraints] health services that are pertinent to the the health needs of that community. These are high ideals - but the key theme of empowerment through the leadership styles associated with the 4Is of transformation leadership are viewed as an important dimension of professional practice. However, in order to gain and appreciation of the potential contribution that transformational leadership theory can make to the development of contemporary health care systems through the empowerment of nursing practice it is important to remember that: such perspectives largely ignore the effect of contingent contextual variables such as the inequitable inequitable or inadequate inadequate distributi distribution on of resources, resources, quantum advances advances in supporting supporting technologies, the inherently irrational nature of the political environment etc., and as a study of the characteristics of executive nurse leadership by (Dunham & Klafehn, Klafehn, 1995) clearly indicates, effective leadership in the health care arena is not

simply a case of utilising a transformational style at the expense of a transactional one,  but on employing critical thinking in ensuring that transformational behaviours augment the transactions which are the foundations of everyday management in order that the nursing profession and the organisation are able to respond to environmental variables within an adaptive relationship of creative reinvention.

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