The Context of Nursing Leadership

A Critical Analysis of Leadership in Health Care

The term leadership means different things to different people; Northouse (2010) defines leadership as a process whereby an individual influence a group of individuals to achieve a common goal. Mullins (2010) stated that leadership is a process which exists at all levels. John Kotter (2001) opined leaders to have the following essential characteristics; confidence, motivation, good communication system, influencing others, decision making and goal setting. Walshe and Smith (2006) Stated that, leadership is paramount to health care as leaders need to develop strong networks within and across organisations to influence change. In the same way Goodwin (2006) suggested that, leaders must find a balance between implementing nationally driven policies and achieving locally significant objectives. Furthermore, address challenges; look for strategic alignment across agencies. Thus, in today’s ever- changing health care environment, nurses require leadership which delivers high quality care, ensuring patient safety and facilitating positive staff development (Hartley and Bennington, 2010).

The assignment explains how the concepts of Authentic Leadership (AL) and Transformational Leadership (TL) emerged and analyse the similarities and differences between these theories. The paper will then focus on a community nursing team which I have known to critically analyse the strengths and weaknesses before applying a leadership theory. Lastly, the assignment turns to discussing my current leadership ability using strengths, weaknesses, opportunities and threat (SWOT) analysis before setting a SMART goal to develop my leadership skills further.


Part 1

AL originated from ancient Greek philosophers who stressed authenticity as an important state through an emphasis on one being in control of one’s life (Irvine and Reger, 2006). It originated in the 1960’s as a means to describe how an organisation reflects itself authentically through leadership (Galloway and Gopee, 2017). In the recent era of globalisation, people prefer AL for building trust and developing suitable leadership style who can manage the individuals successfully (Bass, 1990). Goerge (2003) implied people feel apprehensive and insecure about what is going on around them, and as a result, they choose appropriate leadership that they can trust who are honest and good. Avolio et al (2009) stated that people’s preferences for trustworthy leadership make the study of authentic leadership timely and worthwhile.

Goodwin’s (2006) approach to AL emphasises building the leader’s legitimacy through honest relationships with followers which value their input and are built on an ethical foundation. Both George (2003) and Goodwin’s (2006) approach to AL is more developed by the characteristics of leadership and view authentic leaders as positive people with truthful self-concepts who promote openness. According to Gill (2011), AL is effective for the individuals to build strong relationship with other individuals and balance the system successfully in near future. Walumbwa et al (2008) conceptualises AL with more of a theoretical approach and that it is composed of four distinct but related components: self-awareness, internalised moral perspective, balanced processing and relational transparency.

The definition of AL develops a theme of honesty and legitimacy in leadership across the literature explored and has several positive features. AL can be seen to fulfil an expressed need for trust-worthy leadership in society and provides an answer to people who are searching for sound leadership in an uncertain world. Furthermore, AL provides broad guidelines about how the leaders can learn to be authentic and is seen as a process that is developed by leaders over time rather than a fixed trait. Lastly, the major finding was that although the concept of AL emerged in the 1960’s studies did not begin until 2005 and is a growing area of study in academic research on leadership; it has grown recently from vagueness to the beginnings of a fully mature concept.

On the other hand, the concept of TL was introduced by James V. Downton, a concept further developed by leadership expert James Burns (Gill, 2011). The works of Bennis and Nanus are also representative of TL (Nourthouse, 2013). Bass (1985) differentiated transactional leadership from TL and placed it as part of a continuum with laissez faire leadership. Moreover, Bass and Riggio (2006) suggested that TL’s popularity may be due to its emphasis on intrinsic motivation and the follower development, which fits the needs of current work groups, who want to be inspired and empowered to succeed in times of uncertainty. In this regard, transformational leadership is mainly a leadership style where a leader is responsible to identify the needed changes. Creating a clear vision to develop changes through inspiring and motivating the people in the society. Antonakis (2012) suggests there are four dimensions of TL called idealised influence, individualised considerations, intellectual stimulation, and inspirational motivation. Idealised influence refers that, the leader leads the team members and followers by using previous examples where the leader influences the individuals by meeting their expectations and motivating them. Individualised consideration implies that the leaders arrange effective training and development program for the followers so that they can gain knowledge and skill to perform their duties and responsibilities in a better way. Moreover, the leader empowers the followers in the decision making behaviour in order to gather more ideas from the followers so that the leader can analyse and choose the best decision cooperatively. empowerment and coaching o the followers are therefore beneficial for the leaders who follow transformational leadership style in order to achieve success. the third component is intellectual stimulation includes learning and growth where the leader encourages the followers to learn more and gather more knowledge and skill for their personal and professional development. the fourth component is inspirational motivation where the leader inspires to go to new heights where the individuals can achieve success in near future through more creativity and innovation.

Under transformational leadership style, the four components such as idealised influence, inspirational motivation, individualised consideration and intellectual stimulation are effective to develop a successful leader where the leader can build strong relationship with the individuals through motivation, innovation and creativity and communication. The leader in this transformational leadership model focused on purpose of the vision and goal and influence chances so that the pre-specified objective can be fulfilled successfully. Moreover, the leader inspires the followers and develop people driven goals for fulfilling the needs and preferences of the individuals. innovation and creativity are the importance aspects where the leaders focus on enhancing innovations so that the goals can be achieved more creatively. Inspirational motivation of the leader is effective to influence the individual to accept the changes for fulfilling the commitment.

There are many differences and similarities between TL and AL. With regard to conceptual differences, TL focuses on developing followers for the purpose of performing leadership roles (Avolio, 1999); whereas authentic leadership is more concerned with developing followers' sense of self more generally (Avolio and Gardner, 2005). Inspirational motivation concentrates on inspiring the group members and setting a higher level of expectations for them (Kotter, 2001). The transformational leader acts collaboratively with the followers and takes into consideration their emotions, opinions, interests and demands offering a shared vision of the future (Antonakis and Day, 2018). Mills et al (2009) suggests it is that component of leadership that arouses follower’s enthusiasm and sense of team spirit. However, Tomey (2004) implies this can be seen as dishonest as the transformational leader might not be straightforward with their followers. According to Irvine and Reger (2006) this style may sound preferable because the leader does not express their self-interest to their followers however, it is seen as inauthentic.

Additionally, authentic leaders are not necessarily charismatic or inspirational, yet transformational leaders by definition paint powerful visions and stimulate creativity among followers within an organization. Manning and Curtis (2007) argue that intellectual stimulation motivates followers to rise to solve problems using new ideas. Likewise, Pierce and Newstrom (2006) view intellectual stimulation as promoting knowledge sharing within the organisation to let followers create more innovative ideas and solutions. Conversely, authentic leaders contribute to elevated levels of follower engagement, trust in the leader, well-being, and performance (Gill, 2011). Hence, the explicit focus on the psychological health and well-being of both the leader and followers that is not present within the TL literature.

As for similarities, Avolio and Gardner (2005) note that the underlying leadership processes described by both theories stress the importance of leader self-awareness, positive modelling, follower self-determination, positive social exchanges between leaders and followers, and a supportive and ethical organisational context. Idealised influence aims to develop a shared vision and improve relationships with followers (Avery, 2004). By idealised influence the leader puts great importance on ethical values and they seek to meet the follower’s needs rather than their own (Bass and Avolio, 1994). This is very similar to those reported by Northouse (2012) and Gill (2011) who suggest, in such an atmosphere, followers associate themselves with the leader and they accept the leader’s values and beliefs without questioning. Therefore, TL can be seen similar to AL as the leader is seen to present authenticity in their actions. Their behaviour may reflect on ethics and values they promote through transparency and fairness (Gill, 2011). Avolio and Gardner (2005) point out that while there are notable differences been the posited elements of authentic leadership versus TL, there is also a considerable amount of conceptual overlap.

Moreover, individualised consideration acknowledges the exclusive needs and desires of the group members in an organisation and attends to it positively (Northouse, 2012). Bishop (2009) describes transformational leaders as people who care about their follower’s individual development. This is perceived positively by Pearce and Conger (2002) as this dimension of TL enables every group member to feel important. Payne (2000) describes individualised consideration as leaders concentrating on empowering followers so that a learning climate can be built. Likewise, Irvine and Reger (2006) suggest that in AL you may need high levels of organisational skills to create and sustain healthy work environment. From the literature it has become apparent that the emphasis is on empathy and compassion balanced with honesty for the sake of the employees and their teams in both AL and TL. However, TL has been challenged by research that implies it has trait-like qualities and can be seen as undemocratic and has the potential to be used in negative ways by leaders (Gill, 2011). Underlying both the approaches it is apparent that leaders require authenticity to do what is right and good for their followers and society. Avolio et al (2009) suggest AL and TL reflect a considerable amount of conceptual overlap and concerns have emerged about whether AL is sufficiently distinct from other theories (Avolio and Walumbwa, 2014).

The paper will now discuss a strength and weakness of a district nursing team of whom I have known and one of the major issues faced was the retention of staff within the team. Millward and Bryan (2005) described nursing shortage as a global issue and are considered vital as it affects patient’s health status and quality of care delivered. In order to achieve health care effectiveness, health care systems have to overcome the shortage of qualified health personnel. Buchan and Aiken (2008) suggested that nurses keep searching for better opportunities to improve their skills, knowledge, and economic level and therefore migrate (Mullins, 2010). A qualitative research carried out by Szeremeta and Shamash (2016) found that the current lack of attention and investment in improving skills and developing pathways resulted in losing NHS staff. This is a very recent piece of research making it reliable and applicable to the current staffing crisis within the NHS, however this research was conducted with acute nursing staff therefore, may not be applicable to reflect on the community nursing staff. Although it could be argued that leadership is the same whether it is in the acute setting or in the community (Hartley and Benington, 2010).

In order to address the issue faced with increased nursing staff turnover in the community setting it would be sensible to implement the path-goal leadership as leaders motivate followers to be productive and satisfied with their work (Gill, 2011). Jermier (1996) advocates that this style provides a theoretical framework that is useful for understanding the productivity and satisfaction of followers. Additionally, Cote (2017) agrees it provides practical model that underscores the important ways in which leaders help followers. However, Northouse (2012) implies that the path-goal theory encompasses so many interrelated sets of assumptions that it is hard to use this theory in a given organisational setting. The theory also assumes that leaders have the skills to allow them to switch between various leadership behaviours needed by differing followers (Northouse, 2012). Another flaw noted by Mendez and Busenbark (2015) in this style of leadership is that it is predominantly leader orientated and fails to recognise the interactional nature of leadership. Barr and Dowding (2002) suggests AL has a negative effect on staff turnover intention and positive effects on work engagement.

On the other hand, Whitmore (1992) suggests utilising the GROW model enables the coach to work in partnership with the coachee to raise self-awareness and identify choices ultimately closing gaps between knowledge and performance by empowering the employee. Roger (2012) implies this enables the coachee to be more resourceful and sustain effectiveness which results in personal and professional satisfaction; however the goal that is to be achieved should be SMART orientated. In contrast, the district nursing team had excelled in their performance by meeting patient needs and were providing effective care. There is relatively little national policy focus on quality in community health care, and approaches to measuring and improving quality in community services are less well developed (Edwards, 2014) however there were certain measures in place to monitor whether patient needs were met in the form of monthly caseload reviews, patient feedback and audits. According to the Department of Health (DH, 2008) healthcare is continually shifting towards the community ultimately putting more pressures on the community organisations. Recent criticism of some aspects of current community practice within the NHS has placed the role of delivering quality patient care increasingly under the spotlight (The Kings Fund, 2012). Community health is a vital part for the NHS and is forever changing depending on the demands of the services (Gill, 2011).
In this instance situational leadership may have been applied within this team as leaders can become effective in many different types of settings involving a wide variety of organisational goals (Northouse, 2012). Hersey and Blanchard (1993) suggest this approach provides a model based on the demands of a particular situation. On this occasion effective leadership occurred when the leader could accurately diagnose the developmental level of the followers in a goal situation and then exhibit the prescribed leadership style in that matches that situation. However, Larsson and Vinberg (2010) argue that unlike many other theories this approach does not have a strong body of research findings to justify and support the theoretical underpinning on which it stands. As a result it is not clear on how commitment changes over time for followers and without these basic research findings the validity must be questioned.
Additionally, the Belbin’s team role theory has proven to be effective (Prichard and Stanton, 1999). Belbin argues that a team which consists of mixed roles perform better than those of fewer roles. This was evident in a meta-analytic review carried out by Prichard and Stanton (1999) as it showed the mixed role teams performed significantly better at a management game than the team with only one role. This theory could be applied to the district nursing team as the team consisted of one clinical development lead, two team leaders, four staff nurses, two healthcare assistants, one phlebotomist, and one administrator (George, 2003).

All members where from different cultures and backgrounds thus, the Belbin approach shows the theory can work cross culturally (Cote, 2017). Although, there are flaws with these observational studies as the participants know they are being observed thus they behave in a way that they believe that is expected of them affecting the truthfulness of the study (Aveyard et al, 2016). It is apparent that many characteristics need to be acquired by leaders as they play a vital role in nursing practice and confront many challenges (Avolio, and Gardner, 2005). In order to assist minimising high staff turnover the leaders should utilise the GROW model and implement path-goal strategies of self-awareness, empowerment, critical thinking and discussion to improve job satisfaction which in turn will result in patient care and outcome (Bass and Riggio, 2006). Nonetheless, it can be supposed that situational leaders might have the ability to motivate and include their followers to maintain quality patient care by adapting to the given situation at hand (Bishop, 2009). Hence, it would be sensible to conclude that different forms of leadership inspire their followers during problematic and positive times through developing a shared vision. Furthermore, the Belbin theory has proven to be effective in terms of team performance (Avolio and Walumbwa, 2014).

Part 2

According to the leadership standard, nursing leadership requires many personal characteristics and skills, such as respect, relationship, trust, self-awareness, learning, communication, integrity (Gill, 2011). As a school nurse I aspire to be an authentic leader. To assess my AL abilities, I completed an AL self-assessment questionnaire (ALQ) (Northouse, 2012). This questionnaire contains four different dimensions of AL which are: self-awareness, internalised moral perspective, balance processing, relational transparency (see appendix A), which implies that my current overall leadership is at medium level and there are many areas I need to improve.

Self-awareness refers to the personal insights of the leader (George, 2003) and here I scored a respectable 17. Luthans and Avolio (2003) indicate it is not an end in itself but a process in which individuals understand themselves, including their strengths and weaknesses, and the impact they have on others. In addition, Martin et al (2010) argued it includes being aware of and trusting your own feelings. It is clear from the score that I have a strong understanding of the decisions and actions I make and other people will see me as one who has great self-awareness which makes me more authentic. More recently, research has shown that self-knowledge and self-consistency also have a positive impact on follower’s satisfaction with leaders, organisational commitment, and perceived team effectiveness (Gill, 2011) and this reflects in the score. According to the SWOT analysis (see appendix B) good communication skills is one of my strengths thus I will be able to present myself as an example for the followers and manage performance by setting up clear rules or expected targets.

Internalised moral perspective refers to a self-regulatory process whereby individuals use their internal moral standards and values to guide their behaviour rather than allow outside pressures to control them (Northouse, 2012). Here I scored expected 13 as I allow people to have control to an extent where they influence me. As SWOT indicates I am soft spoken and can get overlooked by the team. In the same way I scored low at 14 for balanced processing. Although I am not completely clear from its title, Luthans and Avolio (2003) refer it to an individual’s ability to analyse information objectively and explore other people’s opinions before making a decision. I believe this area needs improvements as I must be open about my own viewpoints and avoid favouritism about certain issues and remain unbiased. George (2003) advises that balanced processing includes soliciting viewpoints from those who disagree with you and fully considering their positions before taking your own action. Thus, if this is done successfully I can be seen as authentic because I am open about my own perspectives, but am also objective in considering others perspectives.

Relational transparency showed as one of my strengths as I scored highly and refers to being open and honest in representing ones true self to others (Northouse, 2012). Coper et al (2005) proposes it is self-regulating because individuals can control their transparency with others. I am one to share core feelings, and motives with others in an appropriate manner. I am honest and emphatic; which are two key fundaments in relational transparency, although all four concepts can be seen as overlapping one another.

However, there are still some areas that require improvement. For example, my self-confidence fluctuates according to my abilities to perform certain tasks and may have a negative attitude in helpless situations. Moreover, I may bring my personal emotion into the workplace when I lose control of it. From the results of the survey I can notice that leading other people is something I find most challenging. I have identified the area that needs improvement is internalised moral perspective and balance processing. I now need to start to put some effort into improving this weakness. I plan to do this by setting a Specific Measurable Attainable Relevant Time (SMART) goal. I want to be confident to perform certain tasks that may have negative attitudes. This would be measured by completing feedback surveys orientated around my performance from the team members. In order to achieve this I will utilise transformational theory as transformational leaders are more self-aware and display high levels of self-confidence (Gill, 2011). Furthermore, to develop my self-awareness I will use the model Johari’s Window (Barr and Dowding, 2002). I hope to achieve this goal by the end of my placement.

In conclusion, TL can be seen as a more democratic style of leadership where leaders seek the opinion of the followers in the decisions they make. It is evident from the literature that TL involves charismatic and visionary leadership satisfying the needs of followers rather than the followers mirroring their beliefs and values as in AL (Aveyard, Payne, and Preston, 2016). On the other hand, the characteristic of TL and AL is both empowering their followers and foster their positive self-development. Both styles of leadership advocate honesty, ethics, and values however; AL relies on these characteristics slightly heavier than TL (Antonakis, and Day, 2018).

In terms of team leadership and performance Gill (2011) implies it is fair to say leaders have the opportunity to apply any style they deem fit in achieving their goals and objectives. Pearce and Conger (2002) illustrates this point clearly by suggesting applying one or more styles and changing the style if they see one is not effective. According to Northouse (2012) no matter the style the leader applies or management decisions they make they must be able to ensure growth and sustainability in the health sector.

Lastly, different theories have been proposed to facilitate nurse leadership to ensure that there is motivation for achieving the goal and are used interchangeably, since environments and situations are constantly changing in healthcare settings (Millward and Bryan, 2005). Factors such as member skills, the circumstances or the problem at hand, the work environment are put into considerations (Hartley and Bennington, 2010) therefore it was crucial I assessed my current level of leadership to identify areas that required improvement and apply a SMART goal. Through my leadership assessment as a community nurse I believe that I hold AL traits and my current skills lie heavily in self-awareness and relational transparency however lack in internalised moral perspective and balanced processing. To become an effective authentic leader I must achieve the SMART goal set however have learnt that this style of leadership is still in its early development and is evolving. Therefore my AL style must evolve with it too. Another important factor is that I must have followers and that of those who choose to follow me rather than those who are forced to follow through fear or lack of choice.

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