To lead or not to lead: that is the question

Presenting the Janet Kinson Lecture is a great honour, both personally and professionally. My thanks go to Joy Williams, Drs Gordon Caldwell and Ute Weis from the Worthing team and Marie Clark for their nominations, and also the Professional Advisory Council Executive of Diabetes UK. Although I never met Janet Kinson, her book1 was the first one I read when I started in diabetes nursing, and it helped me to begin to understand how different caring for ‘well’ people with diabetes was, from the acute nursing care I had given as a sister on medical wards. My understanding of this lecture is that it enables reflection on areas that are important to the speaker, and in so doing demonstrates their education and learning. My focus is on leadership, because I believe it is essential for patient care and services, and self-leadership is important for us as individuals. Without leadership, resources cannot be used effectively or attracted to or retained in services, as vision and direction will be lacking. Therefore education enabling leadership of ourselves, our teams and services appears absolutely crucial to the continuance of quality patient care and outcomes, and is as important as our education enabling clinical skills. When I reflect on my leadership journey, I can identify the factors I have found important to know, and these will be discussed during this article. They include definitions of leadership, the influence of traditional and contemporary theories and styles on our views of leadership, the barriers preventing leadership and the costs of poor leadership. The importance of leadership will be emphasised throughout, along with my belief that we can lead, and that we need to be realists, not idealists, to be effective and successful leaders. I have been fortunate throughout my career to work with excellent role models, beginning with two exceptional ward sisters at Guy's Hospital where I trained. They motivated me, encouraged my learning and valued my contribution, and inspired me to become a ward sister, modelling their behaviour. I did not consider or understand their behaviour then, I simply copied what I observed, and it is only now, on reflection, that I can attribute their skills and success to leadership. There were several other people over the next few years who inspired me to lead, and the main catalyst for being a leader was when I was appointed Nurse Consultant in Diabetes in 2002, with leadership as a competency. This meant that I was judged on these skills, so I needed to have some! I immersed myself in books, which was counterproductive, as in my haste to learn I overwhelmed myself and consequently nothing went in. The only thing that increased was my frustration. What really helped me was attending the self-leadership programme provided by Eli Lilly, with other nurse consultants and senior diabetes nurse specialists. We learnt leadership tools based on neuro-linguistic programming (NLP)2 which we practised and improved upon during national nurse and Diabetes UK workshops, and within our own organisations. Knowing others (Lorraine Avery, Sean Dinneen and Simon Heller), who wanted to explore leadership in diabetes care, provided an opportunity to present workshops at Diabetes UK between 2004 and 2006. This further developed my learning by exploring issues around leadership in practice, and some of our shared experiences are reflected here; I thank them and everyone else who has accompanied me on this leadership journey so far. According to O' Connor,3 leadership can be defined as: ‘ A way of acting and a way of being that we can all have, not something out there, something for other, famous people.’ He suggests leadership is taking a path, or going on a journey, where the journey itself is the activity, not the destination. If we move into more detail, it is also about engaging others as partners in developing the shared vision, to ensure all are travelling in the same direction. Leaders commit people to action, convert followers to leaders, and leaders into agents of change;4 they can rarely make events occur on their own. There are as many views of leadership as there are definitions. Covey5 states that what is more important than how fast you are going, is knowing where you are heading, which I interpret as it's better to stay in the car park, and agree the direction, ensuring there are sufficient resources for the journey rather than hit the road, any road, fast. Knowing what you are leading and why is important, rather than leadership being solely a lust for power. Why learn to lead, in addition to everything else currently happening in health care? O' Connor3 suggests many positive reasons: to be involved in something that inspires and really matters to you, to have companions on your journey, and to influence areas that are important to you. He also describes leadership as a gift from others, those who choose to travel with you. This suggests a more active involvement by followers, not present in traditional leadership theories, which will now be discussed. Early theories focused on the personal traits of the leader, as though leadership was a characteristic that resided in some people and not in others, suggesting that the ‘ great men and women’ of history were born and not made. This view puts leadership out of reach of mere mortals, emphasised by the following examples and their achievements— Gandhi, Churchill and Mandela. In contrast, more recent theories provide evidence of leadership skills which can be learnt and developed in a range of people. This change can be explained in part by the changes in society. The ‘great man’ theory developed in a relatively predictable, stable world, with comparative economic certainty. However, the major recessions of the 1980s caused organisations to revise how they did things: militaristic top-down management was viewed as inappropriate and instead a leader who could help organisations to successfully adapt to change was required. Consequently, contemporary leaders such as Rudolph Giuliani and Jose Mourinho provide examples of leadership styles, which feel more achievable, and more able to copy. So whom we see as a leader can enable or disable our leadership aspirations from the outset. Leadership styles vary, which is understandable as reasons for your journey, your destination and with whom you travel are personal. There is no one way to lead, which emphasises the importance of flexible responses, depending on the needs of the situation, organisation, and staff competence and development.3 However, how we lead has great relevance to care as the following styles demonstrate. There are three main styles identified— autocratic, democratic and laissez-faire,6 with the transformational style a more recent addition.7 The autocratic style means that the leader makes all the decisions for subordinates who have no influence, generally using coercion. The democratic style describes a participative, people-oriented style, with open interaction between leader and follower, and effective work groups being important. Laissez-faire provides members with complete freedom, with limited leader participation and feedback, and often a loss of group unity. The transformational style enables a culture to grow where everyone can develop their leadership potential, and where change is a way of life. Kouzes and Posner8 captured the five main elements of this style, plus the four implicit personal skills of self-leadership, life learning, reflection and transforming self (Table 1). They describe transformational leaders as ones who search for opportunities to introduce change, and innovate, experiment and take risks, learning from successes and failures. Transformational leaders passionately believe they can make a difference, and envision the future, enlisting others and getting them to see exciting future possibilities. They sustain extraordinary effort through mutual respect, developing capability within an atmosphere of mutual trust, and establish principles of how people should be treated and goals pursued, setting and modelling standards. They recognise the contributions that individuals make, celebrate accomplishments and enable individuals to share in the rewards of others. They are often charismatic, inspiring communicators, achievers and networkers, who are transparent, accessible and flexible.8 Manley7 incorporated these transformational behaviours and skills into the competency framework for nurse consultants. Given all these positive elements, this style makes sense in the context of the chaos in which we work in the NHS, and suggests to me that we need these skills as much as our clinical and educational skills. Challenging the process Inspiring a shared vision Modelling the way Encouraging the heart Enabling others to act Self-leadership Life learning Reflection Transforming self Research by Alimo-Metcalfe and Alban-Metcalfe9 demonstrated the benefits of transformational leadership in organisations. This style was shown to predict a wide range of positive outcomes for the staff involved in terms of reduced stress, increased motivation, increased achievement motivation and job satisfaction. The last outcome is very important, as it is one of the most powerful predictors of organisational productivity and profitability, two key challenges facing the NHS at the moment. Having considered both theories and styles, it is pertinent to consider why leadership is seen as important in health care. Leadership has been emphasised throughout the Labour government's modernisation agenda; White Papers continue to recommend increasing clinical leadership and roles (e.g. nurse consultants), and identify leadership skills as the key to delivery of good health care. Importantly, these leadership skills can be learnt, for patients deserve well-led services; therefore, we must be able to lead teams across organisational, clinical and professional boundaries.10 Effective team-working remains important for effective leadership, as you only lead as a gift from others. Two professions have either enabled or disabled my leadership aspirations— medicine and nursing. The issues raised may also be relevant to podiatry, dietetics and other allied health professionals. Richard Smith11 described doctors and leadership as oil and water. He stated that doctors feel uneasy about power and think of it negatively but, at the same time, are often unwilling to cede power, which is important in empowering and leading. Similarly, they are often wary of abandoning control, yet that is what leadership is about. Some doctors can be awkward with teams, being more inclined to dominate rather than lead them, and as such have created organisations that are hard to lead, and have ignored those with leadership potential. On reflection, many doctors are not used to systems or organisations, and have little experience of setting strategy or ability to see the broader picture, yet often have leadership thrust upon them due to their position of power. Nursing also has difficulty with leadership, as the following view from Redfern12 illustrates: ‘ Nursing berates itself for not having any leadership; leadership is seen as a task for a handful of nurses holding top posts. If these people do not conform to our perceptions of leadership, then nursing has NO leadership. We demand that they map the way forward, yet, when they do, we insist on walking the other way.’ The current debate in the diabetes nursing press reflects this ambivalence and stereotyping of leadership. Diabetes nursing is berated for having no leaders, yet evidence disproves this. Nursing leaders are there, presenting leadership workshops at national conferences, publishing in journals, and successfully leading many service changes. What may be perceived to be missing are the ‘ heroic’ leaders in the top posts; that may be because the groups seen as holding these posts (e.g. nurse consultants) are transformational leaders instead, and so do not meet these expectations. Either nurses can change such expectations, or be the leaders themselves, heroic or otherwise. Nursing is a very hierarchical profession, and we must remember that leadership can happen at any level in the organisation or profession, or we will not recognise it all around us. Leadership is not about posts, but about personal qualities and ways of behaving. One of the most important contributions that nursing leaders make to health care is interpreting NHS strategy into their practice. Incorporating this into sustainable service changes is more likely to obtain support for the vision and implementation, and increase the likelihood of success. Doctors and nurses have problems with leadership, both leading and being led, and as health care professions we need to think more about leadership and encourage the development of the professional who can lead— or at least not stand in their way. All this is hardly surprising given the lack of leadership training before qualifying. Most post-basic courses are uni-professional, which prevents cross-professional learning, and which in turn can be one of the barriers to leadership. The following discusses this in more detail. We cannot ignore the context of leadership in the NHS. Culture, power and hierarchy need to be aligned and positive towards leadership to enable it to happen. My own Masters research supported that of the Guest report13 in that the biggest enabler for the success of nurse consultant posts was a supportive organisation and, in particular, a supportive boss. Without this, there was role failure and an inability to achieve competencies, particularly leadership. According to Cole,14 the Royal College of Nursing LEO (leading empowered organisations) courses had good uptake and outcomes, but nurses returning to the same culture, that did not welcome change, encountered resistance and became increasingly frustrated, realising how disempowered they were. The costs of poor leadership cannot be ignored because of this detrimental impact on staff. This is demonstrated through increased stress (the cause of 60% of all absenteeism)15 which reduces organisational efficiency and team effectiveness, and which in turn prevents implementation of service changes.16 Most people complain that their boss is their major cause of stress, and a boss who is a poor leader will lack the political clout which is necessary to attract resources to their services. Consequently, their patients will suffer, whereas well-led teams are more likely to be efficient and use their resources better— through shared vision— and are more likely to be effective, be better value for money and provide better services for their patients. It is important to note that with efficiency and effectiveness being the goals of the NHS, poor leadership can have a counterproductive and catastrophic effect. If you look, you will find. There is a leadership industry out there, manifest by training, coaching and courses. However, it is often leadership styles that are described, rather than what leadership is, or how to lead. My comfort zone are books, but I was so anxious to learn about leadership that I panicked and read all I could and, not surprisingly, not much went in which further increased my anxiety. The book I would recommend is the leadership in nursing book by Colleen Wedderburn-Tate, because it gave examples and strategies to lead, recognising that every health professional has a responsibility to lead.17 Many courses at First Degree and Masters levels have leadership modules, and I would suggest to the reader that they identify their own areas for development and how they learn, and look for appropriate resources— not forgetting friends, colleagues and role models. The media can provide leadership resources, and I would recommend the film ‘ School of Rock’ starring Jack Black as a musician who pretends to be a teacher to gain employment, and who ultimately manages to lead a group of classically trained musicians so that they become a competitive rock band. This film provides examples of how to lead, and reinforces my belief that many of us can lead our services. We know our patients and team, can develop a goal or vision, can enable colleagues to lead parts of service changes, and— as senior clinicians and managers— have influence and authority; and we should have credibility! The development of true understanding of leadership involves highly personal journeys. We need skills and, in some cases, authority to lead and enable others to lead, and an organisational culture which supports this. Leadership involves influence and time— which is essential when working across organisations and professions to redesign services— and not investing the time to adopt leadership principles has taken us to where we are now. Health care is rapidly changing, and leadership is key in times of chaos; I believe it is as necessary as high quality clinical skills. Most importantly of all, and for these reasons, our patients deserve and need well-led services. To return to my original question— to lead or not to lead? I believe there is no choice but to lead, and learn how to do it well, for all the reasons given. Sir Gerry Robinson in his BBC2 television series ‘ Can Gerry Robinson fix the NHS?’ (Spring 2007) stated that we should not think of the NHS as unmanageable, but manage it. I would suggest that we do not think of the NHS as un-leadable, but should lead it.