Leadership consists of various qualities, skills and aspects relating to the action of leading an organisation or a group of individuals (Ennis et al, 2013). The focal point of the NHS is to enable cultures that provide safe, compassionate and high quality care (West et al, 2015). Furthermore, leadership has an impact on a number of different aspects such as mortality levels, patient satisfaction, staff well-being, financial performance and generally, the quality of care (West et al, 2015). The Francis report discussed the importance of distributed leadership, whereby all healthcare professionals are enabled to think freely, make decisions and take control themselves. It leads to the provision of high quality care (Francis, 2013). This piece of work will assess effective leadership and why it is a necessity within nursing practice.
Ennis et al (2013) implemented a study in order to assess the communication characteristics needed for good leadership within nursing. Interviews were carried out, outlining how effective communication is key in order to provide high quality care, develop as a professional and to harbor working relationships (Ennis et al, 2013). The study produced the following themes: choice of language, listening skills, relevance, non-verbal communication and relationships. Participants outlined that good leaders have the knowledge to choose the type of language used and can adapt it to any scenario that they are faced with. In addition, they suggest that an effective leader considers the outcome and consequence of each conversation (for example, whether further support was needed) (Ennis et al, 2013). When leadership is successful, it enables excellence and ethical and patient-centred care (Ennis et al, 2013).
Furthermore, it was noted that good leaders needed to be able to listen, be affable and have patience (Ennis et al, 2013). One participant outlined that listening should be first and foremost, valuing its importance and showing great interest in what the patient has to say (Ennis et al, 2013). Respondents noted the need for effective communication across all aspects of nursing; with junior staff, between healthcare professions and when directly caring (Ennis et al, 2013). Good clinical leaders need to be able to communicate to a high level, adapting to enable all patients to understand, noting body language, non-verbal cues and avoiding medically complex terms as much as possible (Ennis et al, 2013). The study notes the link between effective communication and the amount of influence that leader has, the team's performance and their development of staff member relations (Ennis et al, 2013). Guidelines by NICE also emphasise the importance of effective communication to enable high quality care (NICE, 2016). Non-verbal communication is also key; effective leaders need to note their body language and level of eye contact, assessing not only their own non-verbal cues, but also those of the patient or fellow professional (Ennis et al, 2013). This will enable them to judge the scenario and to foresee any issues that may arise (Ennis et al, 2013). Within the study by Ennis et al, (2013) respondents outlined that good leaders had excellent people skills, building a good rapport with everyone. To do so, respect and treating each person as an individual is key (Ennis et al, 2013). It is also vital to ensure that no judgements are made and that support is offered when needed (Ennis et al, 2013). Effective leaderships can only be implemented when these areas are adhered to, building work relationships and providing high quality, patient-centred care (Ennis et al, 2013).
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Emotional intellect is a key aspect to adhere to when managing situations and caring for patients (Powell et al, 2015). Controlling emotions and self-awareness are both vital components of emotional intellect (Powell et al, 2015). Doing so decreases the risk of burnout and ensures that patients are receiving high quality care (Powell et al, 2015). In addition, being aware of one's emotions enables a collaboration that is needed to meet the needs of individuals within the complex and increasingly technical NHS system (Powell et al, 2015).
The qualities of a leader
The main traits of a good leader were assessed by Yukl (2013). They consist of a high level of energy, stress coping mechanisms, confidence, control, maturity, integrity, as well as being a high achiever, with low needs for affiliation. Nursing leaders need to be empowering, promote independence, encourage a critical and effective work environment and remain positive (Jukes, 2013). They should enable fellow healthcare professionals to build resilience, enabling them to make their own decisions yet providing protection when needed (Jukes, 2013). In order to achieve structural change for the provision of high quality care, the following should be adhered to: promoting inclusive team work, maintaining trust, seeking contribution, using personal authenticity, valuing relationships, enabling learning and challenging any issues that arise (Cleary et al, 2011). Patients need support and care which cannot be carried out without effective leadership (Cleary et al, 2011). If a nurse does not show effective leadership skills, they often retreat towards more traditional methods of behavior (more documentation and relying on medicine), instead of promoting patient-centred care (Jukes, 2013). Furthermore, leaders need to support any professionals that they are responsible for in following the nursing and midwifery code at all times (Nursing and Midwifery Code, 2015: 18).
The qualities of a manager
Managers oversee a certain area, supervising fellow staff and ensuring that patient care is upheld, in addition to administrative aspects (Jukes, 2013). Concerns are addressed through their specialised nursing experience, good communication and the ability to take the lead (Jukes, 2013). Good communication is key when assessing any risks, managing plans, delegating work and ensuring the effective and safe provision of resources (Jukes, 2013). Delegating work is an integral part of effectively leading, encouraging active learning, whilst freeing up more time for aspects that cannot be delegated (Weir-Hughes, 2011). Delegation is a necessity, especially when staff numbers reduce and pressures rise (Griffin, 2016). Managers also demonstrate excellent leadership skills by improving nurse confidence and upholding morale (Timmins, 2011). They need to ensure that staff are communicating effectively, in order to provide high quality, safe care (Timmins, 2011). This can be carried out by implementing an open leadership style, listening to the nurses and involving the team when making decision (Timmins, 2011). Gilmartin and D'Aunno (2007) outline how nurses prefer managers who are emotionally intelligent, facilitate change and who actively participate. Further stating that this leads to cohesion, a sense of empowerment and reduces stress and burnout (Gilmartin and D'Aunno, 2007). Management and leadership can only be improved by adhering to the following: ensuring a good set of qualities and knowledge, a supportive environment, an adequate number of managers and ensuring rewards or acknowledgement for good practice (World Health Organisation, 2007).
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Ineffective leadership can lead to the unsafe provision of care (Nicolson et al, 2011). This was portrayed during the 1990s, in which nurse Beverly Allitt murdered children by injecting them with insulin. She was not supervised and the deaths were not challenged by management (Nicolson et al, 2011). More recently, the investigation into the Airedale NHS trust found nurse Anne Grigg-Booth to be providing dangerous care. Many patients died under her care, which was noted as an abundance of failures in which dangerous actions were not acknowledged by management (Nicolson et al, 2011). Within the Mid Staffordshire Foundation Trust, a lack of leadership and supervision detrimentally impacted upon the lives of many, with high mortality rates (Nicolson et al, 2011). The Francis Report identified various issues such as, call bells not being answered, patients lying in their own urine and left without water or food (Francis, 2013). Saving money was a priority and management preferred to meet targets than deal with individual needs and thus leadership was poor (Nicolson et al, 2011). Ineffective management has not only led to unsafe care but cost more than £16m in legal fees and implementation costs (Calkin, 2013).
Transformational leadership encourages nurses to provide a high level of care by making influential changes (Cleary et al, 2011). It involves the following actions: building trust with fellow healthcare professionals, showing integrity, inspiring team members, offering intellectual inspiration, adhering to the needs of each individual and providing support (Malloy and Penprase, 2010). With this leadership style, professionals provide clear aims and a pathway for their work, prioritising mutual respect, working together, gaining nurse autonomy and upholding staff morale (Cleary et al, 2011). Doing so prevents burnout, improves job satisfaction and a sense of commitment (Cleary et al, 2011). Transformational leadership can be contrasted with the transactional style in which leaders focus upon meeting targets (it is not creative, reflective and prevents emotional connection) (Cleary et al, 2011).
Support for the transformational leadership style
A study was implemented by Malloy and Penprase (2010) on 122 nurses in order to assess their supervisor's leadership style. The following leadership styles were analysed: transactional, transformational, exceptional-active, exceptional-passive and laissez-faire (Molloy and Penprase, 2010). The study concluded that aspects of transformational leadership were connected with 17 out of 37 areas within the working environment, as calculated by the Copenhagen Psychosocial questionnaire (Molly and Penprase, 2010). Leaders implementing the transactional style also made positive contributions, but fewer than that of a transformational style (Molly and Penprase, 2010). In addition, the laissez-faire, exceptional-passive and exceptional-active styles all negatively impacted the nursing environment (Molly and Penprase, 2010). Corrigan et al (2002) carried out a mental health study, consisting of 236 leaders who had responsibility for 620 staff members. Leaders who noted themselves as high on the transactional style, had staff outlining low transformational scores. In comparison, leaders who noted high levels of inspirational and stimulatory aspects were likely to have staff who felt that their style was transformative (Corrigan et al, 2002). Lastly, staff members who stated that their leader has a transformational style experienced less burnout, a better working environment and support, adhering to conclusions by Malloy and Penprase (2010). In a time of uncertainty, healthcare budget cuts, policy changes and financial strain, transformational leadership is key (Cleary et al, 2011). It encourages staff to treat patients with respect and dignity, promoting patient-centred care and upholding values (Cleary et al, 2011). Many argue however, that there needs to be more evidence into whether transformational leaderships enable better care, improved quality of life and patient satisfaction (Holm and Severinsson, 2010).
NHS leadership review
The government published findings in order to analyse leadership within the NHS (Department of Health, 2015). It noted three main areas of concern: a lack of vision, poor management and leadership and the need for clear pathways in regards to NHS management careers (Department of Health, 2015). The key recommendations include: refreshing the NHS graduate scheme, the transfer of NHS leadership Academy to Health Education England as those responsible for training and introducing a minimum term on some senior management contracts. In addition, managers should be supported and have their knowledge updated regularly in order to prevent 'skill fade' (Department of Health, 2015: 53). The report concluded that, 'the NHS as a whole, lacks a clear, consistent, view of what 'good' or 'best' leadership looks like' (Department of Health, 2015: 20). The recommendations focus upon training, management, support, performance management and bureaucracy (Department of Health, 2015).
To conclude, effective leadership is necessary in order to provide a high level of safe care. It leads to patient-centred care, excellent communication skills and high quality care. Leaders need to communication well, have emotional intelligence, distribute work and implement a transformational style. Whereas poor leadership can lead to death or severe harm, as took place in the independent investigation into the Airedale NHS trust. Ineffective leadership was also a main aspect of why the detrimental acts of Anne Grigg-Booth went undetected by managers (Nicolson et al, 2011). To emphasise, leadership is a key area of the NHS and so it is vitally important to ensure that behaviours, communication skills, qualities, skills, leadership styles and strategies are focused upon to improve (West et al, 2015). Without doing so, the lives of many will be affected.
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