Leadership theory in clinical practice

Jie-Hui Xu

Breast Health Center,Renji Hospital,School of Medicine,Shanghai Jiao Tong University,Shanghai 200127,China

1.Introduction

In many areas of the developed world,modern hospital care is confronted by workforce challenges,changing consumer expectations and demands,financial constraints,increasing demands for access to care,mandates to improve patient-centered care,and issues regarding the levels of quality and safety of health care.1Effective governance is crucial to maximize the effective management of care in the hospital setting.Emerging from this complex literature is the role of leadership in the clinical setting.2The importance of effective clinical leadership to ensure a high-quality health care system that consistently provides safe and efficient care has been reiterated in scholarly literature and in various government reports.3

Leadership is the process of in fluencing others to understand and agree about what needs to be done and how to do it,and the process of facilitating individual and collective efforts to accomplish shared objectives.4This definition shows the importance of leadership,which is an important function of management and helps to maximize efficiency and to achieve organizational goals.In clinical settings,effective clinical leadership has consistently been identi fied as an essential component to ensure quality care and healthy workplaces.5The importance of good leadership is becoming increasingly apparent within health care.This article aims to use different leadership theories to interpret a common scenario in a clinical setting to improve leadership effectiveness.Simultaneously,this article explores different leadership styles and theories and explains how they relate to nursing practice.

The setting of the current scenario is in a surgical unit of a reputable public hospital in the local area.At this large tertiary hospital,which holds more than 2000 beds,hospital administrators have devised a series of work policies.The night shift policy,one of the most important policies in the hospital,states that no member of the staff is allowed to sleep while on duty.

The nurse manager of the surgical unit assumes a leadership role in this scenario.She is responsible for the management of registered nurses,medical assistants,office staff,performance evaluations,budgets,shifts,and attendance for this unit.One day,she was told a nurse often slept on her night shifts.To her surprise,the nurse not only took a nap at the nurse station on the night shifts but also slept on the examining table in the examining room after midnight.Obviously,the nurse was neglecting her duty and violating the night shift policy as well.

In this case,if the nurse did not recognize her mistakes and did not know that sleeping on her night shifts was against policy,patient safety would be ignored and quality care could not be provided,not to mention diminished patient satisfaction and negative outcomes.Hence,the unit director had to take action.The biggest challenge for the unit director was getting the nurse to acknowledge the mistake and subsequently change her behavior.The ultimate goal in this scenario,however,is to prevent the nurse from sleeping on her night shift,to convince her to take her job more seriously,and to encourage a positive attitude toward her work.

2.Leadership theories

2.1.Transformational leadership

The first theory that can be utilized in this scenario is the transformational leadership theory.The concept of transformational leadership was originally identi fied by leadership expert James MacGregor Burns.According to Burns,transformationalleadership is a relationship between the leader and the follower in which they motivate each other to higher levels,resulting in value system congruence between the leader and the follower.6Later,Burn's original thoughts were extended by Bernard M.Bass,who believed that a strong vision and personality are common traits among transformationalleaders.7Moreover,they motivate theirfollowersto adjust expectations,opinions,and inspirations to work toward common goals.8Additionally,he mentioned four components in transformational leadership:ideal impact,strong motivation,intellectual stimulation,and personal consideration.9

Evidence has shown that transformational leadership impacts follower satisfaction and commitment to the organization.10Because of its impact on individual and institutional outcomes,transformational leadership can be used in all organizations.11Thus,transformational leadership is of great importance and applicable to the present scenario.

Speci fically,transformational leadership theory is focused on change.The leaders who utilize this style are regarded as change agents who use their qualities and personalities to motivate their followers to achieve their goals,to share their visions,and to empower them.Transformational leaders in fluence followers by encouraging and inspiring them to achieve organizational objectives.12First,leaders must build a connection of trust with their followers.This connection of trust can be established by being open,fair,and honest with the staff and by motivating them to be independent in their decision-making.13Second,leaders must use effective communication to lead the staff to achieve ultimate goals.Furthermore,leaders should possess great self-con fidence,firmly believe in their vision and have the courage to achieve their goals.

According to transformational leadership theory,first,the nurse manager in the present scenario should schedule an appropriate time and designate a private room for a one-on-one talk with the nurse to reassure the nurse of the leader's respect and trust.At this stage,it is crucial to mention that this is just a talk,similar to the process of story-telling rather than a process of criticism.Second,when communicating with the nurse,the nurse manager should listen carefully to the nurse's thoughts,as it is imperative to recognize the nurse's needs and concerns.Third,the nurse manager should analyze the severity of this problem.Simultaneously,the unit director must present her expectations for the nurse and the unit,which could motivate the nurse toward further career development and promotion.By means of transformational leadership,the nurse's behavior can be in fluenced.Additionally,the nurse will improve her organizational commitment and is more likely to achieve the organization's goals.

2.2.Participative leadership

The second leadership theory that can be applied to this scenario is participative leadership.Participative leadership,also called democratic leadership,is a leadership style in which the team members participate in the decision-making process.14As a result,the followers feel more engaged in the management process,more committed to goals,and more motivated to work efficiently.In the 1930s,the behavioral scientist Kurt Lewin conducted studies and identi fied the signi ficance of the participative leadership style in organizations.15Based on discussions with business leaders and employees,he summarized that participative leadership was the most popular style among subordinates in the business setting.

This leadership style is common in corporate settings,such as information technology companies,hospitals,pharmaceutical firms,universities,and so forth.16Leaders who act as facilitators rather than dictators facilitate the ideas and the sharing of information with the end goal of arriving at a decision.Additionally,evidence has shown that nurses who engage in the participative leadership style are more prone to carry out team functions and individual responsibilities.16Therefore,the participative leadership theory is suitable for this scenario as well.

醫院需要充分利用外部快速發展的電子商務平臺實現業務發生的源頭控制。由于業務真實性核查成本高、難度大，傳統的會計控制限制在對票據真實性的審核上。電子商務平臺和物流業的發展為業務源頭控制提供了可能。醫院可建立服務和物資采購平臺，與天貓、京東、蘇寧易購、1號店、攜程網、政府采購機票管理網站等大型電子商務平臺對接，使醫院的采購業務通過這些高度市場化、可核查的平臺進行，自動選擇性價比高的供應商發出采購需求，避免政府采購速度慢、價格高的缺點，同時還可按需采購，減少物資的庫存，降低醫院的管理成本。

In terms of participative leadership,the leader engages the followers in the decision-making process by consulting teammembers,while still maintaining control.17According to the guidelines for participative leadership,the first step is diagnosing decision situations,which includes evaluating the importance of the decision,identifying people with relevantknowledge,and evaluating whether it is feasible to hold a meeting.The second step is to inspire participation,which includesencouraging people to express theirconcerns,describing a proposal as tentative,looking for ways to build on ideas and suggestions,and showing appreciation for suggestions.18

In the current scenario,first,the unit director should seek to understand why this problem occurred and possible resolutions for it.Then,she should hold a staff meeting to discuss how to address this issue without identifying the nurse.During the meeting,all the staff are encouraged to express their own opinions.In addition,the unit director should actively listen to different views without getting defensive,try to use everyone's input and advice,and show her appreciation for the staff's ideas.

Finally,the leader must synthesize the suggestions and make a complete unit policy to prevent such mistakes from occurring in the future.

3.Comparison of two theories

Although both theories are useful in resolving this problem,transformational leadership plays a more critical role in the present scenario.It notonly positively impacts organizational commitment,but it also in fluences employees'performance.Therefore,in this case,transformational leadership could help the nurse to change both her thinking and behavior.The unit director could keep the lines of communication open so that the nurse feels free to share ideas.Furthermore,the leader can offer the nurse support and encouragement to improve unit commitment.Transformational leadership,which can motivate and inspire the nurse,has a more significant impact on behavioral changes.

Participative leadership also has many advantages.For example,it can build mutual trust relationships between the staff and the leader,and it can improve team collaboration and organizational commitment.The result is greater job satisfaction among the staff and a sense of empowerment.

However,participative leadership has low motivation,and it takes a long time for decision-making.Most importantly,this leadership style does not address the speci fic problem in this scenario.Under this leadership style,the nurse,who slept on her night shifts,is less likely to be inspired or motivated.The unit director cannot understand the nurse's thoughts if participative leadership alone is used.In other words,the root of the problem cannot be identi fied.Therefore,in this scenario,using both the transformational and participative leadership theories is imperative.

4.Additional theory

By using two leadership theories,the problem seems to have been resolved.The nurse will change her behavior,and her organizational commitment has been reaffirmed.However,despite the unit's policy,how to prevent the nurse from sleeping during her shift is still a challenge.An additional theory would be helpful in this scenario.

Transactional leadership is based on the setting of clear objectives and goals forthe followers as well as the application of rewards and punishments to motivate followers and encourage compliance.13In transactional leadership theory,subordinates and leaders enter a contract where the leader provides positive rewards such as a bonus,time off,health bene fits,or simply a paycheck in exchange for the completion of a task.17On the other hand,if tasks are not met or do not meet the employer's expectations,leaders may also use negative rewards such as a “do it or else”threat of job loss.17

Based on the participative staff meeting,the unit director can propose a reward and punishment statement in which the unit director and the staff nurse reach a consensus.The unit director will provide positive rewards to those who make great contributions to the unit.Similarly,the leader will use punishment to those who sleep on the night shifts,who do harm to the unit,who do not meet the job requirements,and so forth.

Transactional leadership clearly describes the roles and expectations of the leaders and the followers.Similarly,the style ensures that the culture within a unit is maintained,with the rules and the behavioral norms strictly followed.

5.Barriers in application

Despite the widespread recognition of the importance of effective clinical leadership to patient outcomes,the barriers for leaders and managers in clinical leadership are considerable.Such barriers,noted extensively in the literature,include a lack of incentives,a lack of con fidence,clinician cynicism,and poor communication.19Other barriers in the clinical setting include poor preparation for leadership roles,curriculum de ficiencies and health professional courses,experience as participants in poorly constructed clinical leadership programs,and inadequate resourcing of development programs.20In addition,the lack of vision and higherlevel commitment,poor interdisciplinary relationships,role conflict,rejection of the “leader”role as unacceptable,resistance to change,and poor team work are important to consider in the application of leadership theories.21,22To utilize the leadership theories effectively in clinical practice,leaders should first identify these barriers to better manage them.

6.Conclusions

Leadership takes practice.Leadership is not a role that is practiced once and then mastered.Nurse leaders who encounter complicated issues should not rush to resolve them.Rather,they should consider these leadership theories and try to apply them in the clinical context.The result is a better outcome.In the scenario mentioned in this article,more than three leadership theories can be applied.In other words,it is impossible to resolve the issue using a single leadership theory.Transformational leaders,for example,inspire others with their vision and collaborate with their team to identify common values.Participative leadership is a managerial style that invites input from employees on all organizational decisions.Transactional leadership is based on contingent rewards and can have a positive effect on followers'satisfaction and performance.Two other leadership styles often used in nursing practice are situational leadership and autocratic leadership.23Different leadership theories should be combined in clinical application in current complex organizations.Thus,the combination of established leadership styles is highly recommended for nurse leaders in clinical settings since various leadership styles and theories are relevant to nursing practice.Nurse managers and clinical leaders should acknowledge the advantages and disadvantages of each theory.Still,the development of leadership skills is an ongoing journey that begins with knowing and understanding oneself.Developing leadership skills is important to enhance personal character;it provides leaders with the necessary tools to achieve success within their career as health care providers.Nurse leaders encounter many different situations every day,and no particular leadership style is suitable for all situations.Nurse leaders should therefore be flexible in their leadership styles and tailor them accordingly.

Applying different leadership styles to different situations seems to be most effective,and thus each leader must know when to exhibit a particular approach to achieve the organization's goals.

Conflicts of interest

All contributing authors declare no Conflicts of interest.

1.Daly J,Jackson D,Mannix J,Davidson PM,Hutchinson M.The importance of clinical leadership in the hospital setting.J Healthc Leader.2014;6:75-83.

2.MacPhee M,Chang L,Lee D,Spiri WC.Global health care leadership development:trends to consider.J Healthc Leader.2013;2013:21-29.

3.Siriwardena AN.Releasing the potential of health services:translating clinical leadership into healthcare quality improvement.Qual Prim Care.2006;14:125-128.

4.Schyve P.Leadership in Healthcare Organizations:A Guide to Joint Commission Leadership Standards.San Diego,CA:The Governance Institute;2009.

5.Yukl G.Effective leadership behavior:hat we know and what questions need more attention.Acad Manage Perspect.2012;26:66-85.

6.Krishnan VR.Transformational leadership and value system congruence.Int J Value-based Manage.2002;15:19-33.

7.Bass BM.Leadership and Performance beyond Expectations.New York:The Free Press;1985.

8.Barling J,Weber T,Kelloway EK.Effects of transformational leadership training and attitudinal and financial outcomes:a field experiment.J Appl Psychol.1996;81:827-832.

9.Tucker BA,Russell RF.The in fluence of the transformational leader.J Leader Organ Stud.2004;10:103-111.

10.Texas Tech University.Leadership styles.Available at:http://www.depts.ttu.edu/aged/leadership/leadstl.htm.Accessed 17 March 2016.

11.East Tennessee State University.Leadership theories and styles.Available at:https://www.etsu.edu/ahsc/documents/Leadership_Theories.pdf.Accessed 10 May 2016.

12.Christian Brothers University.Participating leadership,delegation and empowerment.Available at:https://www.facstaff.cbu.edu/～rlawrenc/.../Courses/...-/Chapter%2004.ppt.Accessed 20 December 2016.

13.Kuhnert KW,Lewis P.Transactional and transformational leadership:a constructive/developmental analysis.Acad Manage Rev.1987;12:648-657.

14.Gill E.What is democratic/participative leadership?How collaboration can boost morale.Available at:http://online.stu.edu/democratic-participativeleadership/.Accessed 2 April 2017.

15.Bass BM,Avolio BJ.The Multifactor Leadership Questionnaire-5x Short Form.Redwood:Mind Garden;1995.

16.Grimm JW.Effective leadership:making the difference.J Emerg Nurs.2010;36:74-77.

17.Aarons GA.Transformational and transactional leadership:association with attitudes toward evidence-based practice.Psychiatr Serv.2006;57:1162-1169.

18.Mountford J,Webb C.When clinicians lead.McKinsey Q Healthc.2009;2:1-8.

19.Martin JS,McCormack B,Fitzsimons D,Spirig R.Evaluation of a clinical leadership programme for nurse leaders.J Nurs Manag.2012;20:72-80.

20.Chadi N.Medical leadership:doctors at the helm of change.Mcgill J Med.2009;12:52-57.

21.Ham C.Doctors in leadership:learning from international experience.Int J Clin Leader.2008;16:11-16.

22.Stanley D.In command of care:clinical nurse leadership explored.J Res Nurs.2006;11:20-39.

23.Mannix J,Wilkes L,Daly J.Attributes of clinical leadership in contemporary nursing:an integrative review.Contemp Nurse.2013;45:10-21.