Midwives magazine: July 2005
In recent years the midwifery profession has undergone an unprecedented period of change. Government publications such as The new NHS modern, dependable (Department of Health, 1997),Making a difference (Department of Health, 1999) and The NHS Plan: a plan for investment, a plan for reform (Department of Health, 2000) have challenged health services to improve their standards and strive to meet increasing public demands. With regard to maternity services, this has culminated in expansion of the midwife’s role to include greater focus on public health and clinical responsibilities that were previously in the medical domain.
This has resulted in increased risk of litigation and consequently a culture of defensiveness, unrest and instability throughout the midwifery profession. These changes, in conjunction with increasing pressures on staffing and resources, and forthcoming reforms to the pay and grading structure within midwifery and nursing (Department of Health, 2004) is creating dissatisfaction among midwives, resulting in a recruitment and retention crisis, further aggravated by recent NMC profiling that indicates an ageing and depleting workforce (NMC, 2004). This article suggests that supporting midwives through these times of change and reform demands effective leadership throughout the profession. Moreover, it implies strengthening midwifery leadership is the responsibility of all midwives, across all levels of the profession. Extant literature and leadership theory demonstrate that all midwives are able to contribute to the modern approach to leadership that is now required by virtue of the skills and qualities exhibited through their clinical role, and by using existing structures to identify and encourage those practitioners with particular leadership ability, that is, supervision. Furthermore, it advocates midwifery leaders adopt the ‘transformational’ leadership style increasingly recommended in health care, as it is centred on change management and lends itself to the leadership qualities seen inherently in women (Pashley, 1998a).
Potential barriers to this are identified, including limitations in existing organisational structures in the NHS that restrict the full potential of midwives as leaders and their appointment to senior positions (Maguire et al, 2000).Where appropriate, suggestions are made regarding ways midwives can counteract these constraints, and the actions necessary to ensure midwives exhibiting leadership potential are given access to the career pathways that enable them to develop their skills and emerge as the leaders of tomorrow. Strengthening modern, visionary leadership throughout the profession will ensure midwifery is equipped with leaders able to effect the changes necessary to meet the challenges arising from modernisation of maternity services. In turn, this will ensure midwives are motivated and inspired to remain in an upwardly-mobile profession that is held in high regard by the public and its associate professional groups.
Developing midwifery leaders
Existing literature reveals inconsistencies in the definition of ‘leadership’. Kouzes and Posner (1997) propose it is the art of mobilising others to want to strive for shared aspirations. In contrast, Pashley (1998a) suggests it is centred on coping with change. There also exists an ongoing dichotomy of opinion regarding whether leadership is an innate quality or a collection of skills that can be learnt. Regardless of this nature-nurture debate, perhaps the most important stage in developing leadership potential within midwives is to first identify the qualities and skills that characterise a leader.
Frequently-quoted definitions include someone with vision and who communicates well (Pashley, 1998a), with integrity and who demands respect (Cross, 1996) and one who is adaptable to change and prepared to take risks (Pashley, 1998b). There are several theories on identifying leaders. ‘Trait theory’ states leaders have innate qualities such as above average intelligence, being highly motivated and in good health (Cross, 1996). In contrast, ‘behavioural-functional theory’ leans towards the belief that leadership qualities can be acquired or learnt. A review of these theories and additional literature regarding attributes constituting effective leadership concludes that midwives are well placed to foster certain leadership skills, and that many already possess some by virtue of their clinical role. For example, midwives are accustomed to teamworking and the importance of effective communication.
Additionally, for years they have maintained a vision that birth is normal and have effected changes to practice that empower women to share this view and to reclaim what is for many a crucial rite of passage. Similarly, through supervision, midwives have facilitated a supportive and proactive working culture in which individuals are encouraged to regularly appraise and update their knowledge for the benefit of their own practice and to protect the safety of women and babies in their care (Skinner, 2001).
Further, midwives exercise leadership activities in their daily practice, although they may not realise it. These include prioritising care needs, advocating women’s choices and demonstrating intra- and interprofessional working to ensure continual improvement in care standards.Additionally, midwives are taking on roles traditionally confined to the medical profession, such as ventouse practice and pre-conception care (Pashley, 1998b). In recent years, the profession has seen the introduction ofconsultant midwives and specialist midwives in, for example, HIV and diabetes. They have also demonstrated involvement in matters such as risk management, audit and research.
These developments have undoubtedly demanded openness to change and a level of courage to meet the associated challenges and take the necessary risks (Barber, 2000). From this, it is clear all midwives possess the capability to be agents of change and develop their leadership abilities. This is not to say every midwife is suited, or expected to aspire to a position of clinical leadership. On the contrary,Malby (1996) suggests that while all midwives can enhance their leadership skills through training, individual limitations will determine the extent to which this can be effective. However, those demonstrating particular leadership ability, and who wish to develop this must be encouraged and given the opportunity to do so.
Strengthening leadership through supervision
The practice of identifying and supporting next generation leaders is known as ‘succession planning’. Tucker (2003) suggests this is fundamental to midwifery leadership development and recommends existing leaders should offer colleagues every opportunity to develop and enhance their leadership abilities. This has traditionally been facilitated through supervision.
Since the passing of the Midwifery Act in 1902, midwifery supervision has been a portal for the identification, development and representation of the profession’s leaders, and is arguably unique in that it is free of hierarchy and distinct from the profession’s management. Comprised of midwives working in various areas of practice and of differing grades and responsibilities, supervisors are nominated for training by their peers. This ensures professional leadership is not entirely devolved to those in senior or managerial positions, as is frequently evident in other healthcare professions devoid of such developmental structures. Kotter (1990, cited in Pashley, 1998b) believes representation at all levels of a profession contributes to a stronger body of leadership overall. Further, active use of the supervision pathway and continued attention to succession planning in which midwives’ professional development choices are recognised and supported will ensure the profession can achieve the excellence in clinical practice advocated in government agendas.
A further avenue of leadership development in midwifery lies in the practice of experiential work-based learning and mentorship (Barber, 2002). Concurrent with the presence of supervision, midwives find themselves advantaged as a result of their familiarity with this. Introduced during pre-registration training and continued on qualifying through preceptorship, midwives are adept in the art of active mentorship in the workplace that Senge (1990) argues is vital to the identification and support of future leaders.
However, anecdotal evidence from clinical midwives suggests existing staffing shortages are resulting in insufficient mentors with the experience necessary to guide and support junior staff. Similarly, there is some conflict regarding the appropriate ratio of supervisors to midwives within given areas. The NMC recommends a ratio of one to 40 (NMC, 2004). However, this varies between local supervising authorities (LSAs) with some advocating a rather different ratio of one to 15 (Local supervising authorities in the south of England, 2003). It is reasonable to suggest the ideal figure may depend on staffing numbers and the geographical area covered by the LSA. In areas where this is vast, a lack of trained supervisors may make ‘hands-on’ mentorship and guidance impractical on a regular basis. Therefore, it is crucial that midwives working in these areas are actively encouraged to develop their potential and are guided through the necessary routes to leadership positions in which they can nurture and support students and novice midwives. This will result in the flowing down of skills and practices that enable junior midwives to become knowledgeable, empowered professionals (Wisniewski, 2001). In turn, this may reduce existing recruitment and retention problems, making midwifery an appealing career choice for future generations.
Further to identifying midwives with potential leadership abilities, it is equally important to recognise the style of leadership that will be most beneficial to the profession now and in the future. It is widely accepted, and indeed evident throughout history, that while many individuals possess the skills and qualities required to be leaders, this does not necessarily mean their leadership will be effective or beneficial (Goleman, 1995).
Individuals such as Adolph Hitler, and more recently Saddam Hussein are particular examples. The leadership style increasingly advocated throughout healthcare literature, and arguably of most benefit to midwifery is that based on the ‘transformational’ model (Kouzes and Posner, 1997). Leaders using this tend to inspire others to exercise their own leadership abilities through use of a people-orientated philosophy. It is also linked to effective change management, an issue of particular relevance within maternity services at present. However, it is the feminist orientation of the model that underpins its suitability to the predominantly female midwifery workforce. Pashley (1998a) suggests the key components reflect innate leadership qualities frequently seen in women. For example, women leaders value caring and emotions, do not hesitate to make intuitive decisions and prefer to structure organisations as teams or networks rather than hierarchies. Goleman (1995) suggests this reflects their ‘emotional intelligence’, a quality seen to be essential in modern leadership, and particularly suited to the people-orientated nature of midwifery.
Further, women are more inclined to negotiate rather than argue, to admit mistakes, share credit and utilise effective interpersonal skills. Evidence suggests this model has proven successful in other primarily female professions, such as nursing. It formed the basis of the RCN Clinical Leadership Development Programme (Sheridan, 2003). This provided training and development of participants’ behaviours within what are considered to be five key areas of exemplary transformational leadership practice. Arguably, these are equally relevant to midwives (see Figure 1). In summary, the model aims to encourage leaders to take opportunities and challenge existing ways of thinking. It recommends individuals use symbolic actions to inspire others to share their vision, and encourages them to actively contribute to the challenges of organisational change. In conjunction with the people-orientated, feminist focus, this makes the transformational leadership model ideally suited to midwifery in the 21st century.
Existing barriers to midwifery leadership
Despite the advantages to midwives regarding transformational leadership and their ability to identify and develop next generation leaders through supervision and clinical mentorship, restraining forces to midwifery leadership as it stands are rife. Literature suggests that the failure to recognise fundamental differences between ‘management’ and ‘leadership’ roles is a key problem.
Furthermore, evidence from midwives implies access to relevant courses, that is, the ‘Leading an empowered organisation’ course is frequently limited to midwives in managerial roles or those who aspire to be. This implies that to be a leader, it is necessary to be a manager – clearly a contentious issue. Some believe the terms are synonymous and that leadership is one facet of the management role (Huczynski and Buchanan, 2001). Others disagree, stating managers produce order and predictability through planning and budgeting, whereas leaders establish vision and direction and inspire others to effect positive change (Kotter, 1990).Within midwifery commentary it is generally agreed management and leadership are linked, but should be recognised as unitary concepts (Cross, 1996). Lee (1999) argues while there are undoubtedly many effective midwifery managers in post, it is questionable whether they are also effective leaders. Similarly, midwives who are effective leaders do not necessarily possess the skills required to be good managers.
Managers tend to be more task-orientated and driven by resource and budgetary constraints, although the extent of this depends on their management style (Stewart, 1996). In contrast, leaders are generally people-orientated and empower their followers to adopt a positive vision to enhance organisational development (see Figure 2). Gopee (1998) suggests failure to distinguish midwives exhibiting potential leadership ability from those orientated more towards management limits their development opportunities and has arguably stifled midwifery leadership in recent years. While it is crucial to differentiate between management and leadership, the two are arguably linked, particularly in the NHS where organisational structures continue to be male dominated and hierarchical. It is widely accepted that men in the NHS are often quick to obtain managerial positions and frequently dominate top levels of the hierarchical structure. Theory pertaining to men in positions of management indicates their preference for ‘top-down’, task-orientated approaches (Stewart, 1996).
Regarding leadership, it is common for them to exhibit qualities reflecting a more ‘transactional’ model (Huczynski and Buchanan, 2001). This differs from the feminist transformational model in that it is based on mutual influence and coalition building. Leaders adopting this style view relationships with their followers in terms of an exchange, that is, giving their followers what they want in return for what he/she desires (Huczynski and Buchanan, 2001). Davidson and Cooper (1992) propose that the male dominance of organisational structures in the NHS obstructs the leadership potential of professions comprised mainly of women, such as midwifery and nursing. It is said women are frequently socialised into dependant roles, perhaps because they do not seek power and control in the way men do, favouring instead more people-orientated team structures (Maguire et al, 2000).
Further, it is questionable whether the female-orientated, transformational leadership model that so readily lends itself to midwifery can flourish in an organisation that continues to reflect opposing styles. This results in women and women-dominated professions being insufficiently represented at senior levels of hierarchical structures. Therefore, while midwives possess strong leadership ability, their development is often confined to intraprofessional parameters, and opportunities to lead on a larger scale in the health service are limited.
Overcoming these barriers
Consideration of ways midwives can overcome these barriers and ensure their profession is equipped with effective leaders necessitates a collaborative effort (Tucker, 2003). However, existing leaders should recognise that in a predominantly female profession, career choices and development opportunities must facilitate women’s innate biological qualities, and that individual midwives’ priorities will differ (Pashley, 1998a). Therefore, it is essential to identify those midwives for whom the contribution to professional leadership is through their own development as leaders, and equally those practitioners who contribute by supporting, mentoring and encouraging their peers.
Clearly, the profile of the profession’s leadership must be raised, in order for the ‘voice’ of midwifery to be heard at higher organisational levels in the health service. Davidson and Cooper (1992) encourage women leaders to reject traditional female stereotyping and ‘find the confidence to do things their way’, in turn realising change within existing NHS culture.Moreover, Steele (1997) comments it is time midwifery leadership is recognised inter-professionally and that midwife leaders are remunerated at a level commensurate with those in associate professional groups.
The introduction of posts such as consultant midwives and practice development midwives who focus particularly on forging communicable links between clinical midwives, managers, universities and Trusts has proved positive in strengthening midwifery leadership. As part of their role, these midwives aim to increase opportunities for career development for junior midwives. In conjunction with supervision, they encourage midwives to be responsible for personal development planning and strive to provide access to courses aimed at facilitating clinical and non-clinical skills inherent to good practice. Increasingly, such courses include training surrounding leadership, decision-making and teambuilding. Maguire et al (2000) strongly advocate this, suggesting development of these qualities in junior midwives must be pursued as deliberately as the acquisition of clinical skills and knowledge. Tucker (2003) highlights that further action to develop potential midwife leaders involves giving them a ‘taste’ of the role, to further their skills and competencies in a safe environment.
This might include shadowing an existing leader, such as a supervisor of midwives. Strengthening midwifery leadership and raising its status within the health service is clearly a complex task dependant on establishing a professional culture sensitive to individual values and beliefs (Jackson-Baker, 2001). It is unlikely a single education or training programme will be suited to the leadership development of all midwives, due to the numerous factors that influence leadership in a workplace, such as environment, resources and differing personalities. Consequently, responsibility lies with individual Trusts and organisations to research their employees’ specific needs. However, this is where the scarceness of midwifery representation at board level in many Trusts may disadvantage midwives.
This article has explored the key issues regarding midwifery leadership. It highlights strengths in the profession’s leadership as it stands, arguably the most significant of which is midwives’ unique ability to identify and develop next generation leaders through the supervision pathway. Further, it demonstrates the predominantly female workforce in midwifery is well placed to exhibit the transformational leadership style increasingly recommended in health care. However, this is restricted by existing organisational structures in the NHS, in which midwifery and other primarily female professions are underrepresented at senior levels. To sustain and strengthen midwifery leadership requires a collaborative effort from all midwives to establish effective succession planning and to support and coach colleagues aspiring to leadership positions.
Furthermore, existing leaders are responsible for providing these individuals with opportunities for development through, for example, mentoring and shadowing. As maternity services evolve, heralded by government reforms and the changing needs and expectations of consumers, midwives find themselves practising in an increasingly complex arena. Strong professional leadership will enable midwives to rise to the challenge of this and support them in their commitment to providing a quality service in which women’s needs are foremost.
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