Strong and effective leaders are essential in order to fulfil the government's plans for the NHS. Rossana Ralston explores a number of leadership styles and asserts which of these is best suited to facilitate high-quality, woman-centred maternity care.
Midwives magazine: January 2005
The NHS Plan: a plan for investment, a plan for reform (Department of Health, 2000) and its Scottish equivalent Our national health: a plan for action, a plan for change (Scottish Executive Health Department, 2000) have forced a rethink of the attitudes, values and skills required to function in the NHS. These new roles and altered responsibilities will need effective leaders at all levels of the health service.
The government's vision is for a patient-centred health service, and if midwives are to play a key role in taking forward this idea, future midwifery leaders must be developed and supported.
This paper aims to explore the concepts and processes of leadership within the context of the midwifery profession nationally, and discusses the use of transformational leadership as the most suitable approach for the 21st century.
Leadership has been well-studied over the years, and despite this it has no single clear and consistent definition, particularly relating to its characteristics.However,most definitions support the view that leadership involves intentional influence being used over others in the attainment of a common goal (Bass, 1990). This is important to midwives, as it recognises that in providing maternity care,midwifery leaders can influence not only women but also the organisation through service delivery, and the midwifery profession itself.
Many leadership theories have been developed in an attempt to understand how behaviour can best be influenced.Among the earliest are the trait theories, often referred to as the `great man' theories (Bernhard et al, 1990). These suggest that leaders are born and not made. They are grounded in the philosophy that leaders possess certain innate qualities or characteristics such as interpersonal skills, diplomacy, self-confidence, emotional control, intelligence, judgement and fluency (Bass, 1990).
Acceptance of the leader-ruler is a positive aspect of this, however, not all who assume the role of leader are capable of leadership ± Handy (1993) reminds us that trait theories rest on the assumption that the individual is more important than the situation. This in itself is a major flaw, especially as leadership should concern involvement of others, the job to be done and the circumstances. Further, use of the term `great man' has obvious gender connotations.
Circumstantial theories (also known as situational or contingency theories) consider that the situation or intervening factors affect leadership behaviour (Bernhard et al, 1990). Leadership was seen as relative to and have emerged from the situation. The main objection to this theory is that a leader does not appear in every problem situation, and even if they do, this does not ensure effective leadership. Being a leader in one situation does not mean one can be a leader in another (Blankenship et al, 1989).
Style theory succeeded both trait and circumstantial theories. The assumption behind this is that employees will work harder and more effectively for managers who employ certain styles of leadership, than for managers using other ones. Lewin et al (1939) compared the three most commonly recognised leader's behaviour in each style and concluded that the major differences were in the focus of power. Autocratic leaders are often described as authoritarian in their approach ± a firm leader who makes unilateral decisions, gives orders to be obeyed unquestioningly, communication is top-down and staff are not expected or encouraged to take the initiative. The needs of staff are rarely recognised in this style of leadership and the culture is commonly of fear, defended on the basis of getting the job done.
Florence Nightingale, in the late 19th century, exercised this style of leadership through the role of matron (Moiden, 2002). This was further promoted by Salmon (1966), with its introduction of a nursing/midwifery hierarchy. It is recognised now that this style should only be used in crisis situations (Carney, 1999). Democratic leaders are often described as participative ± this leader, being part of the team, involves others in decision-making, communication is top-down, bottom-up and side-side. This improves staff morale and ownership as people are treated as adults and therefore more likely to behave that way. The leader's power comes from the group.
Democratic leadership exercises general supervision and there are minimal rules that staff are encouraged to question and debate openly.
Unlike the previous two styles of leadership, 'laissez-faire' leaders are often seen as 'doing nothing' - providing no direction and minimal or no control. They are leaders by virtue of their position within the organisation and do not demonstrate leadership skills. They try to please everyone and work on the premise that staff can lead themselves.
Although democratic leadership appears to be the desired leadership style for today's healthcare agenda, in reality a mixture of leadership styles will need to be used at different times. The skill is in knowing which to use when.
Broome (1990) compared two other commonly-used leadership styles: transactional leadership, characterised by bargaining, is task-centred, providing only a short-term focus with little positive reinforcement for staff. It recognises the use of rewards, whereby the leader rewards followers for achieving their goals. In contrast, transformational leadership is inspirational and empowering, challenging thinking and offering informal rewards at every opportunity. The transforming leader seeks to engage the full person as the follower.
Leadership and management
In order to understand leadership, it is necessary to distinguish between leadership and management, as even today many believe they are one and the same thing (Sofarelli et al, 1998).
Although leadership and management are intertwined, the distinction is crucial when placed within the context of midwifery. The delivery of midwifery care is changing from a task-orientated approach to a team approach, where midwives must collaborate with others to provide holistic care.Management, often referred to as transactional leadership, is about producing a degree of predictability and order, whereas leadership is about producing change (Alimo-Metcalfe, 1996). The management role is about `doing things right' and getting the task done. The leadership role is about 'doing the right thing' and involves vision and direction (Carney, 1999). Therefore, a person can be a leader without being a manager and be a manager without being a leader (Yukl, 1989). Another useful distinction drawn by Watson (1983) uses the 'seven S's framework' that managers use strategy, structure and systems, while leaders take a softer approach involving style, staff, skills and shared goals.
Evolution of leadership in midwifery
Leadership is inseparable from environmental influences. This means that it is essential for midwifery leaders to have an awareness of the origins and pressures for change, and the drivers, characteristics and expectations of the changing context shaping health care today.
More specifically to midwives, Zepherina Veitch demonstrated strong leadership in the 20th century. A powerful advocate of midwifery training, she campaigned to improve the standards of midwifery care (Collington, 2001), resulting in the first Midwives Act in 1902 in England, (1915 in Scotland) and subsequently the Central Midwives Board (CMB). This effectively improved the standards of midwifery care, but had far-reaching implications for every midwife. The regulating and controlling approach led to the role of the inspector, now known as the supervisor of midwives, overseeing midwifery practice.
Multiple NHS reorganisations over the years aimed to improve efficiency and quality of services through changing the roles and responsibilities of nurse/midwife managers, with the term `nursing/midwifery leadership' being interchangeable with `nursing/midwifery management', and leadership roles being assumed by the manager (Henderson, 1995). Salmon's (1966) midwifery hierarchy promoted a top-down management approach and forced midwives into promoted positions without prior preparation. As a result, they were powerless and had difficulty or little opportunity to make a difference (Savage, 1990).
The Briggs Report (1972) brought the amalgamation of nursing and midwifery by replacing the CMB and General Nursing Council with the UKCC. The resultant loss of identity for midwives unfortunately still exists today. Midwifery, the smallest profession, (excluding health visitors) was frequently under-represented at best, or at worst, represented by nursing.
In the 1990s, the NHS management enquiry (Griffiths, 1983) advised on the effective use of manpower and related resources in the NHS. It recommended that general managers be appointed at regional, district and unit levels to take responsibility for managing the whole organisation, including the staff. Overnight, general managers became line managers to both midwife and nurse managers, and in some smaller units nurse managers managed midwives. Although some responsibilities were given to nurse/midwife managers, a top-down management style with centralised control was used.
Despite the many changes in roles and titles through time, there is little evidence of the encouragement of midwives with leadership potential. Rather, NHS management involved a rigid system of rules and procedures, monitoring, controlling and rewarding conformity, not innovation. As a result,many senior midwives found themselves no longer required as managers and either returned to hands-on clinical care or left the organisation.
The hierarchical structure in operation oppressed midwives and the midwifery profession, and was further exemplified by the medicalisation of childbirth. In defining `no birth as normal except in retrospect', the midwife's role became eroded and all childbirth was placed under medical control (Peel Report, Department of Health and Social Security, 1970). Consistent with this theory of oppression, midwives were led to believe that it was right or natural for the medical profession to maintain control of childbirth (Roberts, 1983).
The leadership of midwives at this time was fraught with difficulties, including the misuse of power to obtain greater control over the process of childbirth and women, rooted in a patriarchal model (Cahill, 2001), whereby male medical knowledge was seen as being scientific and factual and hence superior to female intuitiveness and experience.Midwives became demotivated, resulting in a downward spiral of low self-esteem, reduced initiative and assertiveness. Many became dependent and submissive with reduced autonomy and a resultant devaluation. Midwives became conditioned to seeing their role as that of assistant to the doctor, a machine minder or technological handmaiden. Leaders who are perceived, and who perceive themselves, as having no power hold back innovation and change, only serving to reinforce and increase an autocratic culture (Larson, 1983).
In modern midwifery, there is a constant requirement for change in attitudes and working practices. Listening to what customers want and then meeting those wants and needs efficiently and effectively was the message from various reports such as the Winterton Report (House of Commons Health Committee, 1992), Changing childbirth (Department of Health, 1993) and its Scottish equivalent the Provision of maternity services in Scotland: a policy review (Scottish Office Home and Health Department, 1993).However, in order to achieve this, it would require energy, determination, and above all midwifery leadership (Hunt, 1997).
Opportunities had never been greater ± the future was now in the hands of midwives and many reasserted their autonomous role, taking up their place as the lead professional in innovations such as team midwifery, midwife-led units and midwife-led clinics in a drive to normalise maternity care for low-risk women.
However, despite these developments, the reduction in the numbers of professional leaders was again highlighted (Scottish Executive Health Department, 2001a; 2001b). A framework for maternity services in Scotland (Scottish Executive Health Department, 2001b) specifically demanded new ways of providing safe and effective maternity services and for this to occur `midwife champions' would be required.
If leadership is about developing a vision that provides a framework to improve the quality of our maternity services, then exactly who are these professional champions ± the true leaders? Leaders in midwifery have traditionally been perceived to be from institutions such as the national boards and the RCM or from high positions within hierarchies, chief area nursing officer or director of nursing and midwifery, the heads of midwifery (HOMs) and, more recently to add to this elite list, the consultant midwife.
Without doubt, these have all been sources of leadership and have been influential in directing and shaping the services we provide. Perhaps most notable is the RCM in its work and production of Vision 2000 (RCM, 2000) and its position papers, especially Statement no. 2: Modern matron in the maternity services (RCM, 2002). Both these documents aim to secure and assure the highest standards of women-centred care through the provision of professional leadership, while being committed to the needs of midwives.However, both illustrate the conflict of ideals between unionism and professional leadership, a dichotomy that can confuse rather than inspire followers.
A similar division can be seen in many maternity units with hierarchical structures, whereby the HOM is responsible to the general manager and managerial objectives have to be met. The NHS is an organisation that manages for illness (Lenaghan, 1999) ± therefore, the prime concern will be managing the process rather than managing the end result, that is, better health. Leadership will be secondary to managing the organisation efficiently and effectively, and midwife managers must be able to deal with the pressure of the expectations of being a leader and the expectations of management ± meeting the objectives.
However, leadership is not dependent on having a management position, nor is it for the few, elite or well known. Each one of us, whatever position we are in, can, and indeed do, lead and develop midwifery practice. It is part of everyday practice in an era where midwives are leading services independently of obstetricians, working as named midwives and developing professional practice. Leaders make things happen ± they have vision, they support, they strengthen and inspire trust (Garbett, 1995) ± all the attributes the midwife needs when working with women. Every midwife has the potential to lead and influence within the context that they are working, whether that be at the micro- (clinical),meso- (strategic) or macro- (political) level, or at all three levels of the organisation.
The challenge for NHS organisations is how they will develop and equip midwives with skills, so they will be able to influence practice as clinical leaders, across organisations as strategic leaders and at government or national level as political leaders, in order for the government's health policy to be implemented.
Leadership for the 21st century
The latest report from the Expert Group on Acute Maternity Services (Scottish Executive Health Department, 2002) portrays the Scottish Executive's vision for the future development of maternity services.
All midwives need to note the strengths of the report. It advocates a multidisciplinary integrated approach that will maximise seamless care across hospital and community settings. The report has also taken into account workforce issues, education and the clinical competencies needed to deliver this care. However, perhaps the most visionary aspect of this report, and one that has far-reaching implications for midwives, is the challenge to provide woman-centred care that will be essentially `midwife managed'.
How this will be received by the medical profession, who up to now have been viewed as the lead in maternity care, is not yet clear. Neither is it clear how midwives will take on this challenge. This new paradigm shift has the potential for interprofessional rivalry and barriers to progress will be high. Midwives have been acknowledged as the most suitable professional to care for low-risk women throughout pregnancy (Scottish Office Home and Health Department, 1993; Scottish Executive Health Department, 2001b, 2002).
Midwives can no longer abdicate responsibility even though many may prefer to. The infrastructure, support and evidence to meet the challenge are available (McGuire, 2002), however, do midwives have the leadership skills to meet the challenge?
Transactional leadership, with its task-centred and autocratic approach to staff management, can best describe midwifery leadership throughout the changes, but the author believes that transformational leadership is what is needed to lead the way for midwives in the 21st century.
We therefore need leaders who have the attributes to see the big picture and where the contribution of midwives lies within it. For this to happen, midwives need to develop and utilise the qualities of transformational leadership, which focuses on people and solving problems in an ever-changing environment. This model is well-suited to a change climate, because it actively embraces and encourages innovation and change (Sofarelli et al, 1998; Dunham- Taylor, 2000). It has the ability to motivate others to work towards a shared goal and it is characterised by an open, empowering culture where communication, strong values and mutual respect are paramount. It concentrates on communicating a vision, and the fostering and maintenance of a positive image in the minds of the followers (Kouzes et al, 1987).
Midwives must also have a good understanding of the context of health policy and a vision of how to shape maternity services according to this policy, the ability to plan and manage change and the strength and confidence to challenge the status quo. Therefore, the characteristics, qualities and skills of an effective leader are varied and vast, however, the author believes Chevannes (2000) provides an apt description of the key components necessary for midwifery leadership in the 21st century.
Leadership is a key concept of the future. The government has set some difficult challenges for achieving modernisation and change that will ensure the delivery of high-quality services (Department of Health, 2000; Scottish Executive Health Department, 2000).
The NHS Plan (Department of Health, 2000) and its Scottish equivalent assert that never before have midwives had such an opportunity to be at the centre of activities, and be in the position to drive and shape events rather than just respond to them.
Midwives can play a full part in transforming these government reports into reality. This requires strong midwifery leadership to facilitate the changes demanded to deliver high- quality and safe woman-centred maternity care.
All midwives have the potential to lead and they must adopt a style of leadership that empowers the women in their care as well as each other. Transformational leadership appears to be the choice of leadership style best suited to delivery of maternity care in the 21st century.
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