Abstract
This was the question asked by Elaine Maxwell in the last edition of the Journal of Research in Nursing. Specifically, she asked, ‘Leadership: What is it good for?’ (Maxwell, 2020) then clarified the question by asking, ‘who are we leading and to what end?’ Finally, she asked us to seek clarification about and to debate, ‘what professional leadership is, could and should be’.
In this response, I hope to take up the challenge and respond as well as I can, by clarifying aspects of professional leadership and describing why I think leadership is vital by specifically focusing on what I think professional leadership is good for.
First, let me say I agree with many of the points Elaine Maxwell made in her paper. I believe a leader does not have to hold a formal leadership role or position of authority in an organisation. But they do need to understand what this means in terms of their leadership scope, or as Maxwell suggests ‘they will be set up to fail’ (Maxwell, 2020: 176). As well, a focus on leadership styles is pointless in the development of leadership skills and abilities. The styles described (democratic, authoritarian and others) offer only limited insight into how leadership can be learnt or understood or most importantly applied or practised, and in most cases the styles are focused on or developed from the management paradigm. Instead, in leadership training/education greater emphasis should be placed on leadership theories (specifically well-established, evidence-based theoretical perspectives) of leadership. There are many and although each has merit, few have been developed from a purely leadership domain and fewer still were developed from a health-professional perspective or for health professionals to employ. Locating leadership training and education for health professionals on a foundation of leadership theories specifically relevant to health-professional leadership would be an ideal place to start.
In Maxwell’s paper, she described a number of others who had influenced her ideas and practice of professional nursing leadership. It was suggested that she had located a ‘role model’, a senior ‘Sister’ who led in a way that allowed her to practise and display her ‘professional values’. She also described a tutor who embodied the ‘values of the group’ as she created a ‘shared social identity’ (Maxwell, 2020: 176). I found in these descriptions links to what I perceive professional nursing leadership is, could or should be. This was what Maxwell was asking we seek and debate, and as such I believe there are clues in her paper for a resolution to her questions.
I also agree that professional leadership is evident (or can be) more than leadership in the clinical domain and would argue that professional nurse leadership is (or can be) evident in a multitude of spheres, such as management, education, policy development and social or public health development. However, for professional nursing leadership to be relevant it needs to be based on a single set of values that reflect the foundational principles of the nursing profession. This set of values is the solution alluded to in Maxwell’s paper and supported by my claims in this response.
Nursing has always been a values-based profession and the research I have undertaken over 20 years (Stanley, 2006a, 2006b, 2017, 2019) points clearly to nurses and other health professionals seeking leaders who demonstrate in their actions the values fellow nurses identify with and respect or aspire to. The theory of leadership that developed from my research is called ‘Congruent Leadership’ (Stanley, 2019) and was first reported in the Journal of Research in Nursing in 2006. The theory grew from research with nurses (in acute care, aged care and rural and remote practice environments), paramedics, allied health professionals and ambulance volunteers. It is a values-based leadership theory and, as with other values-based theories (‘Authentic Leadership’ (George, 2003); ‘Breakthrough Leadership’ (Bhindi and Duignan, 1997); ‘Servant Leadership’ (Greenleaf, 1977 and Hanse et al., 2016)) that suggests followers will support and identify with leaders who display and act on the values that align with followers. This is the case regardless of the role or function of the leaders, so values-based leadership approaches can be seen and are effective in any health-professional or nursing leadership sphere. The debate then focuses on what these values might be.
Maxwell offers one key attribute she valued, that of a ‘role model’. Other values were evident across the research I have undertaken and in literature supporting other values-based theories. Nurses value approachability, clinical competence, leaders who are supportive, motivational, who inspire confidence and display integrity, leaders who communicate clearly and are able to adapt well to change. I suspect there are other values or attributes that can be added to the list and should be, depending on the specific sphere in which the leader is operating. Educational leaders may not be highly regarded for their clinical competence but will be seen as role models in their field if they display educational competence (with, for example, new teaching technologies). Policy leaders will be recognised as leaders in their field if they display, amongst other things, effective communication and a clear grasp of evidence-based practice for guiding and influencing appropriate policy directions.
What is nursing professional leadership good for? It is good for focusing the profession of nursing on the things that matter most. It is not about management. It is not about styles that only describe leadership behaviours and it is not well supported by theories grown from the management paradigm, or theories that have no research base related to health-professional activity or leadership endeavours. All health professionals and nurses can, and should aspire to, be leaders by recognising the values that are the foundation of our profession and doing their best to apply these in whatever spheres of endeavour they function.
Maxwell also asks ‘what good [does professional nursing leadership] bring?’ I would argue that if the nursing profession loses its anchor to its foundational values and if nursing leaders are not leading with their focus on a clear set of agreed values, there is a real risk we will lose our place at the heart of the health service and as the voice of compassion and kindness in a world grappling with unprecedented challenges. In the face of global pandemics and economic uncertainty, health-service privatisation, technological overload and industrialisation of the health industry and its workforce, what will we be left with if our values are subsumed? Educating nurses to think they all can and will be health-service managers is indeed pointless, although there is a place for educating health-service managers. However, all health professionals including nurses should understand that many others will see them as role models (leaders), even if they do not know it, and that their actions and choices will be seen by followers that they may not even know they have.
Finally, I would be clear that leadership and management are different and, although complementary (Swanwick and McKimm, 2019), health professionals can best learn and understand leadership if the differences between them are carefully considered and if the distinguishing features are outlined. Only then can health professionals truly begin to recognise how leadership can be applied in the healthcare and professional domain.
My question then is what values form the foundation of nursing? What is it that we stand for, or are prepared to stand up for? Professional nursing leaders will struggle to guide or support the nursing profession (regardless of their sphere of activity) if we are not sure what our professional values are. Congruent Leadership, and any other values-based leadership approach, is dependent on recognising and naming the values that leaders should aspire to or lead by. For example, the former Chief Nursing Officer (CNO) for England’s use of the 6 C’s (Stephenson, 2014) may be one place to start (the C’s are care, compassion, courage, communication, commitment and competence). Internationally there are other perspectives, but in England, for example, they permeated many practice settings during that CNO’s incumbency and although there were many detractors and views about these values (Baillie, 2015), Francis suggested they should ‘become the common reference point for all staff’ (nurses and indeed all health professionals) (Francis, 2013: 1399). But I wonder if we think of these as values. Are there others to consider? Baillie (2015) also asked this question, but have we lost sight of these values now there is a different CNO? Did we ever really articulate them and absorb them into our daily practices or were they already part of our routine set of values and work? Do we simply need to give them a voice? Truly great professional nursing leadership is dependant (I think) on the profession being able to articulate its core values, thereby recognising, displaying and living out our core professional values for others to see and follow. It is here that professional nurse leaders can make a profound difference and that is what I think (professional nursing) leadership is good for.