Leading the way: an extract from Contemporary Occupational Health Nursing

In the first of two extracts from a new book, Contemporary Occupational Health Nursing, Christina Butterworth discusses leadership in relation to developing an organisation strategy based on business needs and clinical excellence.

The effective leader creates a compelling vision or mission, which then needs to be developed into a tangible strategy and plan. The occupational health strategy, like any other in business, seeks to achieve a particular goal or set of goals and should be based on the needs of all stakeholders – including the profession, the organisation and its clients.

What is a strategy?

The definition of a strategy is: determination of the basic long-term goals and objectives of an enterprise; and the adoption of courses of action and the allocation of resources necessary for carrying out these goals (Chandler, 1962).

There is more than one format, but all strategic planning needs to go through a systematic process to determine if a formal plan is required. The classic four-step approach is a simple structure to develop and implement a strategic plan:

  1. Where are we now?
  2. Where do we want to get to?
  3. How are we going to get there?
  4. How will we know when we have got there?

1. Where are we now?

At this stage, the context in which the strategy is being developed is analysed. A detailed assessment of key factors in the organisation, the field of OH and the health profile of the population being cared for should be conducted.

An organisation assessment should include: gathering information about the structure and culture of the organisation, its commitment to OH in the past and potential for the future; the financial position; changes to and success of present or past strategies; views of stakeholders; and the governance structure in which the OH service operates. An assessment of the external environment using political, economic, social, technological, environmental, legal and industry analysis may also be beneficial (CIPD, 2010).

Conducting a benchmarking exercise will help determine good practice as a yardstick for future performance. The format can range from a simple questionnaire to a structured interview and review of documentation and practice.

The most widely used tool for the assessment of the present situation is the SWOT (strengths, weaknesses, opportunities and threats) analysis, which involves the team brainstorming each of the four elements.

At the end of the SWOT analysis, there should be agreement on how much the organisation has accomplished, what it set out to do, and how it measures up in terms of resources, structure and delivery of the desired outcomes.

OH nurses should also conduct a health needs assessment to systematically review health issues facing a population and provide valuable data on gaps in health needs.

There are a number of tools available that provide a framework for assessment and help build up a picture of health in the organisation. The benefits of the assessment are to provide evidence about the health of a population and an opportunity to engage with stakeholders and to seek feedback that will help to shape the health strategy.

2. Where do we want to get to?

Step two is the development of the vision and strategic objectives. In a large organisation, the OH vision has to align to the overall vision of the organisation to gain the necessary buy-in. The vision defines the desired or intended future state of a specific organisation in terms of strategic objectives, and should meet the SMART test: it should be Specific, Measurable, Achievable, Relevant and Time-bound.

This step aims to assist stakeholders in reaching a common understanding by simplifying a large number of ideas into a clear statement. It also helps to motivate team members to take action in a chosen direction as efficiently as possible.

3. How are we going to get there?

The strategic plan provides a roadmap to get the OH nurse from the present situation to the vision for the future. The format of the plan should be flexible and mirror those already used in the organisation.

The project/stakeholder team will come together to review steps one and two and then draft the strategic plan, which will be a series of programmes. These comprise a lead person, team members, desired outcomes, tools, resources and a timeline.

The strategy is likely to be made up of a series of programmes that maintain the present services/products, further develop and grow present programmes or conclude programmes that are no longer required.

4. How will we know when we have got there?

Once the strategic plan is ready to be put into place, a set of monitoring points or milestones are required to check how it is progressing. To ensure that this is effective, a number of relevant key performance indicators will evaluate the success factors for the plan.

The OH strategy provides a high-level guide and links activity with the resources needed to achieve it, including time, money, facilities, environment and skills.

Although the strategy may be good and well executed, it does not guarantee success – unforeseen circumstances may arise that affect the organisation – and therefore the plan should be reviewed following any major change.

The NHS Leadership Academy’s Leadership Framework (2011) provides a more detailed model that sets out the standard for leadership to which all staff in health and care should aspire. The model is made up of seven domains. Within each domain there are four categories, called elements, and each of these elements is further divided into four descriptors. These statements describe the leadership behaviours that are underpinned by the relevant knowledge, skills and attributes all staff should be able to demonstrate.

The five core domains are:

  1. Demonstrating personal qualities. Effective leadership requires individuals to draw upon their values, strengths and abilities to deliver high standards of service. This requires them to demonstrate effectiveness in developing self-awareness, managing themselves, continuing personal development and acting with integrity.
  2. Working with others. Effective leadership requires leaders to work with other team members and networks to deliver and improve services. This obliges them to demonstrate effectiveness in developing networks, building and maintaining relationships, encouraging contribution and working within teams.
  3. Managing services. Effective leadership requires individuals to focus on the success of the organisation(s) in which they work. This necessitates the effective planning and management of resources, people and overall performance.
  4. Improving services. Effective leadership requires leaders to make a real difference to people’s health by delivering high-quality services and then developing improvements to them. This demands them to demonstrate effectiveness in ensuring patient safety, critically evaluating, encouraging improvement and innovation and facilitating transformation.
  5. Setting direction. Effective leaders are those that contribute to the strategy and aspirations of the organisation and to act in a manner consistent with its values. This necessitates demonstrable effectiveness in identifying the contexts for change, applying knowledge and evidence, making decisions and evaluating impact.

There are two additional domains that apply particularly – but not exclusively – to individuals in senior leadership roles:

  • Creating the vision. Those in senior leadership roles should create a compelling vision for the future, and communicate this within and across the organisation. This requires them to demonstrate effectiveness in developing the vision for the organisation, and influencing the vision of the wider healthcare system, as well as communicating and embodying the vision.
  • Delivering the strategy. Those in senior roles need to deliver the vision by developing and agreeing strategic plans and ensuring that these are translated into achievable operational strategies. This requires them to demonstrate effectiveness in framing, developing, implementing and embedding the strategy.

The OH strategy aims to develop both operational and clinical excellence in order to maintain or improve health at work. Chapter 9 of the framework provides more details on evidence-based practice and how to apply it to the needs of the organisation.

Strategic delivery

Successfully delivering the OH strategy needs a combination of effective team leadership and stakeholder engagement.

Effective team leadership can be achieved if the leader has a greater understanding of the dynamics of team development and how to manage the potential issues associated with team working.

Team dynamics

Katzenbach defines a team as: “A small number of people with complementary skills who are committed to a common purpose, performance goals and approach for which they hold themselves mutually accountable.” (Katzenbach and Smith, 1993). The makeup and interaction of team members can determine the success or otherwise of the strategic plan. LaFasto and Larson (2001) identified five dynamics to ensure fundamental team success:

  1. The team member: effective team members are experienced, have problem-solving abilities, are open to addressing problems and are action oriented.
  2. Team relationships: the team must be able to give and receive feedback and it needs to be able to work together towards the overall strategic objective.
  3. Team problem solving: an effective team needs a clear and specific goal. It needs open and honest communication to create an environment where team members feel comfortable, relaxed and accepting.
  4. Team leadership: effective team leadership depends on leadership competencies. A competent leader is focused on the goal, ensures a collaborative climate, builds confidence of team members, sets priorities, demonstrates sufficient “know how” and manages performance through feedback.
  5. Organisational environment: the climate and culture of the organisation must be conducive to team behaviour.

Teams do not become effective decision makers solely on the fact that they have a shared goal. Tuckman proposed the four-stage model of team building – consisting of forming, storming, norming and performing – that has become the basis for structuring models.

Forming a team

In the first stage of team building, the formation of the team takes place. Team members get to know each other, the task and what skills they have that may help with its success. They do not want to cause any conflict, so they generally avoid strong feelings and simply go through the task actions.

This stage is usually short and comfortable and the team members have a high level of agreement, while determining their own individual needs and expectations.

The formation stage provides the leader with an opportunity to see how individual team members work and how they respond to each other and the task at hand.


As the group enters the storming stage, they start to compete with each other to get their ideas heard.

As the tasks become more defined, the team members start to confront each other’s ideas and thoughts, the full extent of the work is realised and some members may become overwhelmed. Other members may feel that without the full support of all team members the success of the team is likely to be hampered.

The storming stage is necessary to the growth of the team and needs to be carefully controlled by the leader. The behaviours and emotions need to be normalised and focus should be on the decision-making process and the end goal.


The norming stage is focused around one goal and a strategic objective.

At this point, the team members know each other better and take responsibility for the team and project as a whole, giving up their own needs. They ask each other for feedback and recognise the progress made under the present leadership.

There is often a prolonged overlap between storming and norming behaviour. As new tasks come up, the team may lapse back into typical storming-stage behaviour, but this eventually dissipates.


The performing stage is only reached when team members start to work together more effectively. New members may join the team, but this does not usually affect the team dynamic. The team leader is able to delegate more tasks to team members and they feel more able to work together without leadership direction.

Team members may challenge within the social norm. Even high-performing teams will occasionally revert to the storming stage if they go through significant change.

These stages of team development are all necessary in order for the team to grow, solve problems, support each other through challenges and deliver the strategic plan. This model has become the basis for subsequent models.

Team pitfalls

Patrick Lencioni describes the many pitfalls that teams face as they seek to “row together” by the use of storytelling in his book “The Five Dysfunctions of a Team”. Even well-intentioned teams sometimes struggle to work together or achieve the strategy.

He reveals five dysfunctions and provides guidance on how to overcome these and perform effectively:

  1. Absence of trust. The team members are unable to understand and open up to one another. They are not willing to show any weaknesses, admit their mistakes or show any concerns about their ability or those of others to achieve the team’s goals. Without a foundation of trust, the success of the strategy may be delayed or the team can even fail completely.
  2. Inattention to results. Team members or working groups focus on their own achievement and not the team’s collective results. This weakens the effectiveness of the team and the potential of the strategy.
  3. Fear or conflict. The foundation of trust and commitment to the end results can result in an environment of fear or conflict. Teams need to be open and honest about their fears and concerns so that they can work through the issues without anyone becoming harmed by the experience or potentially sabotaging the outcome.
  4. Lack of commitment. If team members fail to adopt real commitment to the strategy, they will continue to seek self-reward. They need to be able to share their opinions and feel they have been listened to in order to commit to the shared goals.
  5. Avoidance of accountability. Once the team members have achieved buy-in and commitment, they then have to hold each other to account. Strategic plans do not always follow the intended route, in which case difficult conversations can sometimes be required between the leader and the accountable team member. Failure to hold one another accountable creates an environment where avoidance can thrive.

Christina Butterworth is head of health for BG Group, former chair of the Royal College of Nursing’s OH Managers’ Forum, president of the AOHNP (UK) and deputy chair of the Council for Work and Health


Chandler AD (1962). Strategy and Structure. Cambridge, MA: MIT Press.

CIPD (2010). Factsheet: PESTLE analysis. www.cipd.co.uk/hr-resources/factsheets/pestle-analysis.aspx

NHS Leadership Academy (2011). Leadership Framework.

Katzenbach JR, Smith DK (1993). The Wisdom of Teams: Creating the High-Performance Organisations. Boston, MA: Harvard Business School Press.

LaFasto FMJ (2001). When Teams Work Best. Thousand Oaks, CA: Sage.

More on leadership in Contemporary Occupational Health Nursing
This article is an excerpt from the chapter on leadership in Contemporary Occupational Health Nursing. The chapter includes sections on:

  • the fundamental principles of leadership;
  • leadership styles and models;
  • how to develop organisation strategy based on business needs and clinical excellence;
  • the impact of team dynamics and stakeholder engagement on delivering strategy; and
  • the interaction between the leader, the team and the organisation.
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