Effective top-level management requires both empathy with staff and the ability to apply leadership theory to practice. Sarah Witwicka and Anne Harriss explain how this affects occupational health nurses.
Never has it been more important for occupational health nurses (OHNs) to have leadership skills. OHNs are recognised by the Nursing and Midwifery Council (NMC) as specialist community public health nurses (SCPHNs), and leadership is integral to the NMC standards set for the education of SCPHNs. OHNs in management positions are well placed to lead the provision of OH services. Effective leadership requires the ability to understand, critically appraise and then apply leadership theory to practice.
To date, leadership theories have focused predominantly on what leaders do rather than how well they perform (Arnold et al, 1995). The major study by Tamkin et al, published by the Work Foundation in 2010, set out to discover the values and actions of “outstanding” leaders and which attributes set them apart from “good” leaders.
So what are the effective leadership strategies that contribute to the delivery of a high-quality OH service?
Tamkin et al selected six UK high-profile organisations to participate in their study, including EDF Energy, Tesco and Unilever. The six companies provided 77 leaders deemed to be “good (or better)” who were interviewed along with their line managers to explore the thinking and performance of leaders who are considered “outstanding”. Three key concepts of outstanding leadership were identified, which involved thinking, believing and impacting: “thinking and acting systematically on behalf of the organisation”; “believing that people are the route to performance”; and “achieving through their impact on others”. These three key concepts were developed from nine crucial themes. Three of those nine themes will be considered in this article: “thinking systematically and acting long term”; “understanding that talk is work”; and “putting ‘we’ before ‘me'”.
Understanding required
To understand how these themes fit in with the leadership requirements of a high-quality OH service within contemporary public health, there needs to be an understanding of the proposed direction in which OH services are being driven, what is considered to be “high quality” and what is deemed to be “contemporary public health”.
Key factors influencing the future direction of OH services are the Black report (2008), the Boorman final report (2009) and Kirk’s (2010) report on the future configuration of OH services in the NHS. Collectively, these reports emphasise the need for exemplar, accredited services to be configured in order to provide collaborative, organised efforts that promote health and wellbeing and prevent ill health of the working population.
The challenge for service leaders is to facilitate the transformation of current provision into the vision for the future. This transformation can be related to Lewin’s (1951) change model incorporating a three-stage process: “unfreezing”; a period of change; and “refreezing” changes. Lewin’s change model is reflected in Tamkin et al’s concept of “thinking systematically and acting long term”.
This approach is the means by which a leader thinks through situations that are often unstable or arbitrary and then acts carefully upon their considerations in order to prevent harm to team members, thus promoting long-term organisational benefits. An outstanding leader is intent on adopting a style of leadership to maintain longevity of performance (Tamkin et al). It can be argued that the proposed changes to OH services within the NHS, particularly the observations and recommendations of Kirk, will call for different styles of leadership, according to the process described by Lewin.
Parker (2009) supports this argument and explains “strategic”, “tactical” and “operational” leadership. Strategic leadership, according to Parker, relates to change whereas tactical leadership refers to resources and functions, and operational leadership to exploiting available resources. These changing styles rest upon the contingency model of leadership effectiveness (Fielder, 1967).
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Fielder theorised that the leader’s ability to influence a team is dependent on his or her power position, the relationship they have with their team members and the structure of the tasks or jobs. The most significant factor of Fielder’s model, associated with decision-making, is the relationship the leader has with their team members and their esteem for the team leader’s “least preferred co-worker” (McKenna, 1994). The leader is deemed to be most effective when he or she rates the most difficult team member to cooperate with, meaning the least preferred co-worker, in a favourable manner. This reflects a leader who is more person-centred than task-centred.
Although Nazarkolt (2007) supports the argument for changing styles of leadership, the study suggests that there needs to be consideration for the individual to interchange between the roles of “leader”, “manager” and “facilitator”. Whereas the role of manager is centred upon completing current tasks, an effective leader considers future development of the organisation and the facilitator addresses complex tasks involving the input from a number of people (Nazarkolt, 2007). Kotter (1990) supports the interchanging relationship between “manager” and “leader” and suggests that both are necessary for managing the complexity of organisations.
In situations of change, such as the current fluctuating nature of OH services in the NHS, outstanding leaders can adopt the appropriate leadership style according to the changing landscape. Ultimately, as Nazarkolt notes, the leader is likely to adopt various styles each day, but their skill lies with knowing which style to use and when. With the proposed changing configuration of NHS OH services, it is likely that, as organisations merge, some leaders will be relegated to managers and facilitators. If those who remain in leadership posts are to continue to be outstanding leaders, they must build positive relationships with those who have been demoted.
Key concepts
Essential in these circumstances is Tamkin et al’s theme of “putting ‘we’ before ‘me'”.This supports two of the three key concepts of outstanding leaders suggested by Tamkin et al: “believing that people are the route to performance” and “achieving through their impact on others”. The authors describe the process of outstanding leaders “putting ‘we’ before ‘me'” as incorporating their building of an environment within the team with a reduced sense of hierarchy.
This is achieved through the formation of strong bonds and an emphasis on shared importance, collaborative working, shared decision-making and a sense of belonging. The development of a sense of belonging to maximise performance is reflective of Maslow’s (1943) hierarchy of needs. Maslow theorised that individuals become motivated only after achieving a sense of belonging and gaining respect for others and for themselves, leading to self-actualisation and the point at which creativity can be attained.
Outstanding leaders who recognise the need to form strong social bonds within teams reflects emotional intelligence (EI) theory. Goleman (1995) suggests that EI is the individual’s capacity to regulate their own emotions and understand their own moods and feelings as well as the emotions of others around them.
In these turbulent times in NHS service provision, resulting from an economic downturn and an ever-shifting environment, effective leaders will be the ones who can regulate their own emotions and demonstrate empathy with their team members, thus motivating their teams.
Other models supporting Goleman’s concept of EI and the contribution of self-awareness to building strong social bonds within a team include the Johari Window model of Luft and Ingham (1955). The window is constructed from these four “panes”:
i. that known about the individual by themselves and others around them;
ii. that known by the individual by themselves but not by others;
iii. what others know about the individual but is unknown to themselves (a “blind spot”); and
iv. an area that is unknown to the individual and to others.
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This model suggests that a team’s interrelationships are promoted through increased self-awareness and mutual understanding and that these attributes can be built upon by means of self-disclosure.
The developing of social relationships between leaders and their teams through self-disclosure is suggestive of associations evolving over sustained periods.
However, of the 77 leaders participating in the Tamkin study, three left their organisations in the final four months of the research. No explanation as to why they left is given. These departures in themselves may have led to their managers to shift their opinions retrospectively on whether or not they were in fact deemed to be good (or better) leaders.
Tamkin et al postulate that great leaders connect teams to the long-term goals of an organisation or the concept of “putting ‘we’ before ‘me'”. However, other themes supporting the two key concepts of outstanding leaders are “believing that people are the route to performance” and “achieving through their impact on others”.
Perhaps less related to the longevity of the leader is the theme “understanding that talk is work” (Tamkin et al). This theme has a strong focus upon communication. One area of communication the authors highlight is conflict resolution, noting that the outstanding leader does not allow negativity or conflict to rankle, but instead challenges it, facilitating behavioural change or resolution by other means.
An example of challenging difficult team members through communicating with them to bring about such change is given by Ellis and Abbott (2010). They suggest that leaders can effectively manage “difficult-to-manage individuals”. Leaders can do this by collecting information from them through formal and informal discussions to identify, harness and apply the values that motivate them to areas where they are likely to flourish, thus improving productivity and alignment within the team.
Identify opportunities
At the centre of outstanding leaders’ capabilities in “understanding that talk is work” are several types of behaviour: their ability to determine what motivates people through both informal and formal discussions; frequent identification of opportunities for conversations, debate and dialogue; and building social relationships with team members (Tamkin et al).
Through interviews and questionnaires, Stanley (2006) found that clinical nurse leaders could be identified by their effective communication skills, approachability, aptitude for motivating through empowerment and visibility or presence in their clinical environments.
Tamkin et al also found that outstanding leaders identified visibility as an important factor of their role, demonstrating this by walking around their workplaces, talking to team members and by engaging the wider workforce to ascertain opinions as well as apprehensions.
Tamkin et al suggest that outstanding leaders believe that ideas are best sought from the workforce as a whole and that they recognise team discussions as a means of connecting with team members rather than focusing on team objectives. However, the nature of the work in NHS OH services means that team members are frequently assigned to rooms for one-to-one meetings with clients, leaving little time, if any, for the leader to gather the team for formal or informal discussions.
As well as this, the single-room arrangement typically found in NHS OH service environments is seldom conducive for leaders to walk around freely. Nevertheless, Tamkin et al also emphasise the importance of the style by which outstanding leaders communicate to promote openness within the team, achieving this by, for example, expressing their own shortcomings. This in turn is said to lead to openness from others and instils trust in the leader. Highlighting personal weaknesses in an NHS OH service can be said to facilitate growth within a team since this can enable the team members to learn from each other, share their knowledge and engage in reflective practice.
Although Tamkin et al’s findings have been through empirical research, all of the companies that participated in the study were commercially based, unlike current NHS OH services. However, these are being driven towards offering third parties to commission their services (NHS Employers, 2012); therefore, a more commercial, customer-facing service can perhaps be considered the way forward.
Nevertheless, since NHS OH services are aimed at delivering early interventions for ill-health prevention and promotion of health and wellbeing, they are a far cry from those companies used by Tamkin et al.
Gender paradox
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It is worth noting that, historically, OH services are nurse-led and nursing is a female-dominated profession. An analysis of attributes did not demonstrate a skewing of performance ratings according to gender, although of the 77 leaders who were elected for the study, only 15 were women (Tamkin et al). This is not reflective of the population of registered nurses in the UK because in 2005 the NMC stated that just over 10% of registered nurses in the UK were male. In addition, leaders were selected for the Tamkin et al study by their supervisors with no indication that input or opinion was sought from their subordinates. Therefore, selection of participants was by a top-down rather than bottom-up process. Having subordinates involved in identifying “good (or better)” leaders may have achieved very different results on what makes an outstanding leader.
Another consideration related to the application of Tamkin et al’s report to traditionally nurse-led NHS OH services is that in 2011 the Royal College of Nursing (RCN) noted that by 2010 just over 25% of NHS England’s nurses were aged 50 or older. The RCN further noted that this percentage of nurses may look towards reducing their hours and therefore their organisational commitment in favour of engagements outside work.
Nevertheless, Tamkin et al have highlighted the attributes that will be required of leaders within NHS OH services if they are to be effective in delivering a high-quality service within contemporary public health. Three of these attributes, or themes, critically discussed above – “understanding that talk is work”, “thinking systematically and acting long term” and “putting ‘we’ before ‘me'” – may be difficult for any NHS OH service leader to harness, given the economic climate, the future proposals being prescribed to OH services and the expectations of both the client group and stakeholders of the level of service delivery.
Sarah Witwicka RGN, ENBA09, BSc Hons (Psych Sci), MSc (Occ Psy), C.Psychol is a final-year student BSc (Hons) occupational health nursing, London South Bank University.
Anne Harriss MSc, BEd, RGN, OHNC, RSCPHN, CMIOSH, GHR is course director, occupational health programmes, London South Bank University.
References
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