Editorial

Improving the workplace: The pivotal role of nurse leaders

Debra Jackson
Professor, Faculty of Nursing, Midwifery and Health, University of Technology, Sydney (UTS), Broadway NSW

John Daly
Faculty of Nursing, Midwifery and Health; WHO Collaborating Centre for Nursing, Midwifery and Health Development, University of Technology Sydney, Sydney NSW

PP: 082 - 085

Article Text

The nursing profession is confronted with navigating the perfect storm as it strives to build cultures of safety for patients and families while simultaneously handling an epic crisis in workforce issues involving both nurses and nursing faculty. This culminates in a situation of high risk for people, for resources and for whole organizations and systems. (Hinshaw, 2008, p. S4)

In using the metaphor of the perfect storm, Hinshaw highlights the depth of the challenges facing contemporary leaders in nursing, not least of which is the quality of the nursing workplace. Quality of work environment is a key factor in achieving optimal workplace outcomes and retaining nurses (Bowles & Candela, 2005). A healthy working environment is said to be one in which staff can accomplish organisational goals and experience work satisfaction and fulfilment (Shirey, 2006). However, it is now well recognised that for many nurses, negotiating the workplace is experienced as complicated, difficult and even traumatic, and it has been suggested that the healthcare workforce is in a period 'that can arguably be considered the most chaotic and unstable in memory' (Bowles & Candela, 2005, p. 131). Current indications are that without serious system reforms, this situation has the potential for further deterioration.

From a sizeable body of international literature, we know that workplace difficulties for nurses are associated with various factors, which at times can include inter-professional conflict (Bowles & Candela, 2005; Jackson, Clare, & Mannix, 2002; Johnson & Rea, 2009). Literature suggests that workplace difficulties themselves play an important part in the retention of staff as well as influencing staff morale, job satisfaction and worker wellbeing (Hutchinson, Vickers, Jackson, Wilkes, 2006; Jackson et al., 2002; Johnson & Rea, 2009). In addition to negatively affecting nurses, unhealthy workplaces carry financial implications for organisations (AACN, 2005), and have also been implicated in suboptimal patient outcomes (Cummings et al., 2008; Hutchinson et al., 2006, 2008). This is hardly surprising, because how can we claim to provide healing and therapeutic environments for patients and families, when considerable numbers of health staff are simultaneously experiencing these same environments as harmful and noxious?

In the face of convincing literature that highlights workplace adversity and difficulties in nursing, one contemplates the role of leaders and leadership. Though constructed in various ways, it is generally accepted that leadership involves influence, occurs as a result of interconnectedness between people, and has strong interpersonal and relational aspects (Cummings et al., 2008; Jackson, 2008; Zilembo & Monterosso, 2008). Effective leadership and particularly effective clinical leadership is proffered as the panacea to poor management, and the organisational difficulties that are so endemic in many contemporary healthcare environments (Garling, 2008; Jackson & Watson, 2009). Resources exist to influence and assist leaders in healthcare. The American Association of Critical Care Nurses (AACN), for example, has provided direction in the area of promoting healthy work environments for nurses, through the identification of six standards for establishing and sustaining healthy work environments. These are: skilled communication, true collaboration, effective decision-making, appropriate staffing, meaningful recognition and authentic leadership (AACN, 2005).

In identifying authentic leadership as a key standard essential to the creation of a healthy workplace, the AACN positions leadership as being among the central elements necessary to foster a healthy work environment. Authentic leadership recognises the crucial role that follower trust plays in leadership, and acknowledges the role of positive emotions such as optimism and hope in achieving desired leadership outcomes (Avolio, Gardner, Walumbwa, Luthans, & May, 2004). Authentic leadership has been described as being embodied in persons 'who have achieved high levels of authenticity in that they know who they are, what they believe and value, and act upon those values and beliefs while transparently interacting with others' (Avolio et al., 2004, p. 804).

As a concept, authentic leadership is compatible with existing leadership models including transformational and servant leadership (Jackson, 2008). Indeed, Avolio et al. (2004) have noted that rather than adopting any particular behavioural style, the actions and behaviours of authentic leaders are shaped by their deeply held personal principles and beliefs. In the health sector, many drivers for change are imposed from on high, and when considering the central role of personal conviction in authentic leadership, questions are raised (and remain unanswered) about how leaders can continue to lead authentically when they themselves may be compelled to initiate and implement organisational change which may not be consistent with their own personal belief system. In such circumstances, authentic leaders would need to reconfigure or massage the planned change into something coherent with their own personal belief system, or they would not be able to lead such change authentically. Healthcare organisations tend to be large, complex and highly regulated. In the current health environment, change is often rapid and imposed.

Healthcare leadership is influenced by an extensive array of forces, both internal and external to organisations, and leaders require many high level skills to meet the demands these forces impose (Schwartz & Tumblin, 2002). In this context, leadership carries risk, and Heifetz and Linsky (2002) have made the observation that 'we live in a period of history when taking on the risks of leadership in your individual world is both more important and more complicated than ever before' (p. 4). Leaders need support and resources to be able to enact their roles in the complex, turbulent healthcare environments, and may feel they have limited support from both followers and others higher up in their organisations to either effect or persist with essential change processes.

Leadership can be, as Heifetz and Linsky (2002) note, a very risky business where the stakes are high at times. Developing awareness of this and skills in managing tensions and complexities in nuanced ways is likely to influence success in leading in turbulent, politically charged environments. There is a body of literature that provides insights into the complexities of leadership in large organisations, including advice on how to avoid serious failure in leading, and the potentially damaging consequences that can go with this (Heifetz, 1994; Heifetz & Linsky, 2002).

Despite the difficulties this may pose, if leadership is to be effective, leaders cannot stand back and distance themselves from the quality of their workplaces. Presumably, and judging by the literature, a range of harmful workplace actions and behaviours occur under very the noses of leaders, who, it seems, either function in blissful ignorance of these adversities, manage them ineffectually, or even turn a blind eye to them. Given the centrality of interpersonal skills and relationships to leadership it is difficult to understand how so many abusive, negative and unhealthy aspects of the workplace remain unaddressed by nurse leaders. Frameworks, such as that proposed by the AACN, exist for improving the workplace, but large scale systemic change remains elusive.

Factors such as hope, positive expectation and optimism are essential to healthy workplaces. Leaders have a crucial role in creating hopeful work environments (Avolio et al., 2004), and in addition to this, effective leaders require personal insight, strength, fortitude and courage. They are responsible for driving change, maintaining standards and productivity, and for the wellbeing of staff and consumers that come into their environments. However, when exploring the complexity which has to be recognised and managed in facilitating change in health systems, including clinical work environments, some challenging and salient questions surface:

• Are we doing enough to prepare the next generation of professional and clinical leaders in nursing in contemporary healthcare systems?
• What are the barriers and facilitators to enacting effective leadership in the workplace?
• Do current organizational and management structures encourage innovative leadership?
• Is structural oppression a significant impediment to nurses enacting leadership in clinical workplace?
• Has preparation for leadership been under emphasised in nursing and health professional education?
• Are we producing graduates who are empowered to lead in the workplace?
• Is quality leadership an unaffordable luxury in contemporary healthcare?
• Who are the leaders that are empowered to make the decisions?
• How do we facilitate change to help leaders become more progressive and effective?

We are not alone in considering these issues. Questions have been asked in medicine about how to prepare medical graduates for leadership roles as well as clinical practice (Armit & Roberts, 2009; Schwartz & Tumblin, 2002), and the essential role of effective health sector leadership has been recognised in the recent special commission of inquiry into acute care services in New South Wales (NSW) public hospitals (Garling, 2008).

The nursing literature calls for leaders to focus on improving the work environment and enhance working conditions for nurses (AACN, 2005; Bowles & Candela, 2005), and there is much that leaders can do. When considering bullying for example, Johnson and Rea (2009) suggest that if we are to effectively mitigate bullying in the work environment, interventions targeting nurse leaders need to be implemented. This, they argue, would assist in ensuring that nurse leaders are able to recognise some of the subtle behaviours that comprise bullying, and respond appropriately should they observe these in the workplace. Furthermore, in light of literature suggesting that bullying behaviours often emanate from senior levels (Hutchinson, Jackson, Wilkes & Vickers, 2008; Hutchinson et al., 2006; Johnson & Rea, 2009) interventions to encourage leaders to reflect on their own conduct may assist in the development of personal insights that could enhance the workplace. We concur with comments made by Johnson and Rea (2009), and also argue that, in view of the plethora of literature highlighting the difficulties associated with the workplace for many nurses, it is important that leaders reflect on quality of their workplaces, and consider ways they themselves may contribute to the creation of an either healthy, optimal working environment, or a toxic and detrimental one. It is for leaders to set the standard for workplace behaviour, and to establish 'a civil workplace in which all members are treated with respect and in which conflicts are dealt with in a healthy and open manner' (Johnson & Rea, 2009, p. 89).

Regardless of the type of personal leadership style, nurse leaders are challenged to work towards optimising workplace environments. The health sector is a site for healing and care for patients, clients and families. However, for health professional and support personnel, it is a workplace. If we are to improve the health sector as a healthy work site, strategic change is needed. These are of course global issues and reflection on this context evokes the imperative to 'Think globally, act locally' in considering potential strategic responses.

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