Introduction
We are living in a time in which the NHS is facing many economic and social challenges. Our healthcare system is suffering budget constraints, an increased and aged population, higher patient expectations, nursing staff shortages and we are now treating more complex illnesses than ever before (Rivett 2015). In order to implement the changes needed to address these issues the government has put its focus on leadership and developing strong leaders in the NHS (NHS England 2014). However, the term ‘leadership’ is a wide concept and throughout history, there have been many lines of thought on what leadership means and what attributes a good leader must-have. For the purpose of this essay, the focus will be on transactional and transformational leadership because according to the literature those are the leadership styles most prevalent. The current policy agenda regarding leadership in the UK encourages skills attributable to transformational leadership to address the challenges the NHS is currently facing, as opposed to transactional leadership. Nevertheless, the literature suggests that transactional leadership is still the leadership style most followed among nurses. In this essay, I argue why transformational leadership is the way forward to address the leadership crisis in the NHS. First, I give an overview of the theories of transformational and transactional leadership linked to the context of an operating theatre department. Then, I describe the NHS policy framework in relation to leadership, its origin, and its links to the transformational leadership theory. This leads to a discussion of the further benefits of transformational leadership which I argue comes in the form of increased theatre staff development, motivation, and engagement. Following on from this, I discuss the objection that transformational leadership is insufficient to address challenges such as national nursing staff shortages, meeting surgical targets, or lack of funding, and training a manager with the transformational theory requires more training and time. Transactional leadership on the other hand can more easily achieve short-term goals, it's more structured and easier to implement. I reject this by arguing that transformational leadership can lead to more productivity and efficiency, therefore, minimizing the effects of reduced budgets and the lack of nurses and can lead to better outcomes in the long term. I conclude that transformational leadership is the way forward to archive the NHS vision for the future despite the economic and socio-cultural challenges the UK is facing.
Leadership
The concept of leadership can be defined as the process in which a leader interacts and influence others in order to achieve a goal (Sadler 2003). However, Sadler’s definition can lead to multiple interpretations because of its general and unspecified nature. Dugan (2017) argues that there is no one way of defining ‘leadership’ because there are potential as many definitions of leadership as leadership theories. Leadership means different to different people according to their approach to leadership based on their perceptions, preconceptions, and life experiences (Dugan 2017). This may be explained in the context of an operating department in an acute hospital setting because it can be easily observed that different theatre nurse managers interpret how a team should be led differently, influenced by how they were led, what they were taught, and what they have seen other theatre managers doing. Therefore, to better understand the topic is necessary to narrow the issue by looking at specific leadership theories.
In order to better understand the need for strong leadership in the NHS is important too, first of all, take a look at the actual socioeconomic context in the UK. In recent years we have witnessed an increase in the demand for health services and an increasingly older population above 85 years old (Maguire et al 2016). In the last 10 years, from 2007/8 to 2017/18 there has been an increase of 30% of hospital admissions (NHS Digital 2018). When looking at surgical procedures carried out. In 2007/2018 there was a total of 8,606,493 procedures and interventions and in 2017/18 it went up to 11,897,542. This represents an increase of 38.24% in the number of surgical procedures in 10 years (NHS Digital). The increased activity has caused an average increase in spending of 4% every year (King’s Fund 2018). However, it is estimated that this year the NHS budget will only see an increase of 1.9% in 2018 in comparison with the 2017 budget (Nuffield Trust 2018). Personal experience supports this fact; in the operating theatre department where I work there has been a clear increase in activity and Saturday theatre lists and late evening, sessions have been introduced to meet the demand. This profound gap between spending, healthcare spent, and increased demand has made the government look at ways to improve productivity utilizing the current resources (Maguire et al 2016).
In recent years, there has been an increasing interest in leadership as a tool to tackle NHS budget constraints. In 2010, the department of health published the health White Paper Equity and Excellence: Liberating the NHS (DOH, 2010), a document that outlines the vision of the NHS as an organization that put patients at the center and focuses on quality of care, equality, efficiency, and transparency. In order to achieve this, a year later, the NHS leadership academy (2011) issued the Clinical Leadership Competency Framework which acknowledged that in order to successfully meet the targets described in the white paper and transform services it was necessary to have strong leadership in place. This document was therefore developed as a guide and aimed to provide a structure to standardize leadership training and education (NHS Leadership Academy 2011). The importance of leadership in the clinical setting was also reinforced after the Francis report (2014) which highlighted leadership failures as one of the reasons for poor patient care in the Mid Staffordshire NHS Foundation Trust. The focus on leadership is, in addition, highlighted in the NHS England (2014) Five-year forward view which outlines the vision for the NHS for the next 5 years supporting the idea that innovative ways of working are needed to deliver more efficient and cost-effective care. Nevertheless, there are still many questions answered because these NHS policies still fail to help the front-line nurse manager on how to be a better leader despite the time and economic constraints they face.
Leadership theories
For the purpose of this essay, the focus will be on two leadership theories: transactional and transformational leadership. The reason why these two theories have been chosen is that according to my experience these are the two theories mostly represented among nurse managers in the operating theatres. This assertion can be supported by a recent systematic review carried out by McCay et al (2018) in which the author looked at literature published between January 2009 and September 2016 in a bid to study the relationship between leadership styles and staff satisfaction. McCay et al (2018) identified transactional and transformational leadership as the most mentioned leadership styles in the literature. Nonetheless, this study used articles that were not published in the United Kingdom and it only focuses on articles in which leadership styles are linked to staff satisfaction therefore not covering the wide variety of articles published on the topic of leadership. Further research should be undertaken to determine what are the most prevalent leadership styles in the NHS and in particularly among nurses working in the operating theatre as at the moment there is a lack of evidence. However, despite McCay’s limitations, his work does give an idea of the most common leadership styles in healthcare which as mentioned previously are the most common styles I have been able to identify in my nursing career.
The concepts of transforming and transactional leadership were first introduced by James MacGregor Burns in 1978. Burns developed the concepts while studying the attributes of great leaders throughout history and the influence of their socio-cultural and political context (Burns, 1978). According to Burns (1978), a transactional leader identifies the objectives that need to be accomplished, directs staff in order to achieve them, and punishes or rewards employees according to their performance. However, Winker (2010) argues that Transactional leadership tends to be unidirectional as it does not take into consideration the qualities the follower brings to the team. Later in 1985, Bass developed Burn's concept of transforming leadership and came up with the concept of transformational leadership (Bass, 1985). Transformational leadership differs from transactional leadership in which the former, challenges actual structures and focuses on changing them with the involvement of the employee while the latter, focuses on achieving objectives utilizing the working structures already in place (Kakabadse et al 2007). According to Bass, a transformational leader empowers staff to challenge the status quo and encourages them into finding new ways of learning and working, the focus is now on the employee. Northouse (2010), however, argues that the concept of transformational leadership has some weaknesses because the theory is not specific enough and can lead to multiple interpretations and, in addition, the concept showed an inclination towards heroinism and has the potential to be used in a negative way by leaders. The reason for this is that the transformational leadership theory compound multiple traits and characteristics, some of them included in other theories, and its boundaries are not precisely defined (Nemiro et al 2008). The development of these two theories was significant because reinforced the belief that leadership is not just about the leader but about the interaction and the relationship between the leader and the follower.
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Growing evidence from two quantitative research studies (Negussie & Demissie 2013,) suggests that transformational leadership is the preferred leadership style among nursing employees. The reason for this is that transformational leaders inspire employees to achieve a goal for the greater good, hence, making their motivation come from within (Marshall 2010). Marshall (2010) goes further and explains that this is not only about having a clear and defined vision but also about demonstrating interest and concern for employees, coaching them to develop their skills, and valuing staff’s input. In her book, Marshall talks from her personal experience therefore not supporting her argument in a study, however, my personal experience reinforces her statement because theatre nurses often verbalize that their favorite theatre managers are the ones that engage staff in the decision-making process giving them a sense of ownership. Therefore, this confirms the hypothesis that transformational leaders contribute to making staff more motivated to do their job.
Leadership and staff satisfaction
Staff’s motivation is linked to staff’s satisfaction which has been shown to have a clear link with decreased clinical errors among nurses as well as decreased infection rates in the clinical setting (Aiken 2018). This statement is significant in the current economic climate because according to the Department of Health and Social Care clinical errors cost the NHS up to £2.5 billion a year in litigation costs (DHSC 2014). This finding has an important implication not only because as we all know a clinical error can have a deep and lasting effect on patients but because the money spent on litigations and compensations could be used to bridge the current gap between expending and budget. However, some argue that transformational leadership on its own is not enough to keep staff motivated. There are other aspects that can affect staff’s motivation which often nurse managers have no control on such as staffing levels and external workload pressures caused by hospital targets and business plans (McKenzie & Addis 2018).
In contrast, though, the literature argues that at present, the majority of nurse manager’s leadership style is transactional (Jodar I Sola 2016, Morsiani et al 2017). This fact can be explained because often nursing managers lack formal leadership training and still rely on the old fashion way of leadership inherited from previous generations of nurses (Morsiani et al 2017).
Leadership and staff turnover
When looking at staff turnover, Raup (2008) found that in a hospital where managers following the transactional leadership style there was a staff turnover of 29% comparing to 13% in a team where the manager was a transformational leader. This data has a great significance in current times when social changes and restricted budgets mean that being able to retain staff is very important.
This data is significant from an economic point of view. Fidgerald (2015) states that the potential cost of recruiting one band 5 nurses is £403.70 without taking into consideration the cost of supernumerary time and additional training.
Conclusion
This essay has discussed the reasons why transformational leadership is the answer to the crisis the NHS is currently facing. Over the last ten years, there has been a clear increase of activity in the NHS and therefore spending, however, government healthcare budgets have not increased at the same speed creating a funding gap. As a result, the UK Department of Health has put its focus on leadership as a tool to manage services more efficiently to bridge the funding gap. However, conflicting evidence on what effective leadership means is associated with different theories on leadership. This essay has identified that transformational leadership is not only the preferred leadership style among employees, but it is also linked to increased staff motivation, productivity, and staff turnover. However, whilst these aspects are linked to safer practices and therefore reduced litigation spend and more efficient use of resources, evidence suggests that lack of training and economic and time constraints often make nurse managers unable to put the transformational leadership ideas into practice. This explains why currently, transactional leadership is the most common leadership style followed by nurse managers because it is easier
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