Transformational & Charismatic Leadership in Health Care

Title

Transformational and Charismatic Leadership in Health Care

Sub-Title

A critical examination of the role of transformational and charismatic leadership in developing

health care services which are responsive to change and thus more likely to meet the needs of

patients, clients, other users, and those involved in the delivery of such services.

Abstract

This essay begins with an articulation of origins and developments of transformational leadership

theory and whilst supporting the assertion that charisma is an important component of

transformational leadership behaviour argues that it is not in itself a defining feature. The

cascading effect of transformational leadership is explored in relation to contemporary research

both within the US and UK and utilised to articulate the relationship between transactional and

transformational behaviours within health care settings which constitute an optimum change

profile. The nature of vision and charisma within the health care setting are critically evaluated

along with the relationship between transformational leadership and key outcomes such as felt

autonomy, job satisfaction, low staff turnover, service quality and the achievement of

organisational (cultural) change.

Key Words

Transformational Leadership, Transactional Leadership, Full Range Leadership Model,

Charisma, Idealised Influence, Inspirational Motivation, Intellectual Stimulation, Individual

Consideration, Contingent Reward, Management by Exception, Laissez-Faire, Empowerment,

Innovation, Creativity, System Perspective, Patient Directed Health Outcomes, Complexity,

Complexity of Need, Human Relations, Nursing Process, Redesign of Working Practices,

Process Redesign, Vision, Risk Taking, Management of Attention, Management of Meaning,

Management of Trust, Management of Self, Building Relationships, Teamwork, Physician

Integration, Sharing Experiences, Learning Organisation, Work Satisfaction, Job Satisfaction,

Staff Turnover, Occupational Health, Cascading Phenomenon, Leadership Practices Inventory,

LPI, Nursing Development Units, NDUs, NHS.

The concept of transformational leadership is described in a seminal work by the political

sociologist James MacGregor Burns entitled Leadership (1978). In his work, Burns attempts to

link the roles of leadership and followership. He describes leaders as those people who tap the

motives of followers.

Transactional leadership occurs when leaders set up relationships with followers that are based

on an exchange for some resource valued by the followers. Interactions between the

transactional leader and the followers appear to be episodic, short-lived and limited to that one

particular transaction. A transactional leader balances the demands of the organisation and the

requirements of the people within the organisation.

Transformational leadership is much more complex and happens when people are engaged

together in such a way that leaders and followers encourage one another to increase levels of

motivation and morality. In such situations the aspirations of leaders and followers merge to

become one, (Bass, 1998).

Similarly, (Northhouse, 2001; McKenna, 2000) distinguishes between two types of leadership

styles:

“Transactional leadership refers to the bulk of leadership models, which focus on

the exchange that occurs between leaders and their followers. Managers who

offer promotion to employees who surpass their goals are exhibiting transactional

leadership. The exchange dimension of transactional leadership is very common

and can be observed at many levels in the organisation." (Northhouse P, 2001,

p. 132)

"In transformational leadership the emphasis is on people of vision who are

creative, innovative, and capable of getting others to share their dreams while

playing down self-interest; and who are able to cooperate with others in reshaping

the strategies and tactics of the organisation…in response to a fast-changing

world (Tichy & Devanna, 1986)… to these qualities could be added the pursuit

Transformational & Charismatic Leadership in Health Care Page 1

of high standards, taking calculated risks, challenging and changing the existing

company structure, with even the potential for the display (when considered

appropriate) of directive tendencies. (Bass, 1990)” (McKenna, 2000, p.383)

Bass (1985, 1998) provides a more expanded and refined theory of transformational leadership

which develops the work of Burns (1978) and House (1977), by giving far more attention to the

behaviour and needs of followers than had previously been given. Bass (1985, 1998) argued that

the principles of transformational leadership could be equally applied to situations where the

outcomes were not positive than those where the opposite was true and describing transactional

and transformational leadership as a singe continuum rather than mutually independent continua.

Bass (1985, 1998) identifies the main characteristics of transformational leadership as; charisma

idealised influence, intellectual stimulation and consideration of the emotional needs of each

follower, (Hunt, 1996).

Transformational Leadership ContinuumTransformational Leadership

Idealised Influence (Charisma)Inspirational MotivationIntellectual StimulationIndividual Consideration

Transactional Leadership

Contingent RewardManagement By Exception (Active)Management By Exception (Passive)

Laissez-fair Leadership

Non-transactional (non-leadership)

[Source: Adapted from Northouse P, 2001, p.136; Bass B, 1998, p.7-9]

In developing his model of transformational leadership Bass (1985) built upon earlier

charismatic literature and it is not surprising that House’s (1977) model of charismatic

leadership is often mistakenly identified as an archetype of transformational leadership. Weber

(1947) describes charisma as a special personality characteristic that gives a person superhuman

or exceptional powers and is reserved for a few, is of divine origin, and results in the person

being treated as a leader. In addition to displaying certain personality characteristics, charismatic

leaders also demonstrate specific types of behaviours:

they are strong role models for the beliefs and values they want their followers to adopt,


they appear competent to their followers,

they articulate ideological goals which have moral overtones,

they communicate high expectations for followers, and they exhibit confidence in

follower’s abilities to meet these expectations. The impact of this behaviour is to

increase followers’ sense of competence and self-efficacy, which in turn increases their

performance,

they arouse task-relevant motives in followers that may include affiliation, power or

esteem.

Charismatic Leadership CharacteristicsPersonality Characteristics Behaviours Effects on FollowersDominantDesire to influence

ConfidentStrong Values

Sets strong role modelShows competence

Articulates goalsCommunicates high expectationsExpresses confidenceArouses motives

Trust in leader’s ideologyBelief similarity between leader and follower

Unquestioning acceptanceAffection towards leader

ObedienceIdentification with leaderEmotional involvementHeightened goalsIncreased confidence

[Source: Adapted from Northouse, 2001, p.133; Hunt 1996, p.189-190]

Hunt (1996) provides a clear synopsis of the differences between Bass’s (1985) theory of

transformational leadership and the earlier work of (Burns, 1978; House, 1977):

Bass (1985) emphasised an expansion of the followers’ portfolio of needs and wants with

a firm focus on the need for growth, development and self-actualisation,

Bass (1985) allowed for positive and negative transformations, that is transformations

that lead to organisational failure or ethically undesirable outcomes,

Bass (1985) unlike Burns (1978) does not view transformational and transactional

leadership as opposite ends of the same continuum, but views transformational leadership

as higher order (extraordinary) leadership which goes beyond the transactions found in

everyday management,

Bass (1985) considers that transformational leadership consists of four factors; idealised

influence (or charisma), individual consideration, inspirational motivation and intellectual


stimulation. Thus charisma is an important element of transformational leadership but

unlike House’s (1977) theory is not considered to be sufficient in itslef,

Bass (1985) considers that transactional leadership behaviours are based on two

dimensions namely, contingent reward and management-by-exception.

Contemporary health care settings are characterised by discontinuous change, increased

expectations from all service users, increased professional accountability and political pressure

for efficiency incorporating standardised easily measurable outcomes, technologically driven

change, an ageing population and an increase focus on the role of management and leadership

within clinical practice. Thus, despite the conceptual and operational liabilities often associated

with charismatic and transformational paradigms these have become increasingly attractive to

researchers and practitioners within health care and nursing contexts.

(Brown & Sofarelli, 1998) cite (Davidhizar R, 1993) in arguing that in today's changing and

chaotic health care arena the nurse leader needs to utilise the qualities of transformational

leadership which focus on people and solving problems in an ever-changing environment. They

go on to state that transformational nursing leadership actively embraces and encourages

innovation and change and provides the skills necessary for the profession to:

"… stretch its boundaries and be innovative in the way in which problems are

viewed and solved. This will become increasingly more important as nurses leave

the traditional hospital setting and expand their practises into the community. The

ability to find innovative solutions, to extend beyond their boundaries of comfort,

and to test new ways of doing old things, will move nursing further into the centre

of the arena of the new health care services." (Brown D & Sofarelli D, 1998,

p.203)

Trofino, (1995) claims that transformational leadership provides a mechanism for developing a

holistic, (bio-psycho-social), systemic perspective, which empowers nurses to make optimum

use of the enabling technologies to move “beyond even patient-centred health care to patient

directed health outcomes.” (Trofino, 1995, p.42)


(Davidhizar R, 1993) cites the work of Barker (1991) in arguing that; transformational

leadership in health care settings place less emphasis on hierarchical structures, logical decision

making and that rationality becomes less prominent, and that “this transition is appropriate as the

world has become a far more complex place” (Davidhizar R, 1993, p.675). Hence, scientific

approaches to leadership, (and presumably medically, scientifically orientated models of health

care), which do not take into account the complexity of individual need and the contingent

relationship of an ever changing environment are not likely to provide conceptual or practical

frameworks which underpin everyday actions. Davidhizar (1993) citing Barker (1991) argues:

“The new transformational paradigm is characterised by mutuality and affiliation,

acknowledging complexity and ambiguity, co-operation verses competition, and

emphasis on human relations, process versus task, acceptance of feelings,

networking verses hierarchy, and recognition of the value of intuition.”

(Davidhizar R, 1993, p.675).

According to Davidhizar (1993) the techniques of transformational leadership can enable nurse

leaders to design work environments, which satisfy the needs of their followers and enhance the

quality of care given to patients. She makes the important point that transformational leaders

combine a focus on nursing process (‘nursing heritage’) with redesigning the working practices

(process redesign) and the wider environment in order to facilitate team working and the

achievements of followers.

What is interesting about Davidhizar’s (1993) framework for transformational leadership in

nursing is the emphasis and importance she places on charisma (idealised influence) almost to

the exclusion of other transformational dimensions, and the lack of any guidance on how, (or

indeed if it is necessary), for nurse leaders to combine transformational and transactional

dimensions of leadership behaviour to achieve optimum influence. Davidhizar (1993) however,

does not attempt to provide a detailed definition of charisma beyond labelling it as a

“management quality that can empower employees and facilitate co-operation, creativity and

innovation” (Davidhizar R, 1993, p.675).


According to (Davidhizar R, 1993) charismatic leadership can ‘backfire’ in the following

conditions:

- Goals of the leaders are contrary to needs of the society: when followers and leaders are

bound by values which are not beneficial to society (and presumably patients) then such

leadership can be regarded as unethical as its effects are likely to be non-beneficial.

- Emotions become irrational: when emotional commitment to the leader becomes so intense

that a wider sense of rationality becomes lost. At which point followers will have developed

either a dependent or counter-dependent relationship with the leader to the exclusion of all

other influences.

- Leader is judged by exceptional standards: in such situation the strong desire amongst

followers to achieve personal identity with the leader may lead to unacceptable levels of

emotional and physical stress as followers attempt to emulate their leader’s exceptional

behaviour.

However, positive influences of charisma in transformational leadership are identified as:

- Self-esteem: having a positive self-regard is an important personal characteristic of

leadership, which is projected onto followers. Charismatic leaders are confident, highly

enthusiastic and have a high sense of self-worth. These characteristics are important

determinants of influence as subordinates (followers) are unlikely to follow a leader who

appears lacking in self-confidence, personal ability or has little understanding of

organisational goals and the wider environmental influences.

- Focus on People: Within the nursing profession the ability to relate to others members of the

team who are likely to possess high levels of interpersonal skills themselves is an important

determinant of effective leadership/influence. This is especially important given that the

ability to sustain and develop human relationships is an integral component of effective

practice. The charismatic/transformational nursing leader ensures that relationships with


colleagues are used to foster participation in problem solving and decision-making as a basis

for sustaining commitment to shared goals.

“Focus on people is one characteristic of charismatic leadership. In other words,

the leader who utilises a charismatic approach is orientated to people and visibly

focuses on human needs of followers. When subordinates present a concern, the

leader conducts an assessment to find the basis for concern.” (Davidhizar R,

1993, p.677).

- Vision: having a vision is an essential component of leadership for a leader who seeks to

lead with charisma. Having a vision for the development of practice, the ward/dept,

organisation, patient/clients and other stakeholders involves “knowing where the department,

unit or organisation is heading and how society will be served” (Davidhizar R, 1993, p.678).

A vision allows followers to reflect on the current state, identify its shortcomings and

become committed to a desirable future state, which is attainable and predicated on known

professional/ideological values.

“A vision allows individuals to see beyond the tedium of their present

predicament and to rise above the tedium of day-day events. A vision [if shared]

pulls people together in collective purpose and provides stimulation for extra

effort.” (Davidhizar R, 1993, p.678).

An Australian perspective on transformational nursing leadership provided by Sofarelli &

Brown (1998) citing (Davidhizar R, 1993) argues that:

“Transformational leadership is a style which is ideally suited to the present

climate of change because it actively embraces and encourages innovation and

change. A transformational leader [by encouraging and supporting reasonable

risk taking] will provide the skills for the profession to stretch its boundaries and

be innovative in the way in which problems are viewed an solved.” (Sofarelli &

Brown, 1998, p.203)


In defining the nature of transformational leadership within a nursing, health care setting they

cite the work of (Bennis 1986, 1990; Bennis & Nanus, 1985; McDaniel, 1997) in describing

four leadership competencies which they view as central to the provision of transformational

leadership in nursing/health care settings:

Management of Attention: management of attention is demonstrated by leaders who are able to

determine from events, patterns and relationships around them, what is relevant for the future

and then communicate this to followers. (Sofarelli & Brown, 1998) cite McBride (1994) who

states that “transformational leaders are those who have the ability to find meaning in piecemeal

actions and to make those connections for others so they can see the macro level while dealing

with the micro level” (McBride, 1994, p.284). Within contemporary health care systems the

transformational nursing leader will be constantly scanning their environment in order to use

relevant information in the formation and development of their vision.

“The transformational leader will ensure that their followers have all the

information that is required to work towards the shared vision, and will give them

the knowledge and support to enable them to develop the skills required to

analyse the information for themselves and to make decisions based upon that

information. [Thus, developing their followers ability to become transformational

leaders in their own right].” (Sofarelli & Brown, 1998, p.204)

The management of meaning is an essential prerequisite of individual, team and organisational

learning, as organisations strive through learning to achieve a symbiotic relationship with their

environments so that they are able to shape the environment as much as being shaped by in.

Management of Meaning: transformational leaders give meaning to their actions and those of the

organisation primarily through expressing their vision and modelling behaviours commensurate

with that vision. (Sofarelli & Brown, 1998) cite research by Dunham & Klafehn (1990, 1995)

into the transformational nature of leadership provided by nursing executives, in arguing that a


vision is a personal attribute and in order to align followers and the organisation to their vision

transformational nursing leaders must posses powerful communication skills.

“To be effective, a leader must fulfil many functions, but one of the most

important is the management of meaning and the effective articulation of their

dreams to their followers in order to inspire them to accept and be committed to

the vision. Effective transformational leaders are able to create a vision and

effectively communicate that vision to those people they lead, and throughout the

organisation. This required powerful and persuasive communication skills.”

(Sofarelli & Brown, 1998, p.204)

(Sofarelli & Brown, 1998) cite the work of Kets de Viries (1989) in arguing that

transformational leaders use language, ceremonies and symbols in order to reinforce the meaning

of their vision, they also know how and when to make use of humour, irony and colloquial

language which enhances meaning for their followers. They go on to argue, based on the work

of Dunham & Klafehn (1990) that a vision is not for the sole purpose of adding meaning to the

leader-follower relationship; effective transformational leaders can use a vision to revitalise a

whole organisation by giving people a meaning, purpose and a sense of higher value in their

work.

Management of Trust: is essential as leaders cannot empower with trust and trust is essential in

the transformational process. Trust is communicated to followers in many different ways but

one of the most important is through leadership visibility. Followers are not likely to trust a

leader who is often absent (behind closed doors), not prepared to do their share of the work,

avoids developing inter-personal relationships with followers, does not fulfil

commitments/promises and who does not model behaviour commensurate with their vision. The

successful development of trust is the foundation of transformational leadership in nursing as the

interrelationships that nurses develop with fellow professionals, patients/clients and the wider

community is built on an ethos of care and trust.


“Leaders must fulfil their commitments, keep promises, stay on course, live what

they say and be supportive when necessary; they need to be seen by people as

credible and trustworthy. (Kouzes & Posner, 1987) wrote that trust was at the

centre of human relationships and essential for organisational effectiveness.

Leaders within organisations can communicate trust to others by providing and

environment in which trust can develop.” (Sofarelli & Brown, 1998, p.205)

Management of Self: transformational leaders have a high personal self-regard, built on high

levels of self-awareness and self-esteem. They are able to communicate this to others and their

interrelationships with followers will as a consequence be built on positive reinforcement whilst

encouraging reasonable risk taking. They cite Bennis (1986) who states that “leaders know

themselves, they know what they are good at and they nurture those skills and competencies”

(Bennis, 1986, p.86) Transformational nursing leaders value learning, the gaining of knowledge

and the encouraging of others to view mistakes as an opportunity to learn and recognise that

there is no such thing as failure. They cite Kouzes & Posner (1987) who believe that:

“..the self-confidence that exceptional leaders gain through learning about

themselves; their skills, prejudices, talents and shortcomings .. [their] self

confidence develops as [they] build on strengths and overcome weaknesses.”

(Kouzes & Posner, 1987, p.277)

In conclusion Sofarelli & Brown (1998) argue that transformational leadership is ideally suited

to context of nursing, not least because it actively embraces change and innovation within an

ethical framework which complements values and beliefs of the profession.

“A transformational nursing leader will not only be able to achieve this [change]

but will also provide the skills and desires for other professionals to stretch their

boundaries and become innovative in the way that they view problems and their

solutions….the ability to find innovative solutions; to extend beyond their

boundaries of comfort; and to test new ways of doing old things will move


nursing further into the centre of the arena of the new health care services.”

(Sofarelli & Brown, 1998, p. 206)

They go on to argue that whilst traditional management skills, which emphasise transactional

components of leadership are an important and necessary dimensions of nursing leadership, it is

only when these are combined with transformational dimensions will nurses be able to deliver

the type of change and innovation so essential to today’s health care organisations. (Sofarelli &

Brown, 1998) cite Beyers (1995) in arguing that nurses are in an ideal position to influence

change within the health care settings, given that the profession is present in all context and that

nurses that nurse have a expert power base and a good, (holistic), insight into health problems;

“this places them in an ideal position to identify problems, to make recommendations and

implement new models of care” (Sofarelli & Brown, 1998, p. 206)

Dixon (1999) makes the important point that within today’s health care environments which are

characterised by “discontinuity leading to a fundamental shift in the ways in which patient care is

delivered” (Dixon, 1999, p.17). She goes on to argue that within such an environment

organisations need to balance so called soft issues of human relations with harder issues of

budget management. Key to such cultural change is the “metamorphosis of the leader’s ability to

put into action transformational leadership behaviours and characteristics” (Dixon, 1999, p.17).

“Leaders must posses the ability to help organisational players commit to what the

organisation stands for and how work is conducted. This is the foundation of

change. Without this, transformation is doomed to failure. Other key behaviours

include meaningful clear, consistent communication through multiple forms,

acting with integrity and being authentic; and treating people with respect and

dignity. These behaviours engender the trust building so central to teamwork.

Finally creating opportunities for innovation and risk taking provides the fuel that

propels the organisation to a new level of effectiveness.” (Dixon, 1999, p.17)

(Dixon, 1999) argues that:


- Building relationships: by ensuring visibility on shifts, active listening, challenging

traditional viewpoints whilst providing support required to explore new behaviours – new

ways of working,

- Creating a shared vision for the future: which emphasise a positive view of the future

whilst recognising the importance of professional values,

- Developing a strategy for implementing the vision: involving all organisational members

at all levels focussing on core values such as the recognition of expert resources,

conscientiousness, will/can-do attitude, sensitivity to internal and external customer

needs, and creative thinking,

- Recognising the value of teamwork:

- Developing a physician integration strategy:

- Communicating and sharing experiences:

- Creating a learning Organisation:

- Recognising Results Achieved:

In a survey by McDaniel & Wolf (1992) to determine the dimensions of leadership that result in

low turnover and work satisfaction, utilising Bass & Avolio’s (1985), Multi-Functional-

Leadership Questionnaire and Job Satisfaction Questionnaire from an earlier study by Hinshaw

(1987) aimed at developing ‘innovative retention strategies for nursing staff’, in a nursing

department comprising of 1 nurse executive (NCEO), 11 middle level administrators and 77

registered nurses was able to validate the following hypotheses:

Hypothesis 1: Leader self-assessment scores will be higher (p>0.05) than those of the respective followers;Hypothesis 2: Leader self-assessment scores will be higher than the follower’s assessment of the leaderHypothesis 3: (in a facility where leaders report a predominance of transformational behaviour, (as illustrated by their transformational scores), staff nurse work satisfaction will be average or above and correlated to staff’s leader- other scores andHypothesis 4: Staff turnover will be low.


The results derived from the MFLQ were as follows:

Transformational and Transactional Self Score of the Nursing Chief Executive Officer (NCEO) and Middle AdministratorsFactors NCEO Middle AdministratorsTransformational

Individual ConsiderationCharismaIntellectual Stimulation

TransactionalManagement by ExceptionContingent Rewards

3.43.13.73.32.52.52.4

3.0*2.73.23.02.22.02.3

*Statistically Significant P < 0.05 (McDaniel & Wolf, 1992, p.62)

Paired Scores Showing Self-Scores and Other Scores of NCEO, Middle Level Administrators, and RN StaffFactors NCEO Self NCEO by

AdminAdmin Self Admin by

RNsTransformational

Individual ConsiderationCharismaIntellectual Stimulation

TransactionalManagement by ExceptionContingent Rewards

3.43.13.73.3

2.52.52.4

2.6*2.72.32.7

2.0*1.82.1

3.02.73.23.0

2.22.02.3

2.4*2.32.72.3

2.11.92.2

*Statistically Significant P < 0.05 (McDaniel & Wolf, 1992, p.63)

The self-scores for the NCEO and Middle level administrators indicate that the nurse executives

had consistently higher self-assessment scores across all factors compared with those of middle

level administrators, (hypothesis 1). McDaniel and Wolf (1992) state that:

“The score validated the cascading or shared [leadership] phenomenon and were

comparable with those results obtained at similar levels of non-nurse

administrators and nurse executives. As one moves down the hierarchy, it is

anticipated that the transformational scores will decrease slightly, with a

concomitant emphasis on the transactional scoring representing the daily

management in an organisation.” (McDaniel & Wolf, 1992, p.62)

They go on to argue that the higher top echelon transformational scores suggested that more

attention was given to leadership interventions which directly related to the transformational


items on the MFLQ, such as developing an organisational vision or shared values of service

delivery. The declining transformational scores for middle grades may suggest that “an

increasing amount of attention would be given to the operational management of the service that

parallels the decline in administrative hierarchy.” (McDaniel & Wolf, 1992, p.62)

The paired scores show that the self-assessment scores of the administrators were higher than the

scores given to them by the registered nurses, these differences are consistent across all factors

and support hypothesis 2. The transactional scores of the administrators and registered nurses

were lower than the transformational scores which according to McDaniel & Wolf (1992) is a

desirable finding.

“This suggests that while these nurse administrators emphasise the

transformational components of their work, they also build on day to day

management [predicated primarily on transactional dimensions of leadership] to

encourage the nursing staff in their work and the accomplishment of their nursing

goals. The transformational leader would support a vision of nursing and enhance

the nursing staff to share that vision and to develop their perceptive positions.”

(McDaniel & Wolf, 1992, p.63)

The results from the job satisfaction survey supported hypothesis 3, that given the high levels of

transformational leadership practised by the nurse administrators that job satisfaction among the

nursing staff would be average or above. Data collecting relating to staff turnover supported

hypothesis 4.

Research by Morrison et al., (1997) investigating the relationship between leadership style and

empowerment and its effect on job satisfaction amongst nursing staff in a regional medical centre

in the USA, using Bass & Avolio’s (1995) MFLQ to measure leadership and leadership style,

Warr’s et al., (1979) Job Satisfaction Questionnaire and Spreizer’s (1995) psychological

empowerment instrument, returning 275 useable questionnaires from an initial sample of n=442;

indicated that both transformational and transactional leadership were positively related to job

satisfaction with correlations of 0.64 and 0.35 respectively, with only transformational leadership


being positively correlated to empowerment 0.26. The higher positive correlation between job

satisfaction and transformational leadership compared with transactional leadership is argued by

Morrison et al (1997) to provide evidence of the Bass’s (1985) augmentation concept which

(Dixon 1999; McDaniel & Wolf, 1992) practically summarise in arguing that effective

transformational leaders build on the transactions found in everyday management.

Correlation Matrix for Leadership Style, Empowerment and job SatisfactionVariable 1 2 3 4Transformational Leadership -Transactional Leadership 0.54* -Empowerment 0.26* 0.08* -Job Satisfaction 0.64* 0.35* 0.41* -N= 275, *p < 0.05 [Source: Morrison et al, 1997, p.30]

Other studies by Laschinger & Havens (1997), Laschinger, Wong, Macmahon & Kaufmann

(1999) and McNeese-Smith (1997) indicate a causal relationship between transformational

leadership behaviour and perceptions of staff nurse empowerment, levels of occupational health

and organisational effectiveness.

Research in the UK by Bowles & Bowles (2000) using Kouzes & Posner’s (1988, 1995)

Leadership Practices Inventory (LPI) in a comparative study of transformational leadership in

nursing development units (NDUs) and conventional clinical settings, using a sample of 70

nurses comprising of two equally sized sub-groups drawn from NDU and Non-NDU settings.

The self-evaluations using the LPI showed little difference between the sub-groups. However,

the data indicated two differences in which leadership was perceived by followers

(observers/raters):

The observer (raters) score for non-NDU leaders were lower than those from NDU

leaders across each of the five practices of exemplary leadership.


The observer (raters) scores for non-NDU leaders are lower than the leaders’ self-

evaluations across each of the five practices. By contrast observer scores for NDU

leaders were higher than the leaders’ self-evaluations on four out of the five practices.

Mean Self-evaluations for each of the five practices of exemplary leadershipRole Challenge

the processInspire a shred Vision

Enable others to act

Model the way

Encourage the heart

Total Leadership Score

NDU Leader

24.14 23.14 25.29 24.14 25.29 121.43

Non-NDU Leader

24 22.14 25.36 24.57 25.29 121.86

Mean observer evaluations for each of the five practices of exemplary leadershipRole Challenge

the processInspire a shred Vision

Enable others to act

Model the way

Encourage the heart

Total Leadership Score

NDU Leader

25.71 25.25 25.64 24.71 25.21 125.75

Non-NDU Leader

22.92 21.29 24.64 23.82 23.32 115.57

[Source: Bowles & Bowles, 2000, p.73]

Bowles & Bowles (2000) state that

“NDU leaders were more highly evaluated by their observers than their non-NDU

counterparts. They demonstrated a higher level of congruence between their self-

evaluations and observer evaluation and more transformational leadership

behaviour than their counterparts.” (Bowles & Bowles, 2000, p.74)

A review of a sample of 2,013 managers from the NHS identified a far more complex model set

of behaviours than previous US research.

“The most obvious implications of these findings is the staggering complexity of

the role of leadership in the NHS. Another lesson is that the transactional

competencies of management, while crucial are simply not sufficient on their

own. […] what is clear is that existing us models of leadership do not encapsulate

this complexity. Typically, they place and overwhelming emphasis on charisma


and vision: on leaders acting primarily as the role model for their followers. Is

this the product of adopting research methodologies which focus solely on the

views of top managers, or researchers developing models from their own

observations?” (Alimo-metcalfe, 2001, p.40)

The qualities of leadership emerging as most important to staff to staff in NHS are characterised

by concern for others, followed by the ability to communicate and inspire.

Qualities of Leadership Perceived by NHS Staff to be Most ImportantAt the very top of the list of dimension for leadership came Genuine Concern for Others. This includes showing genuine interest in staff as individuals, seeing the world through their eyes, valuing their contributions, developing their strengths; coaching, mentoring and having positive expectations of what staff can achieve. The others, in order of importance, were followers.

Decisiveness, Determination, Readiness to take Reasonable Risks. Ability to clarify shared values and a sense of direction. This reflects a strong element of engaging with colleagues. This is another example of how the model differs from major US ones.

Inspirational Communicator, Networker and Achiever. This is essentially about communicating the vision of the organisation with passion and commitment. Unlike US models of ‘visionary and charismatic’ leadership, it stresses the need for partnership in engaging and extensive range of internal and external interested parties in the process by actively networking with them, gaining their confidence and support through sensitivity to their varying needs. It also about celebrating the accomplishments of the team, department or organisation.

Ability to Draw People Together with a Shared Vision. This relates to having a clear vision and strategic direction in which the ‘leader’ actively engages various internal and external stakeholders in developing; drawing others together in achieving the vision. It encapsulates some of the core values and attitudes exhorted by the government’s modernisation agenda.

Empowering others to lead. A manager who displays this dimension, trusts staff to take decisions/initiatives on important matter; delegates effectively and encourages staff to develop their leadership by providing opportunities to them to take on increased responsibilities.

Charisma. This is concerned with exceptional communication skills, ability to keep in close contact with others, encouraging others to join in.

Transparency. This relates to the aspect of integrity which is about honesty and consistency in behaviour, but also reflects the attitude of placing the good of the organisation before personal gain. It also involves humanity and humility and willingness to modify one’s views after listening to others.

Encouraging Challenges to the Status Quo. This includes clarifying the long term corporate direction while encouraging others to challenge the status quo, with respect to traditions and assumptions about what is being done, how problems are dealt with, and the quality of the service provided.

Accessibility, Approachability and Flexibility. This reflects a style which is not status-conscious, which places great importance on face-to-face, as opposed to distant leadership, and which attempts to ensure that staff at all levels feel comfortable and able to access the individual.

Supporting a Development Culture. This includes empowering individuals to challenge tradition, take risks and express dissatisfaction. In so doing the person presents a powerful role model for leadership.

Ability to Analyse and Think Creatively. Managing Change Sensitively and


This is sees as an essential dimension in the public sector leader. It involves the capacity to deal with a wide range of complex issues and the ability to utilise creativity in problem solving.

Skillfully. This includes being sensitive to the impact which changes in the external environment can have on the organisation; being aware of how these changes will differentially impact on parts of the organisation, being aware of the impact of one’s decisions, and having the wisdom to balance the need to change with some degree of stability.

(Source: Alimo-Metcalfe, 2001, p.41)

According to Lindholm & Sivberg (2000) managers within health care generally and nursing in

particular are increasing the pressure on their subordinates from board level downwards to

provide skilled and competent leadership which will empower their staff to meet the challenges

of providing patient/client focussed health care in the 21st century. Contemporary approaches to

leadership Bass & Avolio (1985, 1990), Burns (1978), Kouzes & Posner (1987), Tichy &

DeVanna (1986), Conger & Kunnungo (1987, 1999) present complex multi-dimensional

models of leadership which argue that change may be engendered though by combining the

judicious use of transformational behaviours with the less frequent use of transactional

behaviours.

“With regard to the turbulent arena of health care, Davidhizar (1993) and

Lafferty (1998) speak about utilising the qualities of transformational leadership,

which focuses on problem solving in a changing environment as the most

appropriate form of leadership. Burns (1978), who produced an early conception

of transformational leadership, argue that leaders and followers raise one another

to higher levels of motivation and morality rooted in common

values…..Transactional leadership by contrast is concerned with day-to-day

operations in an unchanged organisational system and has, according to Dunham

& Klafehn (1990) more of the characteristics of traditional leadership and

management…directed at organisational maintenance… Bass (1985) considers

transformational leadership and transactional leadership to be distinct but not

mutually exclusive processes, and declared that the same leader may use both

types of leadership at different times.” (Lindholm & Sivberg , 2000, p.328)

The key issues here is that the empowerment of nursing by leaders is likely to cascade down to

the community, and an empowered community will then be able to choose [within environmental


constraints] health services that are pertinent to the health needs of that community. These are

high ideals - but the key theme of empowerment through the leadership styles associated with the

4Is of transformation leadership are viewed as an important dimension of professional practice.

However, in order to gain and appreciation of the potential contribution that transformational

leadership theory can make to the development of contemporary health care systems through the

empowerment of nursing practice it is important to remember that:

such perspectives largely ignore the effect of contingent contextual variables such as the

inequitable or inadequate distribution of resources, quantum advances in supporting

technologies, the inherently irrational nature of the political environment etc.,

and as a study of the characteristics of executive nurse leadership by (Dunham &

Klafehn, 1995) clearly indicates, effective leadership in the health care arena is not

simply a case of utilising a transformational style at the expense of a transactional one,

but on employing critical thinking in ensuring that transformational behaviours augment

the transactions which are the foundations of everyday management in order that the

nursing profession and the organisation are able to respond to environmental variables

within an adaptive relationship of creative reinvention.


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Transformational & Charismatic Leadership in Health Care