As members of a research team conducting a large national study to examine the clinical leadership development needs among nurses and midwives in Ireland (Fealy et al. 2009), we were struck by two facts that seemed to us to have rather profound implications for both research conduct and clinical practice. The first concerned the range and quality of the body of literature on the topic of leadership. The second, derived from our research data, was the great difficulty that nurses and midwives seem to experience in clearly articulating their discipline-specific or differentiated contribution to care in the multidisciplinary context.
Quality of scholarship
On the range and quality of literature on the topic of leadership, we arrived at several conclusions, some of which are alarming. The topic of leadership has given rise to a bewildering array of books, articles, commentary pieces and websites on leadership theory and on the various ways that leadership finds practical expression in organisational contexts and within social practices. However, despite the myriad literature on the subject, much that is written is often dense and opaque, contradictory and inconclusive and much of the material draws on other published writings that seem to have no obvious empirical foundations. We characterised the body of literature on leadership according to the relative emphasis placed on the leader type, leadership behaviours or the context in which leadership takes place but, otherwise, concluded that despite all that is written on the subject, little is derived from research evidence (Fealy et al. 2009). Moreover, the means and the ends of writing on the subject seem confused, whereby the process of writing about leadership seems to have become an end in itself. Rather than offering a clear understanding of a complex human and social phenomenon, all that the literature has achieved is to obfuscate and to grow careers for those in a growth ‘industry’ of leadership books, websites and courses.
Jackson and Watson (2009) have also raised some similar concerns regarding leadership, including a concern about the quality of published scholarship in the field. They write that leadership, as a concept, is rarely critiqued, that there is a paucity of published empirical research on clinical leadership development in nursing, and they express concern that there is a tendency to represent leadership as a generic concept, thereby failing to recognise its context specificity. They also draw attention to the fact that an industry of leadership courses has grown across a range of disciplines to satisfy the perceived need for leadership knowledge and skills on the part of employers and employees alike, but given the context specificity of leadership, they pose the fundamental question: ‘can effective leadership be taught’ (Jackson & Watson 2009: 1962).
Our particular critique applies to the general body of literature on leadership theory emanating from a range of academic and practise disciplines and to the expanding body of literature on leadership in nursing and midwifery, most of which seems content to ape the trend of mass production and obfuscation that we observed in the wider academic press on the topic. This rather stark conclusion is not to cast aside all that is written on the subject but rather to make a plea to those writing about and researching the subject in our particular disciplines to assume a truly critical stance.
As a concept, leadership should be reexamined with reference to its essential attributes and, in so far as leadership really does exist, evidence for its particular and unique expressions in our disciplines should be sought through research. In this same connection, we support Jackson and Watson’s (2009: 1962) call for scholarly papers and research reports that critically examine leadership issues in nursing and ‘scrutinise those leadership interventions and strategies that are successful and effective, as well as those that are unsuccessful and ineffective.’ Journal editors have a clear responsibility in this regard and need to be more discerning in the sort of manuscripts that they accept on the subject. What is needed is a renaissance in the scholarship on leadership.
Articulating the disciplinary contribution
When conducting the national clinical leadership needs analysis study, we concluded from our review of literature that clinical leadership was not the preserve of a few senior clinicians but concerned all clinicians and an essential attribute of clinical leadership is the ability to articulate the discipline-specific contribution to care (Fealy et al. 2009). That is, clinical leaders must be able to articulate the distinct nursing or midwifery contribution within multidisciplinary care settings and advance their particular disciplinary perspectives in the practicum and in wider multidisciplinary contexts, including policy fora. Articulating the distinct contribution in the practicum involves both words and actions. Clinical leaders’ particular clinical expertise delimits their scope of clinical practice but also confers on them their disciplinary identity in the multidisciplinary context. When warranted in the care planning and evaluation processes, clinical leaders are able to clearly, credibly and convincingly represent their specialised and differentiated expert contribution.
In our research, we sought evidence of this particular attribute of clinical leadership, through a needs analysis questionnaire and through focus group discussions among nurses and midwives across all grades. Evidence from both data sources suggests that nurses’ and midwives’ clinical leadership development needs were greatest at the multidisciplinary team, interdepartmental and organisational interfaces. While their clinical work involves direct care activities, much of their work is concerned with coordinating and orchestrating care and other administrative functions of the multidisciplinary team and in this work they are constantly acting to compensate for deficiencies and gaps in service and care provision. This ‘compensatory mode’ results in the systematic effacement of nurses’ and midwives’ particular contributions to patient care as they are distracted from their therapeutic practice by an organisational imperative to metaphorically ‘push’ and ‘pull’ patients through beds to achieve the goals of clinical medicine and healthcare management, a phenomenon also observed by Latimer (2000) in the English context.
These compensatory activities determine the scope and content of the care that nurses and midwives can provide, and constrain and dissipate their ability to demonstrate and articulate their unique contribution to patient outcomes; this ultimately has an impact on their ability to develop as clinical leaders for their professions. Without the capacity, adequately, to represent their professional disciplinary contributions at the team, unit, organisational and wider heath system levels, nurses and midwives are denied a powerful source of authority, credibility, legitimacy and status with which to negotiate their own identities and interdisciplinary relationships (Chouliaraki & Fairclough 1999). Instead, power remains concentrated elsewhere, embedded in other disciplines, whose discourses nurses and midwives often expropriate in an attempt to render themselves and their work visible and audible (Latimer 2000). This may, to some extent, explain the colonisation of much of nursing and midwifery discourse, not only by biomedical discourse but also by the managerialist and leadership discourses discussed previously.
Based on the findings of her own and others’ empirical work, further support for which is provided by our own study, Allen (2004) urges an explicit recognition and acceptance that the nurse’s role is precisely that of a healthcare mediator; the nurse is the ultimate flexible worker, juggling competing priorities, channelling information and, crucially, blurring her/his professional and disciplinary boundaries to create order and facilitate patients’ passage through the healthcare system while ensuring continuity of care. Nursing becomes the connective tissue filling the interstices and binding together all the other healthcare cells, with their distinctive functions and related structures, within the health system organ.
While this function may be a necessary aspect of the nurse’s and midwife’s role, particularly within health systems as currently configured, we want to argue that it should not exhaust the totality of the nursing or midwifery contribution to care, and is, to a large extent, a by-product of a dysfunctional healthcare system and of nurses’ and midwives’ inability to resist more powerful discourses. In isolation, the essentially technical and administrative role of healthcare mediator offers a rather impoverished and eviscerated construction of nursing and erases the notion of any distinctive professional clinical and therapeutic contribution to care. Clinical leaders of nursing and midwifery need to resist any such restricted version of their disciplines and to do this will need to articulate a discourse that outlines the scope, content and future of nursing and midwifery as professional clinical disciplines.
Acquiring this discourse and articulating it in clinical and policy arenas are essential attributes of the clinical leader. Academics have a critical role in enabling nurses and midwives to acquire this discourse, to demonstrate in words and actions the legitimacy of their distinct clinical work, including work associated with bodily care, and to render it visible in a range of multidisciplinary contexts, including clinical care and healthcare planning. However, in this connection, a major challenge is the fact that many academics do not themselves possess the sort of specialised and coherent discourse or the requisite nursing and academic capital, being ‘insulated and removed from the realities of clinical practice’ (McNamara 2009: 1577). Indeed, many academics seem content to profess anything but nursing (Thompson & Watson 2006), including leadership and management. Those academics who seem content to add yet more ‘theory’ to the already innumerable theories on leadership development might better serve their discipline by assisting clinicians to acquire a discourse that will enable them to articulate coherently their differentiated clinical contribution to care, and thereby enable them to become clinical leaders.
The national clinical leadership study referred to in this Editorial was commissioned by the (Irish) Health Service Executive and the National Council for the Professional Development of Nursing & Midwifery. We acknowledge their contribution and that of the other members of the research team, whose names appear in the reference list.