The importance of leadership is now widely recognised as a key part of overall effective healthcare, and nursing leadership is a crucial part of this as nurses are now the single largest healthcare discipline (Swearingen, 2009). The findings of the Francis Report (2013) raised major questions into the leadership and organisational culture which allowed hundreds of patients to die or come to harm and further found that the wards in Mid Staffordshire, where the worst failures of care were found were the ones that lacked strong and caring leadership, highlighting the crucial role of nurses in leadership. Research into nursing leadership has shown that a culture of good leadership within healthcare is linked to improved patient outcomes, increased job satisfaction, and lower staff turnover rates (MacPhee, 2012).

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Although the NHS currently faces many challenges such as financial constraints and a growing elderly population, leadership cannot be viewed as an optional role. Previous research by Swearingen (2009) has suggested that educational programmes for nurses do not fully prepare them for leadership roles, and this gap between the demands of clinical roles and adequate educational preparation can result in ineffective leadership in nursing (Feather, 2009). It is important to recognise the critical role that nurses and nurse leaders play in establishing leadership for patient care and the overall culture within which they work (Feather, 2009). Themes explored in this essay will include defining leadership, leadership in nursing, factors that contribute to nursing leadership, and leadership preparation as part of nursing education.
What is leadership and culture?
Leadership can mean many different things and has clearly evolved in meaning over time (Brady, 2010). Common qualities associated with leadership are influence, innovation, autocracy, and influence (Brady, 2010, Cummings, 2010). A key factor which has remained part of leadership during its evolution has been the ideas that leadership can involve the influence of behaviours, feelings, and actions of other people (Malloy, 2010). Culture is different, and refers to the implicit assumptions that each member of a group or organisation perceives and reacts to different things (Malloy, 2010). Culture is often regarded as a good reflection of what an organisation values most: if compassion and safety are highly regarded, staff will assimilate this (Hutchinson, 2012). Interactions by leaders at all levels of an organisation have been identified as the most important aspect/component of establishing and maintaining a culture of leadership (Malloy, 2010, Hutchinson, 2012). The most senior level of leadership within NHS trusts often comes from the board of directors, who have overall responsibility for the overall leadership strategy (Brady. 2010).
Nursing leadership
Although there are many research articles and books about leadership and management, there has been relatively little research until recently into what nursing leadership entails. Cummings (2008) found that perceptions of nursing leadership were different from general leadership because it placed a greater emphasis on nurses taking responsibility for and improving and influencing the practice environment. Brady (2010) reported that anytime a nurse had recognised authority, they were providing leadership to others. By this argument, student nurses are leaders to their patients, a staff nurse is a leader to student nurses and patients, and the leader to all team members is seen in the ward manager (Brady 2010, Sanderson, 2011). It is also important to distinguish between a manager and a leader (Brady 2010, Sanderson, 2011). Mangers are seen to be those who administer, maintain, and control, whereas leaders are those who are seen to innovate, develop, and inspire (Sanderson, 2011). Whilst there is obvious need for managers within the health service, it is vital to realise that there is a clear distinction in the roles of managers and leaders (Sanderson, 2011), and that there are areas where these roles may not overlap (Sanderson, 2011). One of the key challenges facing the NHS is to nurture a culture which allows the delivery of high quality healthcare (MacPhee, 2012) and one of the most influential factors which can impact the delivery of quality patient care is leadership: ensuring there is a clear distinction between management and leadership, and that leaders are equipped with the necessary tools to inspire others to follow their example (Jackson, 2009).
Factors which contribute to nursing leadership
The systematic review by Cummings (2008) demonstrated that research into nursing leadership falls into two categories – studies of the practices and actions of nursing leaders including the impact of differing healthcare settings, and the effects of different educational backgrounds of nurse leaders. The conclusion from the systematic review by Cummings (2008) suggests that leadership from nurses can be developed by a stronger emphasis placed on leadership in education, and by modelling leadership styles on those which have been seen to be successful in the workplace. Several studies also highlighted personal characteristics which were deemed to promote leadership qualities, such as openness and the motivation to lead others (Jackson, 2009, Brady 2010, Sanderson, 2011). Marriner (2009) also showed that contrary to popular belief, age, experience, and gender did not seem important factors when considering the effectiveness of leadership, and that interpersonal skills were more important than financial or administrative skills. However this focus on financial and managerial skills seems to suggest an overlap between management and leadership, which has previously been shown to be two different areas (Richardson, 2010, MacPhee, 2012). They also showed that leadership was perceived to be less effective when leaders had less contact with those delivering care, highlighting the importance of nurses on the ward to also be effective leaders (Richardson, 2010, MacPhee, 2012).
The emphasis which has been placed on interpersonal skills and relationships between healthcare workers is strongly suggestive that this is an important leadership skill, and could be a key part of leadership development programmes (Malloy, 2010). A recent review of the role of emotional intelligence and nursing leadership highlights the need for emotional intelligence in effective leaders and has been shown to be highly influential on healthcare cultures (Hutchinson, 2012). Although the impact of these factors can suggest how best to promote leadership in nursing, it is clear that a thorough understanding and overview of their interactions are needed to fully understand their effectiveness. Sorensen (2008) suggested that these effects can also be promoted through educational programmes, particularly at undergraduate level.
Education
It is clear that leadership is considered to be fundamental to nursing, and that nurses are now expected to act as leaders across a wide variety of settings (Richardson, 2010). If nurses are expected to undertake such roles it is important that they are adequately trained and prepared for this (Sanderson, 2011). Studies have found that many undergraduate nursing courses now view organisation and management to be fundamental parts of autonomous nursing practice, and it is widely part of the curriculum (Richardson, 2010, Sanderson, 2011). However it is unclear what is actually taught, and much of the content appears to be focused on the transition period from student to qualified nurse (Sanderson, 2011). However it seems that current expectations of leadership within the NHS are not suitable to be taught as isolated elements within the curriculum, and should instead be embraced throughout training and beyond (Richardson, 2010, Sanderson, 2011). The development of leadership skills should also be continued through a nurse’s career to continually promote the importance of leadership, and to develop newly-qualified nurses into role models for others (Jackson, 2009).
Collective leadership
In collective leadership there are both individual and collective levels of accountability and responsibility (Cummings, 2008). There is a strong emphasis on regular reflective practice which has been shown to improve the standard of care given by nurses, and strives to make continuous improvement a habit of all within the organisation (Cummings, 2008, Cummings, 2010). This is in contrast to a command and control style of leadership, which displaces responsibility onto individuals and leads to a culture of fear of failure rather than a desire to improve (Feather, 2009). Leadership comes from both the leaders themselves and from the relationships among them and with other members of staff. Key to leadership is also the idea of followership – that everyone supports each other to deliver high quality care and that the success of the organisation is the responsibility of all (Hutchinson, 2012). It is important to recognise that good leadership does not happen by chance, and that collective leadership is the result of consciously and purposefully identifying the skills and behaviours needed at an individual and organisational level to create the desired culture (Hutchinson, 2012). This is in contrast to more traditional leadership development work, which has focused on developing individual capacity whilst neglecting the need for developing collective capability (Cummings, 208, Cummings, 2010). This style of leadership has been linked to poorer patient outcomes, decreased levels of job satisfaction, and higher levels of staff turnover (Sorensen, 2008). The challenge of recruiting and retaining leaders at all levels must be recognised, as there is need for clinical leadership at every level (Cummings, 2010).
Research has shown that where leaders and relationships between leaders are well developed, there is an increased quality of care due to all staff working towards the same goals and a well-established culture of caring (Sanderson, 2011). In addition to this, there is also an increasing drive to form leadership partnerships with patients (Sanderson, 2011, Hutchinson, 2012). Collective leadership with those receiving care functions in a similar way to multidisciplinary team working as this style of leadership with patients needs a redeployment of both power and decision making in addition to a change in thinking about who should be included in the collective leadership community (Hutchinson, 2012). Several authors (Cummings, 2008, Jackson, 2009, Malloy, 2010) recommended that NHS leaders should work with those seen as patient leaders to facilitate the changes outlined in the Francis Inquiry report (2013).  There have been frequent reports that staff working in healthcare settings are often overwhelmed by the workloads required and are unsure of their priorities, sometimes because there are too many priorities identified by senior managers (Cummings, 2008). This can result in stress and poor quality care for patients (Cummings, 2008, Cummings, 2010). Whilst mission statements about efficient and high quality care can be helpful for staff, they are only helpful when translated into objectives for individuals (Jackson, 2009). Establishing and maintaining cultures of high-quality care relies on continual learning and improvements in patient care from all members of staff, and thus taking responsibility for improving quality (Jackson, 2009, MacPhee, 2010).  Where there is a well-established mentality of collective leadership, all staff members are more likely to work together to solve problems, to ensure that the quality of care remains high, and to work towards innovation (MacPhee, 2012).
Conclusion
The importance of effective leadership to the provision of good quality care is firmly established, as is the central role that leadership plays in nursing (Cummings, 2008). It is now also clear that leadership should be found at all levels from board to ward and it seems obvious that the development of leadership skills for nurses should begin when training commences and should be something which is honed and developed throughout a nursing career (Feather, 2009). For health care organisations to provide patients with good quality healthcare there must be a culture that allows sustained high quality care at multiple levels (Francis Report, 2013). These cultures must concentrate on the delivery of high quality, safe health care and enable staff to do their jobs effectively (Jackson, 2009, Francis Report, 2013). Part of this is ensuring that there is a strong connection to the shared purpose regardless of the individual’s role within the system and that collaboration across professional boundaries is easily achieved (Cummings, 2010). Nurses can be a key part of this by using collective leadership to establish a culture where all staff take responsibility for high quality care and all are accountable (Malloy, 2010). This may require a shift in mentality of the way many see leadership – from seeing leadership as a command-and-control approach, to seeing leadership as the responsibility of all and working together as a team to work across organisations and other boundaries in the best interests of the patient (Brady, 2010).
References
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