Inclusive nursing leadership in the Twenty-First Century

Purpose:

Nursing leaders have multiple challenges that influence their role and function. Increasingly advanced technology, the expansion of nurse’s roles, issues of gender and professional socialisation, competency based education and unconscious conflict all influence nurses' motives to care.

Research into leadership and management is often focused on effectiveness,  behavior and leadership styles.  In contrast, this paper discusses the findings of an international, multi-disciplinary Delphi Study that has aimed to explore the concept and nature of “inclusive leadership” in relation to the nursing profession. The paper argues that discourses on the topic and a plethora of interpretations, descriptions and definitions influence the effective function of middle and higher nursing managers.  Hence, this paper highlights and discusses the interdependence between the discourses and provides recommendations for further research.

The effects of professional socialization in an, at times, dysfunctional nursing culture have been discussed by various authors (Esterhuizen, 2010; Farrell, 2001; Freshwater, 2000). The importance of interrogating constructs of professional nursing culture is magnified as societal demographics change around the world. Increase in global migration is making it imperative for nurses to value, appreciate and respect difference, irrespective of the geographical setting. These developments point to an urgent need for inclusive nursing leadership to serve a future multi-ethnic staff and client population and develop competencies for the 21st century and beyond.  

One cannot discuss inclusivity in nursing without pausing at the educational preparation of nurses in general and of nursing leadership in particular. It is, therefore, worrying to discover that at all levels of the educational arena, major deficiencies have been identified in global competence for the 21st century, including skills such as lack of communication, leadership, work ethic, critical and reflective thinking, and self-regulated skills. Twilling and Fadel (2009), indicate that employers require new graduates and registered staff to be competent in all these areas.

It seems paradoxical that, while global and intercultural competencies have been considered a priority in nursing education for decennia, integration of these twenty-first century, global, intercultural and leadership competencies still appear to be lacking. Esterhuizen and Kuckert (2013) suggest that acquiring a combination of knowledge, skills, and attitudes in working with diverse populations, both locally and internationally should be encouraged and argue the need for this to be mandatory in a university nursing education and continuing education programs.

With the plethora of terms and definitions related to inclusive leadership, The British Council Global Education Dialogues (GED) funded and commissioned a project to collect, debate, analyse and describe examples of best practice in inclusive leadership globally.

Methods:

Experts,identified as having extensive knowledge, expertise and experience in the field of leadership from different disciplines, were approached to participate in a four round Delphi Study.The panel members were asked to prioritise 50 statements relating to inclusive leadership that had been collated from the literature and were in the public domain.  To assist the participants, a Q-Sort format was used and statements were prioritised in a grid by each individual. They had the opportunity to make comments about why they placed the statements in the order they did, or make comments about the statements themselves.

In the first three rounds, the prioritised statements were analysed and the number reduced per round according to the input from the experts (Round 1: fifty statements; Round 2: twenty-five statements and Round 3: nine statements). The statements were reduced to six and presented to delegates at the Hong Kong Global Education Dialogues (HK GED) in February 2014, together with a number of key themes that emerged during the conference.

After input from the HK GED, the six final statements were further redefined and reduced to four. In the final round of the Delphi study, each statement was related to key themes, points of discussion and propositions that emerged during the conference and panel memberswere requested to read each section, answer a number of questions about the statements and provide exemplars from their areas of practice.

Results:

Four main statements resulted from the Delphi study:

• Senior teams under-represent the communities they serve and staff they lead.
• Inclusive leadership is doing things with people, not to people. In practice this means that inclusive leadership responds to feedback in ways that show people's concerns have been heard and taken seriously. Employees experience a sense of belonging.
• Inclusive leadership is the ability to effectively leverage diversity and most importantly the diversity of thought that comes with it. Inclusive leadership is to appreciate and respect transcultural or intercultural differences.
• Inclusive leadership creates an inclusive organisation and inclusive leadership of diverse teams results in better and safer decisions.

The expert panel’s final four statements on inclusive leadership can be further reduced to two main themes: (1) The role of diversity in facilitating grounded and implementable decision making and (2) Valuing and developing all staff in order to optimise organisational effectiveness.

Interestingly, while discussion at the GED HK Conference centred largely on gender equality, little attention was given to other under-represented groups such as ethnicity, sexual orientation, disability, etc.

In an article by Trastek et al (2014) in which the authors discuss four leadership models used in healthcare, they conclude that Greenleaf's (1977) 'Servant Leadership' model would be the most appropriate for healthcare, above transactional, transformational or adaptive leadership models. This is an interesting perspective as the study on inclusive leadership showed that inspirational and transformational leadership are seen to be achieved through leading by example. And the characteristics mentioned in terms of'Servant Leadership' are, for the most, very similar to those of 'Inclusive Leadership'. There is, seemingly, a large difference between the underlying philosophies and premises. Inclusive leadership seeks the generic goals of providing opportunities for staff to develop, mentorship and role modelling with the aim of allowing fair opportunities for all to take organisational responsibility and achieve their potential - ultimately to engage staff and promote staff perception of being valued, leading to increased productivity, stability and potential succession planning. While servant leadership maintains closer links with a traditional nursing philosophy that espouses the idea of moral conscience and 'serving the highest needs of others' (Trastek et al, 2014 p 379). Although there are parallels, it is questionable whether the ascetic approach of servant leadership is feasible within the production-led, economy driven climate of current healthcare systems. Also, whether this form of leadership would allow a new generation of leaders to develop the skills that are essential in addressing 21st Century challenges. It is important that inclusive leaders are aware that change is continual and is vital to meet changing challenges. However, organisations don't change, but people change so managing organisational change means leading individual change (Freshwater, 2014b).

There is a fundamental assumption is that people can become disempowered through their experience and their environment, but that re-empowerment can occur through leadership role modelling. So within the context of - often oppressive - nursing socialisation, employees need to experience tangible encouragement of inclusion/diversity through visible leadership, appropriate organisational infrastructure, regular communications, training, flexible working, mentoring, and employee resource and network groups.

Mentorship, althoughnecessary to develop a critical mass through mentorship and networking that support nursing leaders to deal with current "norms"has, itself, has a number of risks and challenges (de Vries, 2011). de Vries goes on to suggest, that engaging a specific group in ‘emancipatory’ activities seems to attempt ‘correcting’ an element that doesn’t fit within the dominant discourse. Inclusivenessdoes not mean reinforcing a status quo, but concerns influencing change that spans gender, sexuality, ethnicity, social, economic or educational domains. Nursing leaders, therefore, need to be active in promoting diversity and inclusion at all levels. It is insufficient to acknowledge widening participation at a policy level without engaging in inclusivity (Esterhuizen & Chan-Combrink, 2014). Furthermore, de Vries (2011) supports the idea that one dogma should not be replaced with another and suggests a ‘bifocal approach’. Organisational change needs to occur simultaneously with individuals developing presence and skills necessary for a senior role irrespective of gender, sexual orientation, ethnicity or disability.

Conclusion:

Discussion from the Delphi study also highlighted that by including direct and indirect input, the organisation is able to minimise risk in decision making with regard to strategy and in relation to staff well-being, retention and satisfaction. Although generally accepted and espoused that diversity within leadership roles can provide creativity, flexibility and agility to cope with change and changing needs (Chin, 2013; Bjorklund and Holt, 2012; Everly et al, 2012; Phipps, 2012), diversity in nursing leadership does not mirror the spectrum of society nor the nursing workforce. Inclusivity needs to use diverse talents and creativity which, in turn, leads to richness and empowerment and is appropriate to the changing environment and needs.

In conclusion Freshwater (2014a) suggests:

The importance of different perspectives were described as in a kaleidoscope; providing richness of colours due to the difference in perspectives but that space for reflection is needed to consolidate ideas, thoughts and experience.