2014). 2018. 2010; Marchal 2011). A model consisted of five components (Purpose, Inclusive, Empowering, Ethical, and Process) that focuses on a group or organization's positive social development and advancement. In addition, the first author and the organizational psychologist engaged in three additional reflective discussions. 2010). Symptoms within somatization after sexual abuse among women: a scoping review. Nicolini D, Sher M, Childerstone S. et al. Relational leadership was found to be associated with patient satisfaction by Kroposki and Alexander (2006). The standard account of moral distress and why we should keep it. As well as motivating managers, it was seen to lay a relational foundation that could then also support their ability to receive and work with constructive criticism (SDMT reflective meeting, October 2016). There is not so much venting… They are much, much better’ (FM3 interview, October 2014). This document is an output from a project funded by the UK Aid from the UK Department for International Development (DFID) for the benefit of developing countries. In this literature, the notion of ‘relational leadership’ positions leadership as an interpersonal phenomenon associated with collaboration, empathy, trust and empowerment (Cummings et al. Developing a theory of Relational Leadership as Meaningful Co-Action as the way that leadership was accomplished in the case study organization. The LD interventions were deliberately framed by Thinking Environment principles, explained further later, in which the organisational psychologist (AdT) and one member of the research team (SC) are trained. Ferguson, Stephanie L. 2015. Working in one sub-district in Cape Town, we co-created LD processes with FMs from nine PHC clinics and with the six members of the sub-district management team (SDMT). 2014), for community responsiveness (Cleary et al. Our approach also enabled us to role model the value of trusting in the abilities of others to find solutions to their own challenges. More details on the overall approach and methodology are available in a published source (Lehmann and Gilson 2015). Included relational leadership skills building (e.g. A gift to see all of this work come together’ (SDMT coaching notes, June 2016). 2018. Actors, settings and relationships framing the LD interventions (as of January 2016). This context presents an important constraint to the development of a more distributed, relational leadership. Their intention was to have monthly half-day meetings where they could learn from each other and share best practice. We also judged that the dominance of these mechanisms crowded out the space for more relational approaches. To make meaning from these experiences for this article specifically (Patton 1999; Barnett-Page and Thomas 2009), the first author read through the observational, interview and reflective discussion data as well as the documents, reports and publications from the overall DIALHS project, and extracted all data elements that spoke about management, leadership, the governance context of the sub-district and the LD interventions. This is a preview of subscription content. Nonetheless, the space and time available for relational leadership in this setting was limited by the dominance of bureaucratic management and accountability processes. Supervisors … And yet, under stress and in a compliance and punitive environment, FMs and everybody else are less likely to listen and the ability to change is reduced (LD/research team reflective meeting, May 2014). 2010; Marchal et al. Experiences of PHC facility managers in Cape Town, South Africa, Leadership development. Comparing the findings with nursing leadership literature supports a conceptual framework for person-centred leadership. Relational leadership reconceptualises leadership, not as a hierarchical relationship between ‘leaders’ and ‘followers’, but in terms of a set of ‘relational practices’ or competencies which blur the distinction between leaders and followers. And finally, our LD processes were all group or team based (e.g. FMs feeling that staff aren’t committed enough) to a sense that—through using leadership practices—shifts can be achieved in staff and individual empowerment’ (LD/research team reflective meeting, September 2012). Our action-learning approach has implications for the interpretation of our findings. In today's ever changing and demanding healthcare environment, identifying and developing nurse leaders is one of the greatest challenges faced by the nursing profession. In South Africa, a case study of the leadership roles of primary care facility managers (FMs) suggests that managing people and relationships, and self in relation to others, is the primary demand of daily practice (Daire and Gilson 2014). Firstly, there are a variety of LD approaches, including group or individual coaching, mentoring, reflection, action learning, 360-degree feedback, job assignments and community of practice approaches, amongst others (Day 2000; Ely et al. 2011) and safe environment (Edmondson 2003; Nembhard and Edmondson 2006) that literature suggests is needed for LD. Role of organisation ethics in critical care medicine. Then when, in early 2014, the SDMT signalled their intention to change the way in which they were conducting their facility supervision visits and asked for support from the LD/research team, this provided an opportunity to take the lessons from the previous FM support processes forward. While our study was not designed to measure impact in a quantitative sense, qualitative insights suggest an emerging shift towards a more relational leadership, reflected in the actual ability to strengthen supportive relationships. Krantz, James. Globally, leadership has important implications for all stakeholders in the healthcare professions with responsibility for maintaining high standards of care. 2010; Carey et al. Servant leaders are committed to employee development and accept ideas from all workers. © 2020 Springer Nature Switzerland AG. Thereafter, the first author used thematic analysis to interpret the data using themes generated both from relevant bodies of literature and from the data themselves, and the initial analysis was then discussed within the author team. Within this emergent design, we drew structure from the Thinking Environment as a methodology that is appropriate for enabling a distributed relational leadership. Although still unusual in LMIC debates, these ideas regarding the importance of relationships in health systems strengthening are mirrored within the broader high income country leadership literature. FMs also mentioned that the ‘sub-district team has really improved in terms of support and feedback’ (FM5 interview, August 2015). Avolio, Bruce, Fred Walumba, and Todd J. Weber. There are a number of implications of this study for those who wish to influence policy and practice in the space of health leadership and LD in LMICs. In. 2013). In the experience reported here, gains from relational LD included increased trust and team cohesion across and within levels of the district health system. Doran et al (2004) found that a transactional leadership … Feminization unveiled: Management qualities in contemporary writings. Again, the coaching was embedded within the Thinking Environment methodology and the overall approach within each session involved working with the current governance and leadership concerns that were raised by the SDMT. In contrast, FMs expressed a preference for an alternative style of supervision, with ‘support and mentoring 70–80% of the time and monitoring and evaluation 20–30% of the time’ (SDMT-FM reflective meeting, June 2014). (2010), an LD intervention needs to be tailored to the particular context—and even within similar organizational settings, the eventual LD design would need to contain different LD approaches, addressing different (groups of) participants and implemented at different times. ———. 2012. Since 2010, researchers from two universities have worked with managerial colleagues from both authorities in a long-term collaborative project (DIALHS). Amongst other benefits, this methodology enables the trusting relationships (Carey et al. Organisational ethics: A literature review. However, in this context positive identities lived alongside a sense of victimhood—a perception that the system ‘sees us as toilet paper’ or as ‘labourers’ (Notes from FM coaching, August 2012). The morale was poor and we were all burnt out. they have a stated intention of being supportive, and being useful and being generative)—which is a transformative way of engaging with their system—and how it manifests—they conduct the observations in a transactional way… The entry point for engaging becomes compliance.’ (LD/research team reflective meeting, April 2014). Similar to the notion of ‘embedded’ health policy and systems research (Koon et al. 2009; Cummings et al. Previously they would have resorted to grudging compliance and later complained about the decisions. For example, while the intention of the SDMT was to be supportive during their facility supervision visits, the imperatives derived from central accountability mechanisms meant that support and mentoring was dominated by a compliance-driven approach: ‘It’s supposed to be about mentoring and support—but is in fact a very detailed audit… The part of management that is very well looked at during the visit is that part that looks at whether the equipment is there, are people where they should be, are staff there on time … but not the side of management that looks at people.’ (LD/research team reflective meeting, April 2014). The concept of leadership is a complex and multi-dimensional phenomenon; research conducted … Cullen, John B., Bart Victor, and Carroll Stephens. Organisation ethics in healthcare organisations: Proactively managing the ethical climate to ensure ethical integrity. We are now heading back to our ACE … Given this context, the SDMT and FMs had had limited exposure to relational leadership approaches and needed to experience them in order to understand their benefits. The paradox of post-heroic leadership: An essay on gender, power and transformational change. While leadership literature from LMICs is limited, a body of work does however point to the importance of relationships in health systems strengthening. Keywords: nursing leadership, patient outcomes, systematic review Martin, Kelly D., and John B. Cullen. 2014). 2009) and have also recognized that the ‘formation of communicative space’ is a form of action (Kemmis 2001, in Reason, 2006, p. 193). The monthly half-day research team meetings held throughout the project combined with regular reflective discussions with the SDMT and PHC FMs, enhance the rigour of our analyses, by supporting reflexivity, and allowing emerging insights to be tested. 2003) while a study of distributed change leadership suggested that the presence of distracting strategic priorities and fragmented organizational structures was found to impede progress (Fitzgerald et al. Now, they are more relaxed and cheerful and people are able to speak their mind in a positive way. For example, evaluations from a long-term LD programme within the Alberta Cancer Board in Canada showed mixed results (Sharlow et al. Similarly the LD/research team observed ‘a gap between what their [the SDMT] intention is (i.e. Although our study is, to the best of our knowledge, one of the first to report on efforts to strengthen relational leadership in an LMIC health system, these findings are not unique; the transformation of health system cultures is challenging in many settings. 2012. The challenges involved in balancing the requirements of the organisation with the needs of individual patients may result in moral distress for nurses and other healthcare professionals. At its core, relational leadership recognises leadership as centred in the relationships that form between both formal and informal leaders and those that follow them, far more so than the personality or behaviours of individual leaders. Within this article, we describe the overarching LD design that emerged through our collaboration, explain the governance context in which it was implemented and consider whether and how our approach to LD has, so far, enabled relational leadership. Diagnosis of Mycobacterium bovis Infection in Free-Ranging Common Hippopotamus (Hippopotamus amphibius). Victor, Bart I., and John B. Cullen. 2013. However, in learning lessons about how to enable leadership development (LD), a number of evaluation challenges need to be borne in mind. This article reflects on 5 years of LD experience in a low-income setting within Cape Town, South Africa. Relational practice in nursing: A case analysis. Nursing is a dynamic and challenging profession requiring engaging and inspiring role models and leaders. Because of this, its meaning is still uncertain. FM short course training in health management. Relational Leadership, for the first time in a UK local authority Executive Team. Figure 1 depicts the health system actors, organizational settings and managerial relationships that have framed the engagements that are the subject of this article. The SDMT noted that, in their experience, the FMs were becoming more engaged and assertive; for example, they were beginning to speak up in meetings, to the extent that they could express their concerns about new initiatives when they thought them not feasible to implement. 2015). Findings suggest that the sub-district is located within a hierarchical governance context, with performance monitored through the use of multiple accountability mechanisms including standard operating procedures, facility audits and target setting processes. 1 It's impossible to become an expert leader without successfully mastering the skills of interpersonal engagement, and only through authentic connection can nurse managers create trust and influence clinical nurses … Relational ethics is a relatively new perspective on nursing care. Relational Leadership™ emphasizes the “who” and “why” in addition to the “what” and “how” of change, encouraging leaders to optimize the full breadth of human interactions as they manage relationships to achieve authentic connection, common vision, and interdependent action to bring about change and innovation. In South Africa, while many managerial functions have been decentralized to the sub-district and facility level, accountability to city, provincial and national managers is maintained through the use of a number of bureaucratic mechanisms. Relational leadership offers a new perspective of leadership that addresses these challenges. In this conceptualisation, leadership is not restricted to those holding managerial positions, but rather is a process of mutual influence through which an emerging social order and/or actions are co-constructed (Uhl-bien 2006). 2000. Silverman, Hugh J. Secondly, we sought to work with the key governance and leadership challenges and opportunities that were raised by the SDMT and FMs. Our data for this article therefore include observational and interview notes, transcripts from reflective discussions, and written reports from the organizational psychologist. ———. 1988. The ethical life of healthcare organisations. Nurses are often asked to think about leadership, particularly in times of rapid change in healthcare, and where questions have been raised about whether leaders and managers have adequate insight into the … So, here we are. Secondly, greater understanding needs to be generated around the ‘how’ of LD—such that those undertaking LD, health managers and policymakers become more comfortable in working with emergence and tailoring the package of LD initiatives to the specific context. However, in keeping with others who argue that leadership styles do not entail an ‘either/or’ dichotomy (Cummings et al. As part of the broader DIALHS (District Innovation and Action Learning for Health Systems Development) collaboration, this article reflects on 5 years of action learning and engagement around leadership and LD within primary healthcare (PHC) services. Their positive and motivational attitude helps nurses thrive in goal-driven environments, enriching the feeling of community among co-workers. Childs, Brian H. 2000. In addition, within these processes, the LD initiatives allowed participants to deepen their understanding of identities (self) and their relationships, as explained further in Box 1. Storch, Janet L. 2004. The Thinking Environment is underpinned by a number of perspectives, including: (1) the quality of everything we do depends on the quality of the thinking we do first; (2) the quality of our thinking depends on the quality of our relationships; (3) the mind that holds the question or issue can most effectively resolve it; and (4) while human nature cannot be proven to be inherently good or bad, explicitly assuming a positive view on human nature (e.g. In summary, the Thinking Environment provided the base methodology for engagements, and engagements emerged through action-learning processes. I was ‘born again’ from a session with [the organizational psychologist]—she really changed me so much in that one mentoring session…Just by listening and being calm…It brings with it a certain culture.” (SDMT reflective meeting, December 2014). In other words, the learning is itself an intervention in the system. Leadership as relational practice. 2010; Day et al. 2009. For example, the initial stakeholder engagement between senior management and LD consultants that is an important and common precursor of LD (Sharlow et al. Pearson, Steven D., James S. Sabin, and Ezekiel J. Emanuel. 2011). McCarthy, Joan, and Settimio Monteverde. Leadership Theories. It is not an assignment about a disease. They also reported benefits from their use of the leadership skills: ‘last week was the third staff meeting where I’ve used [the new skills]…I noticed that in the main body of the meeting people were now talking as opposed to before when they would just sit and nod but make no input. The LD interventions that emerged through this process of reflection and action are illustrated in Figure 2, and are described in more detail in Table 3. Dallas, Lynn L. 2004. While accountability mechanisms can be important for enhancing health system functioning, the way in which these mechanisms are implemented can have an impact on whether they are motivating or demotivating to health system actors, and on whether they generate a more hierarchical or a more relational culture (Cleary et al. Relational leadership model. Instead, as the report argues, ‘it is the sturdiness of the system as a whole, with leadership exercised effectively at multiple levels, which will stand the test of a serious challenge. In our experience, the ethos of action learning, on the other hand, is able to generate the rich, context specific lessons not only about what may be needed to strengthen leadership in similar settings but also what sort of effects the LD response might be generating. Building on this foundation of personal LD, the LD approach further sought to “make the benefit of relationships more visible so that the FM does not feel derailed from the ‘real’ tasks by managing relationships” (LD/research team reflective meeting, September 2012). What are the Components? 2011. These shifts include enhanced trust in the ability of FMs to use their discretion to improve services in their facilities, greater respect in the way that accountability processes were managed, and enhanced mentoring skills, with hints of the potential for broader performance gains linked to reduced patient complaints and staff grievance cases. The violence! Nonetheless, our experience suggests that the broader health system governance context might continue to be an important constraint to distributed LD. Chase et al. Corresponding author. While the LD/research team regularly engaged as a group in order to support learning and reflexivity, in general terms, the organizational psychologist took the lead in designing and implementing the LD interventions, while the researchers took the lead in making meaning from the experiences and were less involved in the implementation of the LD interventions. The LD/research team that was involved in the leadership engagements included an organizational psychologist and a number of health policy and systems researchers. Susan Cleary and Lucy Gilson are members of the Consortium for Resilient and Responsive Health Systems (RESYST). There were gunshots this morning … It’s a huge thing…We are losing so much and it’s frustrating … It’s difficult to keep your cool” (SDMT reflective meeting, December 2014). This article presents a model of relational leadership based on a review of leader-member exchange (LMX) and interpersonal trust. Organisation ethics is the study of the ethical issues which arise in the context of managing and running complex organisations, such as healthcare organisations. Facility and sub-district managers are responsible for ensuring that these standards are met, and that procedures are implemented to address concerns arising from national complaints procedures, patient satisfaction surveys and clinical audits, amongst others (Scott et al. In essence, the first two perspectives emphasize the importance of relationships for productive team engagements and learning, the third emphasises the importance of allowing colleagues to find the solutions to their own challenges and the fourth emphasises the importance of trust for interpersonal engagements. Leadership is an issue which has received increased attention within the field of organisation ethics over the course of the past two decades. The FMs also commented that ‘their judgment was not always trusted by management. 68.183.111.220. In LMICs, relational leadership can be strengthened through collaborative reflective … They contributed a lot’ (FM4 interview, October 2014). 2006. The ‘National Core Standards’ process (National Department of Health 2011) is an example of a national accountability imperative involving lengthy checklists of facility buildings, equipment, structures and processes. Relational leadership relate to relationships and people while task- focused leadership focuses on job completion, deadlines and directives. Within the umbrella of the action learning design of DIAHLS, the research approach was flexible and qualitative. For those wishing to test or implement packages of LD, our experience suggests the need to be intentional about repeatedly engaging with (senior) managers about what a distributed relational leadership is and why it is important, advocating for visible senior support for the practice of relational leadership to generate commitment to what is ultimately a long-term process. Suhonen, Ritta, Minna Stolt, Heli Virtanen, and H. Helena Leino-Kilpi. ), Creating a physical space that says to people ‘you matter’, Consider how health facilities (patient waiting areas, toilets, staff room, offices) and administrative building spaces can better demonstrate respect and care, for example by removing broken furniture and equipment, Seven 2-h long sessions aimed at creating a community of practice. Person-centred nursing leadership. 2011, p. 66). From boardroom to bedside: A comprehensive organisational healthcare ethics. In, ———. Oxford University Press is a department of the University of Oxford. Developing the relational competencies which are a prerequisite of relational leadership may transform nurses’ understanding of their own agency and revolutionise their experience of the work they do. Thirdly, the implementation of each LD intervention was followed by at least one reflective discussion between research and practitioner partners in order to learn from experience, also allowing the leadership capability of reflection to be nurtured (Horton-Deutsch and Sherwood 2008). Hutchinson, Marie, and Debra Jackson. Conflict of interest statement. Ten components of the Thinking Environment related to health system governance, relationships and values. As Etienne Wenger points out in her book Communities of Practice, it is about the meaning and identity that are created when people work together. In conclusion, this experience suggests that processes of relational LD can promote the relationships necessary for effective team engagements, can encourage actors to trust each other to exercise productive discretion and can enhance the ability of managers to engage with their colleagues in a more supportive way. For example, routine health information is captured by clerks within primary care facilities and used to inform planning, target setting and monitoring processes at the local government and/or provincial levels. The processes specifically aimed to enable FMs to develop the relationships that generate effective team engagements, and to build their capacity to trust their own insights in order “to develop their own [managerial] ‘how to’ kit’” (SDMT reflective meeting, July 2013). We have understood reflective practice as a means to learn from experience (Schon 1983; Mann et al. The project is also funded by the Atlantic Philanthropies (Grant no. When the research team brought this feedback to the SDMT, they acknowledged that although monitoring progress against targets was a critical part of their jobs, one should not ‘shoot the person when things are not working; rather sit down and think what other possibilities and options are. 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