What does leadership mean to specialist community public health nurses?

Compassionate leadership

Unsurprisingly, due to its focus on health and wellbeing, compassionate leadership has been widely discussed in nursing literature. Jemal et al (2023) propose that compassionate leadership is also a critical component of the effectiveness of healthcare provision and treatment. This form of leadership relates to better organisational performance and workforce wellbeing, so relevant to address the current nursing workforce issues of retention and recruitment.

The post-pandemic impact continues to affect staff health and wellbeing, with problems such as vacancies, recruitment and retention (Bailey and West, 2020). These pre-existing issues were exacerbated by the pandemic, which brought nurses additional challenges, such as rapid changes to the physical working environment and a higher intensity of patient care (Couper at al, 2022).

SCPHNs had to cope with more indirect societal issues arising from their caseloads, such as travel and social restrictions, education, and workplace closures, leading to social isolation and poor economic outcomes for families and household budgets (Children's Commissioner, 2019; Douglas et al, 2020).

Consequently, a combination of workplace and societal issues may have produced additional psychological effects for nursing staff, as revealed when 94% of Trust leaders said they were concerned about the level of burnout across their workforce (NHS Providers, 2021). SCPHN HVs have reported their services were further stretched, leaving them feeling overwhelmed with detrimental impacts on their wellbeing (Morton and Adams, 2022).

A compassionate leadership style is concerned with an interpersonal process, which involves noticing, feeling and sense-making of situations in ways that connect with others (Harris and Jones, 2023). This leadership approach is rooted in the basic human instinct to care, and to create safe and connected relationships where the motivation is affiliative, collegiate and promotes social safeness, leading to greater productivity and mental wellbeing (Blumenthal and Lee, 2023).

Healthcare leaders find this challenging to apply in clinical practice, as it may be in direct contrast to a more traditional leadership focus on the completion of tasks, where patient care needs have priority above the experiences of healthcare staff. For nursing leaders, this would involve approaches that consider the power balance between leader and followers, to lead teams in ways that enhance productivity and mental wellbeing.

While it cannot be denied that effective teams require a shared vision and goals, this does not need to be at the cost of psychological wellbeing. Evidence shows that the intentional practice of compassion-focused activities has a significant positive impact on a range of psychological and physiological systems, including the frontal cortex, amygdala, heart rate and immune functioning (Passmore and Oades, 2015; Goleman and Davidson 2017; Passmore, 2019). Therefore, a compassionate approach could improve both the psychological and physical health of staff.

Ramachandran et al (2023) recommend exploring the six dimensions of compassionate leadership: empathy; openness and communication; physical, mental health and wellbeing; inclusiveness; integrity; and respect and dignity. Considering these dimensions involves a shift in leadership mindset and cultures, to focus on staff wellbeing in the short term, and to elicit improved quality care of patients in the longer term.

Research has shown this is an effective approach, moving away from outmoded leadership styles known to result in poorer mental health outcomes for staff and task success for the leader, at the expense of the team's efforts (Blumenthal and Lee, 2023).

Adopting the professional nurse advocate (PNA) role (NHS England and NHS Improvement, 2021) and using a model of restorative supervision taught on the PNA course is one feasible way to address this.

The restorative function of the PNA role has been shown to have a positive impact on the wellbeing of staff as it reduces burnout, stress, and absence (NHS England and NHS Improvement, 2021). Restorative and compassionate leadership models have the potential to improve nurses' health and wellbeing. Authors have suggested that compassionate leadership can be associated with the idea of ‘servant leadership’, which incorporates qualities of empathy and a deep commitment to others (Meuser and Smallfield, 2023). However, caution must be employed when relating servant leadership to nursing roles, as literature suggests this can lead to emotional burnout for leaders as they do not prioritise their own objectives or individual needs (Canavesi and Minelli, 2022).

One way to mitigate this is to use a ‘healthful leadership’ approach. Dickson et al (2022) identify healthful leadership as one relational style of a compassionate leadership approach. Their review identifies six common behaviours characteristic of healthful leadership practice:

Factors that enable healthful leadership are created by the culture within which individuals lead and from the leader's personal attributes, values and style. Leaders who embody values of empathy, courage, compassion and authenticity can create conditions for positive and healthful relationships. These conditions are commonly found in other relational leadership styles such as authentic leadership, where the focus is on developing genuine relationships and developing others. Dickson et al (2022) report that healthful leadership practices are not prioritised by nurse leaders, and studies on the impact of this style in relation to nursing wellbeing are lacking.

A healthful leadership approach can be supported with models used to improve nursing health and wellbeing, such as the ABC model outlined in Figure 1. This can be used in staff discussions to enable leaders to identify where they can focus their efforts in clinical practice, and provides a good starting point from which to examine workforce issues and staff needs.

Authentic leadership

Authenticity has been defined as ‘a life-long process of self-discovery that includes realising personal potential and acting on that potential’ (Star, 2008). Fundamental to authenticity is the notion of people remaining true to their core values (Galloway, 2022). Gardner et al (2005) state that authenticity in nursing means being in the present, being real and genuine in who you are, and possessing and demonstrating character.

Authentic leadership is a new nursing concept that is often not well-defined (Long, 2023). Authentic leadership is built on the concept that individuals are self-aware and understand their sphere of influence (Galloway, 2022). According to Raso (2019), an authentic leader is a genuine, trustworthy, reliable and believable individual in a position of responsibility. They build trust among team members, patients and other health professionals. Trust is foundational for effective communication, collaboration and a positive work environment. A positive work culture, in turn, enhances job satisfaction, reduces burnout and promotes overall wellbeing among nursing staff.

Leaders who adopt an authentic leadership style are concerned with developing genuine relationships with others and bringing out the best in them (Raso, 2013). Authentic leaders also exhibit individualised consideration of staff, motivating them and stimulating creativity and innovation (Galloway, 2022). They practise what they believe in with integrity, even when they make a mistake, and in doing so they demonstrate transparent decision-making, confidence, optimism, hope and resilience (Galloway, 2022; Long, 2023).

Authentic leadership aligns strongly with the A-EQUIP model (NHS England, 2021) and that of the PNA role. The PNA role builds strong relationships built on trust, transparency and honest conversations, and this has been recognised as fundamental to support the psychological safety of the SCPHN workforce (Jennison and Walker, 2023). Nurses are constantly striving to improve their leadership skills to achieve those traits highlighted, as there is a mutual understanding these can lead to improvements in our healthcare environment (Raso, 2019). Trust is gained through honesty, integrity and having a moral compass. Teams recognise these qualities as trustworthy and are more likely to be influenced by a leader who demonstrates these within their leadership and decision-making.

There is evidence that nurses who are authentic make for positive working cultures (Alexander and Lopes, 2018). Nurses who feel their leaders are authentic are more likely to voice concerns, share ideas and engage in constructive dialogue. This type of communication is essential for addressing challenges, fostering innovation and continuously improving patient care.

Authentic leadership is crucial in nursing for several reasons as it directly influences the quality of patient care, team dynamics and the overall work environment (Waite et al, 2014). Engaged nurses are more committed to their roles, leading to increased productivity and a positive impact on patient care. Authentic leaders help build resilience among their teams by acknowledging challenges, providing emotional support and fostering a culture that values wellbeing (Northouse, 2029).

This resilience is essential for coping with the stressors of the profession and demonstrates a commitment to the highest standards of practice, ethical conduct and continuous improvement (Waite et al, 2014). This sets the tone for the nursing team and contributes to the profession's overall credibility and reputation.

Evaluation of individuals' views and opinions

Results from the evaluation captured the views and opinions of SCPHN practice educators and practice assessors supporting students in clinical practice. Their answers provided an insight into how they perceived their own current style of leadership.

The key themes are identified in Table 1 and their responses show how they perceived themselves as compassionate leaders, role modelling, energetic and authentic. It was also recognised how the responders identified their preferred leadership style in their clinical practice. It can be agreed these are the skills and qualities required to support student nurses and to support student SCPHN. SCPHNs develop an artistry over the period of their studies and in the post-qualifying period that cannot be taught, but it develops with the support of a highly skilled practice educator or practice assessor who is the epitome of excellence in communication and interpersonal skills.

It is not surprising that transformational leadership is recognised and provided as an answer to support students by practice educators and practice assessors. Galloway (2022) describes transformational leadership as having a perspective that is wider than just an action. It involves coaching and supporting people, and aligning the interests of ‘the team’ with the interests of the organisation in which they work. Galloway (2022) recognises how trust is central to transformational leadership, as are respect, knowledge of and interest in followers, and the ability to provide opportunities for development of them.

In addition, transactional leadership has made an appearance in the survey, and this can be understood to be required for task-based situations involving extrinsic rewards. In this situation, it could be argued that students need to achieve a task to progress and develop with their studies. However, it has been suggested that leaders who support students and newly qualified colleagues will adopt a situational leadership approach (Barry et al, 2016).

Interestingly, responders did not provide the answers that were expected with their third question. While ‘supportive’ was recognised as the most compassionate quality of a leader, other qualities featured lower on the scale of compassionate, such as ‘encouraging of people's differences’ and ‘focused on what is best for their employees’.

There was an opportunity to explore this further and the responders reflected and concluded that they would still agree with the order ranking of most compassionate.

It was agreed by the responders that ‘supportive’ and ‘thoughtful and kind’ were required by leaders to enable others to develop and thrive within the team. Kindness is often overlooked and can be interpreted as a natural quality for many healthcare staff. Wei et al (2019) recognise that kindness is pivotal to support nurses to develop resilience and this can be demonstrated by leaders who role model these behaviours.

Question four asked, ‘Which value is most important to you in a leader?’ (Figure 3). The top scoring response was ‘clear, shared inspiring purpose or vision’ and this aligns with the ABC model of nurses' core needs (The King's Fund, 2023) and the Contribution and Belonging elements. Critically, the value that did not score any support was ‘positively valuing difference’ which could be considered a direct conflict to the core needs (The King's Fund, 2023) and the Autonomy element of the ABC model.

Table 3 shows a summary of the answers provided to question five. All the answers capture the key themes of compassionate and authentic leadership styles (Northouse, 2021; Galloway, 2022). It is recognised that nurses are motivated by intrinsic rewards and want to feel valued within their role and have a sense of belonging (Dames, 2019; The King's Fund, 2023).

Dames (2019) concluded that nurses need to be supported as they make the transition to registered practice; this can also be applied to those who are making the transition to SCPHN. The role of the PNA can be well placed to support student SCPHNs and newly qualified colleagues. The A-EQUIP model (NHS England, 2021) supports the workforce to develop both professionally and personally. The model can be used as a tool to incorporate a robust structure to support students and teams alike.

Situational leadership

One theme that emerged from the survey was related to transactional leadership. This approach includes both intrinsic and extrinsic motivators for SCHPN students, and practice assessors and educators. Therefore, this may lead to an approach which encompasses situational leadership with flexibility and change management.

Galloway (2022) suggests situational leadership allows a leader to alter their approach according to circumstances and that a leader can be either task-oriented or person-oriented as appropriate, depending on the situation. It is also one of the first theories that includes followers as a key part of considerations.

Situational leadership in nursing is essential due to the dynamic and complex nature of healthcare environments and the competing challenges facing nurses daily (Walls, 2019). Patients in healthcare settings have diverse needs, and their condition can change rapidly. Situational leadership allows nurses to adapt their leadership style based on the specific needs of individual patients, ensuring personalised and effective care.

This consideration extends not just to the situation itself; situational leadership is a sophisticated framework from which leaders may make assessments about the readiness of followers and the context (Northouse, 2019; Galloway, 2022). Nursing teams consist of individuals with various levels of experience and expertise, and situational leadership recognises that not all nurses require the same level of guidance and support. It allows nurse leaders to tailor their approach, providing more direction to less experienced staff while giving experienced nurses greater autonomy (Walls, 2019).

Nurses often face situations that require quick and critical decision-making, and situational leadership enables nurse leaders to assess the urgency and complexity of a situation and adjust their leadership style accordingly, whether it involves guiding the team through an emergency or allowing experienced nurses to take the lead in routine tasks (Galloway, 2022). Situational leadership emphasises collaboration and allows nurse leaders to foster a team-oriented culture.

Leaders can adapt their approach to promote communication, co-operation and shared decision-making among team members. For the most efficient leadership approach, situational leaders should determine the motivations and orientations of followers and adjust their style accordingly (Galloway, 2022).

Situational leadership is valuable in driving quality improvement initiatives (Drew and Pandit, 2022). Nurse leaders can assess the readiness of their teams for change, adjust their leadership style to support the implementation of new practices, and encourage a culture of continuous improvement (Walls, 2019).

Patient safety is a top priority in nursing and by adopting situational leadership, nurse leaders can ensure that their teams are well-prepared to address safety concerns, respond to emergencies and follow established protocols to prevent adverse events (Merrill, 2015).

However, this more traditional leadership style focuses on meeting the needs of the service and patients first, rather than prioritising the workforce wellbeing to raise patient care quality. The promotion of workforce wellbeing is crucial to ensuring staff retention, recruitment, and reduced absenteeism (Jennison and Walker, 2023). The A-EQUIP model and the PNA role are pivotal in supporting practice educators and practice assessors to support their SCPHN students.

Prior to the pandemic, in 80% of UK areas, health visiting caseloads were already above the 250 children maximum average recommended by the Institute of Health Visiting (iHV) (Conti and Dow, 2020). Due to a reduction in face-to-face contacts during the pandemic, many HVs reported concerns that they would miss parental mental health conditions, child growth concerns and the wider determinants of health (Conti and Dow, 2020). Years of underfunding and the decision to categorise health visiting as a ‘partial stop’ service during the pandemic were identified as root causes of a service struggling to meet rising levels of families' needs (Morton and Adams, 2023). With rising caseload numbers and a shift towards more prescribed ways of working, many health visitors reported that their ability to work as autonomous practitioners was eroded (iHV, 2020).

It could be suggested that this unique and complex mix of factors has been influential in declining SCHPN retention figures. The iHV (2023) reports that HV workforce numbers have fallen by more than 40% in England (in workforce data reviewed from October 2015–April 2023). The government has attempted to address this by introducing the NHS Long Term Workforce Plan (2023) intended to focus on NHS workforce needs, to meet the future challenges of the service, including SCPHNs. The plan is light on detail for health visiting, but includes commitments to improve retention through career development initiatives, flexible working and improved staff wellbeing. This includes an ambition to expand training places for HVs, district nurses, and qualified school nurses from 1811 in 2022 to 3788 places by the year 2031. The plan reveals the most common reasons for leaving the NHS as:

The future NHS human resources and organisational development report (NHS England, 2020) is cited in the plan, and refers to how professionals can work differently to create a consistently compassionate, inclusive, and values-driven culture to improve staff experiences. However, the plan's recommendations do not examine in detail ways in which leadership approaches relate directly to the reasons staff choose to leave the NHS.

Considering the plan focuses on inclusivity and values-driven cultures, the Mentimeter responses for question four have not applied any significance to SCPHN practice. Could it be argued that the lack of visible significance is more of an expected consideration for practitioners? Could it be suggested that practitioners feel this is too large an issue for them to address, and that this is more of a cultural change that they feel unable to influence?

Moving forward, recommendations for the future could include:

Any educational courses for practice educators and practice assessors need to have an underpinning of the A-EQUIP model and the PNA. This must include the key attributes of the PNA training, which embodies communication, leadership, restorative supervision and quality assurance.

Conclusion

In this article, we have presented a discussion on the different leadership styles; namely, compassionate and authentic, and their relationship with SCPHNs who provide support and role models for care and teach the next generation of colleagues.

The findings illustrate honest and important views of experienced SCPHNs who are supporting students in clinical practice. In the past, transactional leadership styles were a more flexible approach for rapidly changing healthcare organisations, but post-pandemic we need a new leadership approach that has a focus on individual wellbeing and workforce issues. Authentic and compassionate leadership styles should be embedded within the SCPHN role to make this difference.

Key points