Preparing the nursing profession: Educating to lead or training to be manageable?
AEJNE Volume 4 - No.2 March, 1999.
Throughout its history the nursing profession has been responding to changing technological, educational and social forces. These changes present challenges to the profession, particularly to nurse leaders. This paper addresses the roles and responsibilities of nursing educational leadership in these times of change. It asks if nurse educators are playing their part in preparing nurses to understand the concept of professional leadership and considers approaches to educational leadership that would enable the profession to respond to the challenges of change in a positive manner.
Whether change is sought, resisted, or happens by design, the
Whilst it is imperative that nurses develop leadership skills, the key attributes and elements of leadership are not universally agreed. For example, leadership and management are terms that are often used interchangeably in the media and everyday conversation yet they are different in nature. The literature suggests that there are many definitions for leadership (Foster, 1989, Kenway and Watkins, 1994, Grace, 1995, Ogawa and Bossert, 1997) and is equivocal about where leadership fits with management. A review of the literature reveals that there is consensus between authors only in that the two terms refer to differing concepts. Foster (1989:48) claims that there must be something more to leadership if it cannot be reduced to management. Grace (1990) cautions that from an historical point of view the concepts of leadership and management were linked in practice. Marquis and Huston (1992:3) cite Gardner as claiming that leadership requires more complex skills than management and that management is only one role of leaders, but several others exist. In a later work Marquis and Huston differentiate more specifically between the two in the following major areas: managers have an assigned position, carry out specific functions, direct subordinates (both willing and unwilling), and have formal responsibility and accountability for their actions. It could be argued that the result of these activities leads to maintaining order, direction and perhaps a certain degree of inertia. Management focuses on the status quo. On the other hand, leaders obtain their power through influence, often have no formal position, direct willing followers, focus on empowering others and often hold goals that do not reflect those of the organisation (1996:5). Barnum extends this idea defining leadership that changes or 'transforms', as primarily 'an attitude more than in relation to tasks, as an approach more than specific behaviours' (1998:65). In identifying some of the differences between management and leadership Razik and Swanson (1995) claim it is possible to be an effective manager without strong leadership skills but believe that it is not possible to be a good leader without good management skills. In brief, some but not all managers may be leaders and some, but not all leaders may hold management positions.
Where does nursing education and the role of educators fit into this picture of leadership and management? Foster (1989) sees leadership as emanating from two concepts, the Political-Historical Model, and the Bureaucratic-Managerial Model. The former relates to the work of individuals whose vision and concept of leadership meet a need to alter social circumstances for the better. The latter refers to organisational positions with more structure, prescription and control, having what Barnum refers to as a formula for the 'tasks of management' (1998:65). On first reflection Florence Nightingale meets the criteria of a leader under the Political-Historical Model. Her reforms to health care and nursing education fulfil Burn's idea of a transformational leader (1978, cited in Foster, 1989), namely a leader who created 'new social realities' and raised the image and status of nursing (Palmer, 1983). However, whilst Florence Nightingale represented a vision of nurses as educated, reflective practitioners, this was not what eventuated. The prevailing male-dominated medical establishment and societal views of women at the time account for constraints and restrictions on the implementation of her ideas (Dean and Bolton, 1983). It could be argued that because of these social and political issues of the Nineteenth century, Miss Nightingale moved from being a visionary, transformational leader to a managerial or 'situational leader'. She became a bureaucratic-managerial leader with the responsibility of ensuring nursing tasks were achieved in a way that met her reforms but in a manner that more importantly, met the needs of medicine and the health care organisational structure. It would appear in doing so, nursing education took on the managerial traits of the time and became the training of the manageable, the preparation of nurses to meet the requirements of an organisational formula not the preparation of nursing leaders of the future as envisioned by Miss Nightingale. This scenario of the early years of nurse education may be construed as highlighting the distributional dimensions of empowerment through education whilst the constitutional dimensions were not taken up to empower the profession itself (Hayden, 1994).
If training is an organisational method of ensuring that people have knowledge and skills for a specific purpose, 'to perform the duties of the job' and education is 'designed to develop the individual in a broader sense' (Marquis and Huston, 1996:275) then from Miss Nightingale's time on, nurses were trained not educated. Nursing education was 'managed' by forces predominantly outside of nursing. The medical profession decided the educational content necessary for nurses to carry out the duties needed to care for the sick. Training was based around a 'Medical Model' system. A system that Bolton (1981:35) claims excluded subjects such as politics, economics and sociology that would expand knowledge and encourage questioning and develop in nurses the qualities of leadership. Nurses were trained in hospitals, trained to meet the 'service requirements of the hospital' (Baly, 1973:162).
There was little change to nursing training requirements in Australia from the turn of the century to the nineteen sixties and seventies despite changes in general education, women's roles in society and in medicine and technology during this time. The main method of learning for nurses remained task orientated in a 'learning by doing' clinical situation. This orientation entrenched the 'medical model' as the curriculum makers and nurses were taught to carry out the decisions taken by the doctors. Changes in nurse education were slow to make an impact and adjustments were only introduced as technology and the accompanying changing tasks required.
One change which had a major impact on nursing and nurses in Australia was the transfer of nurse education from hospital based schools to the tertiary sector. Fatin (1986) indicted that she believed the transfer of nurse education to colleges and universities to be one of the most significant events in the entire history of the nursing profession. She claimed that: 'it will alter the lives and career expectations of many thousands of nurses in this country in a way that has not been seen since Florence Nightingale introduced training and organisation into nurses lives' (1986:28). In 1984 nursing began to move into the tertiary sector where the promise and rhetoric of increased professional status, internal control, self regulation, peer review and quality control prevailed (Jenkins, 1989). This move was espoused to be the way for nursing to gain autonomy and academic recognition through educational leadership. Yet it could be argued that the traditional, Bureaucratic-Managerial Model of educational leadership was transferred along with nurse education, into the tertiary sector. The rhetoric of increased control over nursing education by nurses, may be translated as an exchange from the domination by medicine and hospital organisational policies, to the inherent danger of nursing being subsumed by a politically more powerful academic bureaucratic structure.
Nursing has not been valued for its autonomous social contributions, independent decision making, scholarly productivity, or collective striving for recognition, power and legitimisation in professional, political (and) policy making (Woods, 1990:152).
Booth, (1994) argues that the majority of the 'leaders' in nursing education were unprepared for their role. They continued to administer nursing education within the bureaucracy of the tertiary setting, without the knowledge and skills needed to initiate effective change, thereby taking a management role of preparing the nursing profession.
Educational leadership has been demonstrated however. The development of nursing competencies that incorporated both critical thinking and technical skills became a primary focus. It is unfortunate that the majority of nurse educators and clinical nurses have continued to focus on and use the competencies from a predominantly techno-rational perspective. This focus on technical skills has given limited attention to the development of critical thinking. The profession, including nursing educators, rather than showing leadership through what Holm, Inman and Ward (1997) call, 'leadership in practice', and Codd (1989) refers to as a commitment to educational values and principles, has continued to emphasise the 'how' of nursing. It could be argued that this focus on 'skills'has perpetuated the Bureaucratic-Managerial Model inherited from the time of Florence Nightingale. Schon (1983) comments that this dominance of technical rationality is inappropriate in professional education, but believes that most forms of professional education are driven by a model of technical rationality. Educational management rather than visionary leadership?
If nursing education is to play a significant part in preparing nurses for the changes in health care predicted for the twenty-first century, then the profession needs to analyse leadership attitudes and dispositions and construct a clear vision for the future. It needs to examine how the qualities of leadership can be fostered and encouraged in both the beginning and experienced practitioner, nurse administrators and educators, whatever their sphere of practice.
What then are the approaches to educational leadership that nurse educators should be pursuing to enable the profession to respond to the challenges of change? Foster (1989) asserts that if leadership is to be considered in different ways it should meet four criteria. These criteria are that leadership must be critical, transformative, educative and ethical. Authors such as Smyth (1989), Bowman (1997), and Leddy and Pepper (1998) support Fosterís assertion that educational leadership may be described as a collaborative, empowering and transformational approach. Grace claims that the argument that Foster mounts is a logical extension of the reflective practitioner and that 'educational leadership should be a particular form of reflective and critical practice' (1995:53). Brookfield (1995) however, argues that reflection is not by definition, critical. In order for leadership to be critical it must have one face turned towards change and 'change involves the critical assessments of current situations and an awareness of future possibilities' (Foster, 1989: 43).
Foster's (1989) notion of leadership as a critical practice may lead to an orientation in which education in critical skills, problem solving and open inquiry, becomes the major thrust. Nurse educators may be challenged by these activities through reflective thought and action. Educational leaders not only facilitate learning and professional socialisation; they also embody and impart educational values. Critical practice in relation to leadership becomes a method of reflecting upon practices and addressing issues through critical inquiry. Educational leadership as reflective action would involve a change from the traditional styles of leadership. Bowman (1997) claims that reflection on practice is increasingly considered an essential attribute of educational leadership. Coyle (1994) asserts that leadership requires time for leaders to reflect, confer and then to act. Leadership perspectives that address reflection on practices that challenge the status quo may result in increased autonomy and academic recognition. Nurse educators should strive for an education system that will influence and lead the nursing profession rather that the profession being managed and lead by outside forces.
Nurse educators should be in the forefront of change in regard to health care. It is central to nursing leadership that nurses have an educational preparation that includes not only a strong clinical component, but also administrative skills, business and negotiation preparation and an understanding of leadership attitudes (Fonville, Killian and Tranbarger, 1998). Nurses in clinical practice with such a background would be admirably placed to mentor new graduates to develop their clinical reasoning skills, link theory to practice, and encourage reflection on practice. Such collaborative leadership, supported by Holm et al. (1997) and Bowman (1997), makes nursing an empowered and transformative team rather than a cog in an hierarchical wheel. It is the leaders at the bedside that link changes in health care with the responsibilities of the profession's future. Such collaboration between education and practice contributes to mutuality as clinicians and educators work together to agree on the direction and nature of changes to the profession. Bennis (1986) cited in Razik and Swanson (1995:48) contends that for leadership to be transformative it knows what it wants, communicates those intentions successfully, empowers others, knows when and how to stay on course and when to change. This is the challenge for nurse educators and the nursing profession.
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