What makes a good clinical leader?

‘Managers are necessary but leaders are essential.’ (Slim, 1957) It’s the sort of saying that could easily appear on a fridge magnet or coffee mug because it captures the essence of a deepseated truth that we all know from our experiences about the relationship between leadership and management, but find difficult to verbalise. Not only are the differences in this relationship between leadership and management difficult to verbalise; but for the clinical nurse it is even more difficult to work out what particular ‘hat’ you are wearing or should be wearing when trying to lead and manage a team through a busy shift. The reason I like that short quote from Slim is that, although it was written over 50 years ago and although Slim wrote it from his background of being an army general, it manages to capture what every clinical nurse knows; that no matter how good your manager is at ‘managing’, unless they have some leadership skills the team will not achieve its potential.

Leadership and management What then is the difference between management and leadership? Take a few minutes to think about this and then write down three skills or qualities that a manager should have and three skills or qualities the leader should have. If we return to Slim and the quote and read it in the context of the paragraph in which it was written, this is how Slim describes the differences between management and leadership. ‘Leadership is of the spirit compounded of personality and vision; its practice is an art. Management is of the mind, more a matter of accurate calculation, of statistics, of methods, timetables, and routine; its practice is a science. Managers are necessary; leaders are


essential. A good system will produce efficient managers but more than that is needed. (Slim, 1957) Much as I like this perspective that Slim gives on the differences between management and leadership, I’m not sure how useful that is to our daily work in clinical nursing practice. Consider the scenario below: Jayne is the ward sister of a 40-bed unit. She has eight full-time and six part-time staff nurses and twelve fulltime healthcare assistants (HCAs) and eight part-time HCAs. Some staff work 12-hour shifts, others work 6- or 8-hour shifts depending on their formal and informal contracts of employment. Now consider just two aspects of Jayne’s role as ward sister; first, planning the off-duty rota and second, retention of staff.

Planning the off-duty rota Planning the off-duty rota for such a complex group of staff requires very obvious managerial skills. Jayne need to make sure adequately qualified and experienced staff are on duty to deliver appropriate nursing care, manage medications, give intravenous fluids and all the other requirements for that particular ward. She then needs to match the requirements with the skills of her staff. Complicating matters even further are the peculiarities of each member of staff relating to the hours they work. Other staff will have annual leave or study leave to be taken into account. You definitely need some good management skills to plan the off-duty rota, but do you need any leadership skills? Every clinical nurse will have been on the receiving end of the off-duty rota. We know what it’s like to have five early shifts in a row or three weeks of night shifts when others only seem to have one, or getting a late shift when we have requested an early one. It is this aspect of planning the off-duty rota and the communication of decisions that have been made that call on our leadership skills rather than our management skills.

Retention of staff Jayne has a total of 34 staff in her team; some qualified, some HCAs, some full-time, some part-time. The staffing is delicately balanced; if 10% of her staff were to leave she would find it

very difficult to manage the care needs of her patients. Replacing permanent and experienced staff with agency or ‘bank’ staff, as we all know should only be an emergency action not a medium- or long-term solution. While some movement and change of staff is inevitable, and to some extent ‘healthy’, a rapid turnover of staff only disrupts teamwork, which leaves the ‘experienced few’ carrying a far greater workload. Spend a few minutes thinking about the skills Jayne will be using to aid staff retention. If your situation allows, discuss this with some of your colleagues. What can a ward sister do that will reduce a rapid turnover of staff? Jot your thoughts and conclusions down before reading on. I asked this question of a group of experienced clinical staff and these are some of the answers: ■■ Listen to the needs of the staff ■■ Put on training sessions ■■ Support staff in their professional development ■■ Make sure the off-duty rota is fair and requests are honoured wherever possible ■■ Clinical supervision and mentoring ■■ Staff meetings ■■ Leading from the front i.e. working clinically and demonstrating good practice ■■ Setting high standards, but not unrealistic ones ■■ Saying ‘thank you’ to staff after a particularly busy shift of difficult situation ■■ Organising social events. How does your list compare with the list above? I’m sure you have identified a number of these and hopefully a few more that are drawn from your own experience as well. Are these skills of leadership or are they management? Many of those qualities identified above could be seen as both management and leadership skills; I don’t think many are exclusively leadership skills, although I think ‘leading by example’ is probably one of the more ‘pure’ leadership skills. I like the use of a Venn diagram (Figure  1) to illustrate the distinctiveness of the differences between leadership and management, but also the overlap particularly evident in everyday clinical practice.

What makes a good clinical leader? Take a few minutes to reflect on that Venn diagram in Figure 1. Ask yourself the question, what makes a good clinical leader based on that model? Or, more specifically, how can I develop my clinical leadership abilities based on that

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any years ago I was on a management degree and one of the modules required me to write an essay on ‘transformational leadership.’ It is proposed that there is a particular style of leadership that is charismatic and carries people forward through change and difficult times. I remember one wonderful quote that I used in that essay, which has stayed with me over the years and I have used in discussion with many clinical staff:

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PROFESSIONAL ISSUES model? Here are my thoughts and reflections: ■■ What leadership abilities do I have? ■■ What management skills do I have? ■■ Do the staff who work in my team see me as their manager or leader? ■■ Does my manager see me as the manager of my team or the leader? ■■ When do I need to take on a predominantly leadership role? ■■ When do I need to take on a predominantly management role? ■■ What areas of clinical practice involve me to take on both leadership and management at the same time? ■■ What areas of my responsibility involve short-term goals for my staff and what areas relate to long-term goals? ■■ If I’m focused on managing can I also inject some qualities of leadership? I hope you can see how useful this simple diagram can be in helping you to reflect on your leadership and management role. Try using it and re-thinking your ideas on Jayne and her focus on the off-duty rota and retention of staff. If you reflect on your own

Let me leave you with some final words from Field-Marshall Slim: ‘Infuse your management with leadership … Like me, they would rather be led than managed. Wouldn’t you?’ (Slim, 1957) Leadership


The overlap area in clinical practice Figure 1. Clinical leadership and management

experience of being in different teams you will realise that different people lead and manage teams in slightly different ways. The essence of developing your own skills and abilities is to assess your strengths and abilities, be honest with yourself regarding your weaknesses and seek to build on your strengths and develop your weaknesses.

There may be a few positions in today’s health service that require a person to have superb management skills but require little in the way of leadership skills; however these are not clinical nursing positions. Any qualified nurse needs to be able to manage and lead, often both at the same time. If we as clinical nurses give up our leadership skills because someone has said we need to be managers, then standards will drop and staff will depart. BJN Conflict of interest: none Slim W (1957) Leadership and management (address to the Adelaide Division of the Australian Institute of Management). http://tinyurl.com/nh9us8b (accessed 3 June 2014)

John Fowler

Independent Education Consultant

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What makes a good clinical leader?

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