The Ely inquiry into the systematic brutal treatment of patients in a Cardiff mental institution was the first formal inquiry into NHS failings (Department of Health and Social Security, 1969). Since that time there have been more than 100 inquiries with inadequate leadership persistently identified as a major concern (Sheard, 2015). National responses have included the NHS Healthcare Leadership Model, delivered by the NHS Leadership Academy and its partners (2013). A range of online and face-to-face programmes aim to increase an organisation's leadership capacity by developing leaders who pay close attention to their frontline staff, understand the contexts in which they work and the situations they face and empower them to lead continuous improvements that enhance patient outcomes and safety (NHS Leadership Academy, 2013).
At King's College London, ‘Developing Professional Leadership’ is a core module of the Advanced Practice (Leadership) pathway. The module critically appraises theoretical and professional perspectives on leadership and supports participants to take up leadership roles with attention to ethical practice. Both national and college leadership activities promote an understanding of vertical transformational leadership (VTL) and shared leadership (SL).
Vertical transformational leadership
VTL is a hierarchical leadership model that describes an individual leader who, through various influences and mechanisms, elevates himself or herself and followers towards self-actualisation (Pearce and Sims, 2000). VTL values collaboration and consensus, integrity and justice, empowerment and optimism, accountability and equality, and honesty and trust (Braun et al, 2013). A vertical transformational leader inspires others by interpreting complex data, creating a vision and formulating a strategy for its attainment (Avery, 2004). They aim to create an organisation that is agile, responsive, open to learning and future ready through innovation and creativity. They do this by appealing to followers' emotions and internal motivations, and by building rewarding relationships and raising morale. They use delegation, consultation and collaboration to engage followers but retain power so that responsibility and accountability for a vision and its strategy rests with the leader (Avery, 2004).
Behaviours associated with this leadership style have been classified by Avolio et al (1991) as the four ‘I's: idealised influence, individualised consideration, inspirational motivation, and intellectual stimulation:
Tse and Chiu (2014) have advised that leaders adopt a balanced approach to the use of the four Is that is contingent upon their followers' orientation. For example, if group cohesion is required then idealised influence and inspirational motivation are appropriate leader behaviours. However, if greater creativity is needed from staff, then a leader is advised to exhibit individual consideration and provide intellectual stimulation. Conversely, mismatching leadership behaviour to follower orientation can have detrimental effects. For example, providing intellectual stimulation with high expectations but offering insufficient individualised consideration.
During times of large-scale dramatic organisational change an effective vertical leader is necessary for recalibrating and reviving an organisation (Binci et al, 2016). They can provide clarity, motivation and empowerment. There are several examples of positive VTL outcomes in NHS trusts that have managed to improve their Care Quality Commission ratings. This was achieved through measures to revive cultures and empower staff with open communications and active support (Health Foundation, 2015). Critics argue that VTL dependence on a single figure can be futile for an organisation, especially if the individual is prone to dysfunctional behaviour (Wang and Howell, 2012). In response, an ‘authentic leader’ is proposed (Jackson and Parry, 2011); this is someone with a ‘high socialised power orientation’, who is humble, modest, deflects recognition for achievements, who celebrates the team, and exhibits vertical and shared leadership behaviours. Through self-awareness and reflecting on actions a VTL leader can exhibit authentic leadership behaviour.
VTL overlaps other leadership approaches including authentic, servant, charismatic, inspirational and visionary (Avery, 2004). What often differentiates VTL is its motivation or focus, which is typically on achieving organisational goals. VTL is also associated with pseudo-transformational and transactional leadership. The former is a dysfunctional form of charismatic leadership, characterised by narcissistic behaviours associated with dictators and sensational political and corporate leaders. Transactional leadership is practised by positional managers whose job it is to set expectations and engage in corrective or autocratic measures that aim to maintain efficiency. Transformational leaders do utilise some transactional methods to achieve goals and the two leadership styles can be complementary. However, VTL is two-way leadership with follower influence whereas transactional leadership represents one-directional hierarchical leadership.
Shared leadership
SL is a non-hierarchical leadership model that describes leadership that emerges within a group, depending on the context and skills required at a given time (D'Innocenzo et al, 2016). SL values openness and trust, engagement and inclusiveness, reciprocity and fluidity, democracy and empowerment, and networking and support (Jameson, 2007). Shared leaders are peers who possess no authority over the group outside the context of their shared contribution. Individual leadership is de-emphasised and a vision and its strategy are created and owned by the group. Open discursive engagement is favoured for mutual sense making through the pooling of diverse skills, knowledge and experience. SL is dynamic, multidirectional and collaborative. Power is shared so that responsibility and accountability for a vision and its strategy rests with the group (Avery, 2004).
SL is often associated with, but different conceptually from, co-leadership, distributed leadership, and self-managing teams. Carson et al (2007) suggested that these all lie on a continuum with co-leadership at one end and shared leadership at the other. Participation, consultation and delegation are used in SL as are the four Is of transformational leadership. SL has been described as a type of group transformational leadership as transformational behaviours within a shared leadership model achieve similar results to VTL (Wang and Howell, 2012). SL necessarily exists in organisations such as the NHS where different professional groups with their own leadership structures need to collaborate. Transforming a culture through shared leadership requires patience and investment. It is an iterative process involving cycles of learning and reflection that require trust, personal and professional maturity, and organisational support.
SL leadership behaviours can become widespread within teams, lessening their dependence on one leader and the potential effects of rogue single leaders (The King's Fund, 2011). This is vital in environments where problems are increasingly complex and leaders are required to possess multiple problem-solving skills. Cost efficiencies can result from diminishing hierarchical leaders' workloads and a consequent reduction in their posts among highly skilled cohesive groups (Tse and Chiu, 2014). Critics argue that SL efficiency is influenced by group dynamics, which may be prone to relationship conflicts that lead to decision paralysis (Pearce and Sims, 2000). Additionally, the emergence of a vertical leader who could manipulate the workforce for political or corporate gain may be an unintended consequence of SL.
Both VTL and SL are moderated by internal and external factors. VTL is influenced by levels of trust, follower receptiveness, personality traits, task complexity and urgency. Stress and burnout can lessen leadership benefits while trust can enhance performance outcomes (Robert and You, 2018). SL is moderated by trust, time, group size and cohesion, skill mix, confidence, task complexity and interdependence (Nicolaides et al, 2014). Trust, sufficient time, a balanced skill mix and group cohesion have a positive influence, while task complexity, especially at formative stages, hinders effective SL.
The two approaches are complementary. During the formative stages of shared leadership, a vertical leader is crucial to guide and sustain shared leadership. Some final decisions will need to rest with the hierarchical leader. As the team gains confidence, a vertical transformational leader's role evolves to consultant, mentor, facilitator and, at times, recipient of group leadership. A significant body of evidence associates VTL and SL with positive individual, group and organisational outcomes (Wang and Howell, 2012; Nicolaides et al, 2014; D'Innocenzo et al, 2016). VTL predominantly influences individual and organisational outcomes while SL is more influential at the group and organisational levels. Table 1 summarises some of the differences between the approaches, although they share much more in common.
| VTL | SL | |
|---|---|---|
| Power structure | Hierarchical | Non-hierarchical |
| Vision and strategy | Responsibility of the leader | Responsibility of the group |
| Uses | Large scale or sudden change |
Ongoing development and change |
| Primary benefits | Individual and organisation | Group and organisation |
Source: Avolio et al, 1991; Avery, 2004; D'Innocenzo et al, 2016
Practical applications
Leadership is a dynamic process involving collective values, behaviours and resources. Followers play a pivotal role in attributing and sustaining leadership. ‘Followership’ is more than just being an employee and involves characteristics and behaviours that an individual exhibits in relation to their leaders (Uhl-Bien et al, 2014). For example, being obedient and subordinate while being prepared to challenge constructively and act proactively to support problem-solving processes. In public service, the status of an individual can change from follower to leader quite regularly, requiring all to play a part. VTL and SL can support ‘engaging the team’ and ‘leading with care’, two of nine dimensions in the NHS Healthcare Leadership Model (NHS Leadership Academy, 2013). These two dimensions form the basis of the leadership model and are closely linked since engaged teams are a product of caring leadership. However, it is useful to consider them independently to understand their relationship to VTL and SL.
Engaging the team
Currently there is an urgency to engage frontline staff and increase leadership capacity to promote patient safety and organisational development (West, 2018). This is not new. In 1998, Merkens and Spencer deemed follower engagement and the development of shared leadership necessary for an organisation's survival. Change is now a constant feature of NHS cultures in which leaders must instigate service re-organisation and support staff through periods of flux. They need to be able to reach out to all parts of a system, to remain present and involved in change processes, and embed improvement cultures while ensuring consistently high levels of compassionate care (Ham et al, 2016). This can be achieved only if they also champion the full engagement of their staff and other key stakeholders in improvement methodologies. Engagement is a product of trust, inspiration, motivation, empowerment and the alignment of visions and values (Saks, 2006). It can be fostered through VTL or SL and use of the four Is. Team engagement is critical for promoting shared leadership (Saks, 2006). Complacency must be avoided and potential barriers to engagement identified and managed.
Alban-Metcalfe and Alimo-Metcalfe (2013) define dengaging leadership as ‘near’ leadership: leaders who show genuine concern, honesty, consistency, accessibility and act with integrity. Gardner et al (2005) referred to authentic leaders who demonstrate self-awareness, accept ownership and responsibility for themselves and act with no hidden intentions or agendas. Zhua et al (2011) demonstrated how authentic transformational leadership enhances group ethics and develops follower moral identity and moral emotions. In turn, this can foster collective leadership because authentic leaders naturally lay a foundation of trust for others to strive toward similar ends. Collective leadership helps to distribute and disseminate change (West et al, 2015). Engaged teams feel valued and empowered and their members can independently undertake additional tasks out of empathy, care and compassion for others (Tsai and Wu, 2010). Collective leadership reflects qualities of shared leadership. It needs to be carefully nurtured and supported by an organisation to avoid disengagement from change processes. Support, care and compassion among employees must not be overlooked.
Engaged teams can harness the negotiation, conflict resolution, problem-solving and leadership skills of individual members. Organisations become more resilient and can deal with complexity swiftly and efficiently, preventing and managing crises and sustaining organisational development by spreading transformational attributes from a single leader to the collective (Wang and Howell, 2012).
Leading with care
A person's values and corresponding behaviours influence their leadership style more than their competencies (Deinert et al, 2015). They set the tone for an organisation's culture, whether leadership is conveyed with care or not, and therefore the ways in which staff and patients are treated. Although values are difficult to measure, their essence is detectable in an organisation's culture and in a leader's focus. Leading with care through inclusive, supportive and empowering leadership was found to be crucial by Hamlin (2002) in a study of behavioural outcomes in the NHS. There are important lessons from the most recent NHS Staff Survey in these respects. Although managerial responsiveness to staff wellbeing has improved in recent years, staff engagement, including their ability to contribute to improvements and their sense of being valued by managers, has decreased slightly (NHS Survey Coordination Centre, 2018). Supporting documentation argues that NHS trusts need to give staff the skills, freedom and responsibility necessary to improve care, enhance motivation by focusing on values of quality care for patients, and build transparency and fairness across the organisation to generate high trust cultures that empower staff to contribute to decisions that affect them (Dawson and West, 2018).
Through individual consideration, inspiration, motivation and intellectual stimulation, VTL demonstrates caring leadership attributes such as honesty, fairness, integrity and support (Saks, 2006). Benefits include improved wellbeing and job satisfaction for individual staff, and enhanced group identity, cooperation and cohesion (Gillespie and Mann, 2004). Followers are inspired to see new possible futures and the means to achieve desired outcomes with the confidence to act. The status quo is questioned, problems are reframed and creative problem-solving occurs. Engaged, intelligent followers who are ready to act through self-leadership are demonstrating characteristics of shared leadership (Baker et al, 2007). This emphasises the complementarity and overlap of VTL and SL as active and effective followership and leadership can result from these internal and external motivations.
Case scenario
Although leadership models can seem quite distant and academic, nurses need to understand their implications for their professional lives, whether they are leaders or followers. The scenario in Box 1 provides an example of collective or shared leadership with which the first author was involved during a clinical placement.
Conclusion
VTL and SL are both appropriate in healthcare contexts and can be complementary under the right circumstances. The key is being able to recognise appropriate opportunities to develop and utilise each as either a leader or follower (Binci et al, 2016). Familiarity with the models, their methods and uses are important in these respects. It is equally important to recognise and engage in any cultural change that may be necessary for leadership to be effective. Transformational change does not have to be revolutionary or top-down. Minor changes at the frontline can deliver significant benefits if team members are engaged and led with care.