Transformational leadership: leading

the way for midwives in the 21st

century
4 June, 2008

PAGE MIDWIVES MAG FEATURE MID: JAN 2005

Strong and effective leaders are essential in order to fulfil the
government's plans for the NHS. Rossana Ralston explores a number
of leadership styles and asserts which of these is best suited to
facilitate high-quality, woman-centred maternity care.

Strong and effective leaders are essential in order to fulfil the

government's plans for the NHS. Rossana Ralston explores
a number of leadership styles and asserts which of these is best
suited to facilitate high-quality, woman-centred maternity care.

Midwives magazine: January 2005

Introduction

The NHS Plan: a plan for investment, a plan for reform (Department of
Health, 2000) and its Scottish equivalent Our national health: a plan for
action, a plan for change (Scottish Executive Health Department,
2000) have forced a rethink of the attitudes, values and skills required
to function in the NHS. These new roles and altered responsibilities
will need effective leaders at all levels of the health service.

The government's vision is for a patient-centred health service, and if

midwives are to play a key role in taking forward this idea, future
midwifery leaders must be developed and supported.
This paper aims to explore the concepts and processes of leadership
within the context of the midwifery profession nationally, and discusses
the use of transformational leadership as the most suitable approach
for the 21st century.

Definition

Leadership has been well-studied over the years, and despite this it
has no single clear and consistent definition, particularly relating to its
characteristics.However,most definitions support the view that
leadership involves intentional influence being used over others in the
attainment of a common goal (Bass, 1990). This is important to
midwives, as it recognises that in providing maternity care,midwifery
leaders can influence not only women but also the organisation
through service delivery, and the midwifery profession itself.

Theory

Many leadership theories have been developed in an attempt to

understand how behaviour can best be influenced.Among the earliest
are the trait theories, often referred to as the `great man' theories
(Bernhard et al, 1990). These suggest that leaders are born and not
made. They are grounded in the philosophy that leaders possess
certain innate qualities or characteristics such as interpersonal skills,
diplomacy, selfconfidence, emotional control, intelligence, judgement
and fluency (Bass, 1990).Acceptance of the leader-ruler is a positive
aspect of this, however, not all who assume the role of leader are
capable of leadership ± Handy (1993) reminds us that trait theories
rest on the assumption that the individual is more important than the
situation. This in itself is a major flaw, especially as leadership should
concern involvement of others, the job to be done and the
circumstances. Further, use of the term `great man' has obvious
gender connotations.

Circumstantial theories (also known as situational or contingency

theories) consider that the situation or intervening factors affect
leadership behaviour (Bernhard et al, 1990). Leadership was seen as
relative to and have emerged from the situation. The main objection to
this theory is that a leader does not appear in every problem situation,
and even if they do, this does not ensure effective leadership. Being a
leader in one situation does not mean one can be a leader in another
(Blankenship et al, 1989).

Style theory succeeded both trait and circumstantial theories. The

assumption behind this is that employees will work harder and more
effectively for managers who employ certain styles of leadership, than
for managers using other ones. Lewin et al (1939) compared the three
most commonly recognised leader's behaviour in each style and
concluded that the major differences were in the focus of power.
Autocratic leaders are often described as authoritarian in their
approach ± a firm leader who makes unilateral decisions, gives orders
to be obeyed unquestioningly, communication is top-down and staff
are not expected or encouraged to take the initiative. The needs of
staff are rarely recognised in this style of leadership and the culture is
commonly of fear, defended on the basis of getting the job done.

Florence Nightingale, in the late 19th century, exercised this style of

leadership through the role of matron (Moiden, 2002). This was further
promoted by Salmon (1966), with its introduction of a
nursing/midwifery hierarchy. It is recognised now that this style should
only be used in crisis situations (Carney, 1999). Democratic leaders
are often described as participative ± this leader, being part of the
team, involves others in decision-making, communication is top-down,
bottom-up and side-side. This improves staff morale and ownership as
people are treated as adults and therefore more likely to behave that
way. The leader's power comes from the group.

Democratic leadership exercises general supervision and there are

minimal rules that staff are encouraged to question and debate
openly.
Unlike the previous two styles of leadership, `laissez-faire'leaders are
often seen as `doing nothing' ± providing no direction and minimal or
no control. They are leaders by virtue of their position within the
organisation and do not demonstrate leadership skills. They try to
please everyone and work on the premise that staff can lead
themselves.

Although democratic leadership appears to be the desired leadership

style for today's healthcare agenda, in reality a mixture of leadership
styles will need to be used at different times. The skill is in knowing
which to use when.

Broome (1990) compared two other commonly-used leadership styles:

transactional leadership, characterised by bargaining, is taskcentred,
providing only a short-term focus with little positive reinforcement for
staff. It recognises the use of rewards, whereby the leader rewards
followers for achieving their goals. In contrast, transformational
leadership is inspirational and empowering, challenging thinking and
offering informal rewards at every opportunity. The transforming leader
seeks to engage the full person as the follower.

Leadership and management

In order to understand leadership, it is necessary to distinguish

between leadership and management, as even today many believe
they are one and the same thing (Sofarelli et al, 1998).

Although leadership and management are intertwined, the distinction

is crucial when placed within the context of midwifery. The delivery of
midwifery care is changing from a task-orientated approach to a team
approach, where midwives must collaborate with others to provide
holistic care.Management, often referred to as transactional
leadership, is about producing a degree of predictability and order,
whereas leadership is about producing change (Alimo-Metcalfe, 1996).
The management role is about `doing things right' and getting the task
done. The leadership role is about `doing the right thing' and involves
vision and direction (Carney, 1999). Therefore, a person can be a
leader without being a manager and be a manager without being a
leader (Yukl, 1989). Another useful distinction drawn by Watson (1983)
uses the `seven S's framework' ± that managers use strategy,
structure and systems, while leaders take a softer approach involving
style, staff, skills and shared goals.

Evolution of leadership in midwifery

Leadership is inseparable from environmental influences. This means

that it is essential for midwifery leaders to have an awareness of the
origins and pressures for change, and the drivers, characteristics and
expectations of the changing context shaping health care today.

More specifically to midwives, Zepherina Veitch demonstrated strong

leadership in the 20th century. A powerful advocate of midwifery
training, she campaigned to improve the standards of midwifery care
(Collington, 2001), resulting in the first Midwives Act in 1902 in
England, (1915 in Scotland) and subsequently the Central Midwives
Board (CMB). This effectively improved the standards of midwifery
care, but had far-reaching implications for every midwife. The
regulating and controlling approach led to the role of the inspector,
now known as the supervisor of midwives, overseeing midwifery
practice.

Multiple NHS reorganisations over the years aimed to improve

efficiency and quality of services through changing the roles and
responsibilities of nurse/midwife managers, with the term
`nursing/midwifery leadership' being interchangeable with
`nursing/midwifery management', and leadership roles being assumed
by the manager (Henderson, 1995). Salmon's (1966) midwifery
hierarchy promoted a top-down management approach and forced
midwives into promoted positions without prior preparation. As a result,
they were powerless and had difficulty or little opportunity to make a
difference (Savage, 1990).

The Briggs Report (1972) brought the amalgamation of nursing and

midwifery by replacing the CMB and General Nursing Council with the
UKCC. The resultant loss of identity for midwives unfortunately still
exists today. Midwifery, the smallest profession, (excluding health
visitors) was frequently under-represented at best, or at worst,
represented by nursing.

In the 1990s, the NHS management enquiry (Griffiths, 1983) advised

on the effective use of manpower and related resources in the NHS. It
recommended that general managers be appointed at regional, district
and unit levels to take responsibility for managing the whole
organisation, including the staff. Overnight, general managers became
line managers to both midwife and nurse managers, and in some
smaller units nurse managers managed midwives. Although some
responsibilities were given to nurse/midwife managers, a top-down
management style with centralised control was used.

Despite the many changes in roles and titles through time, there is little
evidence of the encouragement of midwives with leadership potential.
Rather, NHS management involved a rigid system of rules and
procedures, monitoring, controlling and rewarding conformity, not
innovation. As a result,many senior midwives found themselves no
longer required as managers and either returned to hands-on clinical
care or left the organisation.

The hierarchical structure in operation oppressed midwives and the

midwifery profession, and was further exemplified by the
medicalisation of childbirth. In defining `no birth as normal except in
retrospect', the midwife's role became eroded and all childbirth was
placed under medical control (Peel Report, Department of Health and
Social Security, 1970). Consistent with this theory of oppression,
midwives were led to believe that it was right or natural for the medical
profession to maintain control of childbirth (Roberts, 1983).

The leadership of midwives at this time was fraught with difficulties,

including the misuse of power to obtain greater control over the
process of childbirth and women, rooted in a patriarchal model (Cahill,
2001), whereby male medical knowledge was seen as being scientific
and factual and hence superior to female intuitiveness and
experience.Midwives became demotivated, resulting in a downward
spiral of low self-esteem, reduced initiative and assertiveness. Many
became dependent and submissive with reduced autonomy and a
resultant devaluation. Midwives became conditioned to seeing their
role as that of assistant to the doctor, a machine minder or
technological handmaiden. Leaders who are perceived, and who
perceive themselves, as having no power hold back innovation and
change, only serving to reinforce and increase an autocratic culture
(Larson, 1983).

In modern midwifery, there is a constant requirement for change in

attitudes and working practices. Listening to what customers want and
then meeting those wants and needs efficiently and effectively was the
message from various reports such as the Winterton Report (House of
Commons Health Committee, 1992), Changing childbirth (Department
of Health, 1993) and its Scottish equivalent the Provision of maternity
services in Scotland: a policy review (Scottish Office Home and Health
Department, 1993).However, in order to achieve this, it would require
energy, determination, and above all midwifery leadership (Hunt,
1997).

Opportunities had never been greater ± the future was now in the
hands of midwives and many reasserted their autonomous role,
takingup their place as the lead professional in innovations such as
team midwifery,midwifeled units and midwife-led clinics in a drive to
normalise maternity care for low-risk women.
However, despite these developments, the reduction in the numbers of
professional leaders was again highlighted (Scottish Eexecutive Health
Department, 2001a; 2001b). A framework for maternity services in
Scotland (Scottish Executive Health Department, 2001b) specifically
demanded new ways of providing safe and effective maternity services
and for this to occur `midwife champions' would be required.

If leadership is about developing a vision that provides a framework to

improve the quality of our maternity services, then exactly who are
these professional champions ± the true leaders? Leaders in midwifery
have traditionally been perceived to be from institutions such as the
national boards and the RCM or from high positions within hierarchies
± chief area nursing officer or director of nursing and midwifery, the
heads of midwifery (HOMs) and,more recently to add to this elite list,
the consultant midwife.

Without doubt, these have all been sources of leadership and have
been influential in directing and shaping the services we provide.
Perhaps most notable is the RCM in its work and production of Vision
2000 (RCM, 2000) and its position papers, especially Statement no. 2:
Modern matron in the maternity services (RCM, 2002). Both these
documents aim to secure and assure the highest standards of women-
centred care through the provision of professional leadership, while
being committed to the needs of midwives.However, both illustrate the
conflict of ideals between unionism and professional leadership, a
dichotomy that can confuse rather than inspire followers.

A similar division can be seen in many maternity units with hierarchical

structures, whereby the HOM is responsible to the general manager
and managerial objectives have to be met. The NHS is an organisation
that manages for illness (Lenaghan, 1999) ± therefore, the prime
concern will be managing the process rather than managing the end
result, that is, better health. Leadership will be secondary to managing
the organisation efficiently and effectively, and midwife managers must
be able to deal with the pressure of the expectations of being a leader
and the expectations of management ± meeting the objectives.

However, leadership is not dependent on having a management

position, nor is it for the few, elite or well known. Each one of us,
whatever position we are in, can, and indeed do, lead and develop
midwifery practice. It is part of everyday practice in an era where
midwives are leading services independently of obstetricians, working
as named midwives and developing professional practice. Leaders
make things happen ± they have vision, they support, they strengthen
and inspire trust (Garbett, 1995) ± all the attributes the midwife needs
when working with women. Every midwife has the potential to lead and
influence within the context that they are working, whether that be at
the micro- (clinical),meso- (strategic) or macro- (political) level, or at all
three levels of the organisation.

The challenge for NHS organisations is how they will develop and
equip midwives with skills, so they will be able to influence practice as
clinical leaders, across organisations as strategic leaders and at
government or national level as political leaders, in order for the
government's health policy to be implemented.

Leadership for the 21st century

The latest report from the Expert Group on Acute Maternity Services
(Scottish Executive Health Department, 2002) portrays the Scottish
Executive's vision for the future development of maternity services.

All midwives need to note the strengths of the report. It advocates a

multidisciplinary integrated approach that will maximise seamless care
across hospital and community settings. The report has also taken into
account workforce issues, education and the clinical competencies
needed to deliver this care. However, perhaps the most visionary
aspect of this report, and one that has far-reaching implications for
midwives, is the challenge to provide woman-centred care that will be
essentially `midwife managed'.

How this will be received by the medical profession, who up to now

have been viewed as the lead in maternity care, is not yet clear.
Neither is it clear how midwives will take on this challenge. This new
paradigm shift has the potential for interprofessional rivalry and
barriers to progress will be high. Midwives have been acknowledged
as the most suitable professional to care for low-risk women
throughout pregnancy (Scottish Office Home and Health Department,
1993; Scottish Executive Health Department, 2001b, 2002).

Midwives can no longer abdicate responsibility even though many may

prefer to. The infrastructure, support and evidence to meet the
challenge are available (McGuire, 2002), however, do midwives have
the leadership skills to meet the challenge?

Transactional leadership, with its taskcentred and autocratic approach

to staff management, can best describe midwifery leadership
throughout the changes, but the author believes that transformational
leadership is what is needed to lead the way for midwives in the 21st
century.

We therefore need leaders who have the attributes to see the big
picture and where the contribution of midwives lies within it. For this to
happen,midwives need to develop and utilise the qualities of
transformational leadership,

Which focuses on people and solving problems in an ever-changing

environment. This model is well-suited to a change climate, because it
actively embraces and encourages innovation and change (Sofarelli et
al, 1998; Dunham- Taylor, 2000). It has the ability to motivate others to
work towards a shared goal and it is characterised by an open,
empowering culture where communication, strong values and mutual
respect are paramount. It concentrates on communicating a vision,
and the fostering and maintenance of a positive image in the minds of
the followers (Kouzes et al, 1987). Midwives must also have a good
understand- ing of the context of health policy and a vision of how to
shape maternity services according to this policy, the ability to plan
and manage change and the strength and confidence to chal- lenge
the status quo. Therefore, the characteris- tics, qualities and skills of
an effective leader are varied and vast, however, the author believes
Chevannes (2000) provides an apt description of the key components
necessary for midwifery leadership in the 21st century (see Box 1).

Conclusion

Leadership is a key concept of the future. The government has set

some difficult challenges for achieving modernisation and change that
will ensure the delivery of high-quality services (Department of Health,
2000; Scottish Executive Health Department, 2000).

The NHS Plan (Department of Health, 2000) and its Scottish

equivalent assert that never before have midwives had such an
opportunity to be at the centre of activities, and be in the position to
drive and shape events rather than just respond to them.

Midwives can play a full part in transforming these government reports

into reality. This requires strong midwifery leadership to facili- tate the
changes demanded to deliver high- quality and safe woman-centred
maternity care.

All midwives have the potential to lead and they must adopt a style of
leadership that empowers the women in their care as well as each
other. Transformational leadership appears to be the choice of
leadership style best suited to delivery of maternity care in the 21st
century.
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