Facilitating effective health promotion practice in a public health unit: lessons from the field

Jessica Berentson-Shaw1 1 Auckland Regional Public Health Service, New Zealand and

Kerry Price1 1 Auckland Regional Public Health Service, New Zealand 1Auckland Regional Public Health Service, New Zealand

Correspondence to: Dr Jessica Berentson-Shaw, Auckland Regional Public Health Service, 11 Dorking Road, Brooklyn, Wellington, New Zealand. Fax: +64 4471 2637; e-mail: jessicaberentson@gmail.com

Abstract 

Objectives: Health promotion is a core function of public health services and improving the effectiveness of health promotion services is an essential part of public health service development. This report describes the rationale, the process and the outcomes of a realignment designed to improve the effectiveness of health promotion activities in a public health unit (PHU) in New Zealand.

Methods: A practice environment analysis revealed several factors that were hindering the effectiveness of the health promotion unit's (HPU) activities. Two primary change mechanisms were implemented. The first was an outcomes-focused model of planning and service delivery (to support evidenced-based practice), the second was the reorganisation of the HPU from a topics-based structure to an integrated one based on a multi-risk factor paradigm of population health.

Results: During the realignment barriers were encountered on multiple levels. At the individual level, unfavourable attitudes to changes occurred because of a lack of information and knowledge about the benefits of evidence and research. At higher levels, barriers included resourcing concerns, a lack of organisational commitment and understanding, and tensions between the political need for expedient change and research and development need for timely consideration of the impact of different models of practice.

Conclusions and Implications: This realignment took place within the context of a changing public health environment, which is significantly altering the delivery of public health and health promotion. Realignments designed to facilitate more effective health promotion and public health practice will continue, but need to do so in the light of others’ experience and debate.

Health promotion in New Zealand has traditionally been a core activity of health services. Although not always physically located within public health units (PHU), health promotion is becoming more aligned with conventional public health practice. As a result, the discipline of health promotion has been required to prove its contribution to population health gain.

Health promotion theory is robust and scientific; research has revealed, however, that the theory is not always translated into practice.1 The challenge for the larger public health discipline is to find ways to ensure that health promotion theory is fully integrated into health promotion practice and that health promotion activities are contributing to population health gain.

Public health structure in New Zealand

In New Zealand, health promotion services (and other public health services) are contracted primarily by the Ministry of Health and are delivered by a combination of governmental and non-governmental organisations.1 The largest government-based providers of health promotion services are the regionally based PHUs. In the future, the recently established, government-funded primary health organisations may assume this role.

The PHU that is the focus of this paper serves the most heavily populated and ethnically diverse region in New Zealand. It has four business units that deliver services relating to: health promotion, communicable disease prevention and investigation, public health intelligence, and environmental health. It is changes made to the health promotion unit (HPU) that are the focus of this report. The context for these changes is provided by structural changes that were occurring in the PHU at the time.

Implementing effective health promotion practice

The broad aim of the changes discussed in this paper was to implement more effective practice in the HPU; more specific aims, however, were required to achieve this end. A wide review of several discrete and varied bodies of literature relating to health promotion, public health and organisational structures and systems was undertaken to inform these more focused aims. Relevant issues drawn from each body of literature are discussed below in brief detail.

While the health promotion literature identifies several general features of health promotion practice, evidenced-based practice (which we take to mean the use of evaluation and research to design, deliver and measure the impact of health promotion activities) is deemed critical for effectiveness. Crucially, the use of evidence in health promotion practice in New Zealand or Australia is not appreciably emphasised.1 4 A large body of clinical and non-clinical literature has explored reasons as to why evidence-based practice is not emphasised in health settings and within health promotion specifically it has been suggested that there may be a lack of dissemination of evidence and a poor understanding of evidence and research in general. However, implementation research has found that disseminating evidence more widely and making it more accessible has not been found to facilitate evidence-based practice.5 7 The organisational literature may offer some answers as to why this may be the case.

Research has found that the use of research and evaluation in practice (in all health settings including health promotion) is hindered by organisational resources and

infrastructures that do not promote and support evidence-based practice.6 9 Examples of this include an organisation failing to commit financial resources to actively undertake research, not implementing role-specific structures that support staff in the development of their research skills, and not encouraging or emphasising research partnerships. The literature suggests that organisational systems and structures may need to be changed or developed when they impinge upon the success or effectiveness of activities and outcomes of that organisation, in this case evidence-based and effective health promotion practice.7,10

In light of the literature, the first aim of the changes was to identify an organisational system that would provide a context and supportive environment for evidence-based health promotion practice.

A review of the organisational literature (relating specifically to public health practice) identified that, in addition to an organisation's systems, certain service delivery structures are prohibitive for public health practice effectiveness and organisational development. Specifically, vertical or topics-based structures are problematic.11,12 Topics-based or vertical structures have been identified as contributing to structural inflexibility and they also reduce a health system's ability to upscale activities and meet contemporary health challenges, due in part to the funding restrictions that can occur in topics-based structures.3,11 A review of health systems in Australia indicated that topics-based structures produce programs that have little reference to one another and this creates an inability to addresses multiple health issues.11 Topics-based structures can also lead to single-discipline approaches to health issues, where multidisciplinary approaches are more effective and at worst they may produce poorer outcomes and higher costs.13,14

There are, however, structures that have been identified as beneficial; structures planning and delivery systems that generate flexible, integrated and responsive health promotion activities and that encompass ecological approaches to public health are increasingly recognised as having the potential to achieve the most traction for health gain.12

Ecological approaches recognise and work to improve health within a system of disease, health and risk behaviours, environmental factors, and health and social systems.

The second aim of changes made to the HPU and discussed in this paper was to investigate and identify the specific structural issues in the delivery of services that were impeding the effectiveness of the HPU, and to implement an improved system.

Method

 

Analysis of current practice and structure

The first stage of the process was an analysis of the HPU's practice environment, as is recommended.7 For impartiality, the analysis was undertaken by an external consultant. The analysis included a stocktake of current activities in the HPU and an examination of the program planning, delivery and reporting processes. The consultant was asked to look

specifically at organisational and structural issues. The results called two issues to attention.

The first issue related to the outputs-focused framework of delivery. Outputs-focused service delivery focuses on reporting on the immediate product or services of the public health activity,15 for example the number of health promotion programs being delivered. Outputs-focused service delivery frameworks are typical for most PHUs in New Zealand; however, they do not support evidence-based practice as evaluating health improvement is not a prerequisite of reporting.

The second issue that was called to attention was that the current structure did not encompass a multiple determinants and multiple outcomes view of public health. The HPU was continuing to engage in historical work with little or no view to emerging health issues, and there tended to be a single discipline approach to activities; all this was due in part to the topics-based structure of the team. The analysis indicated that changes to the service delivery framework and the HPU structure were necessary.

Implementing outcomes-focused service delivery

To address issues with the outputs-focused service delivery framework, an outcomes-focused model of delivery was proposed not just for the HPU, but for the entire PHU. The outcomes-focused service delivery model had existing recommendations internationally16,17 and within New Zealand.18,19

Within outcomes-focused models of delivery, reporting is done on the final result (or outcome) of products and services delivered by the PHU.15 In the case of PHUs, these final results are wider health targets or outcomes, for example the rate of cancer in a target population. Outcomes-focused reporting ensures that the evaluation of health outcomes occurs and is related to service activities and service review.2 Evaluation becomes a systematic and organisation-driven activity. As activities must be linked to health achievement, during planning there is an increased focus on research concerning the likely success of programs.

Outcomes-focused service delivery requires that organisations engage in only a limited number of activities. These activities are informed by a ‘vital few’ health outcomes or targets. Each vital health outcome has an indicator for evaluation and reporting purposes.18 Reducing performance indicators to a vital few is seen to assist organisations in more efficiently assessing their own effectiveness.20 Described in Figure 1 are some of the sources that were used to identify the vital few outcomes for our PHU. Theses sources can and often do include activities that have been or are successful in the PHU; the setting of the vital few allows for a new or different emphasis to be placed on these activities and how their effectiveness is measured. Further information on outcomes-focused delivery and management is available in more detail.18,19

When setting the outcomes for the HPU, the vital few outcomes of the PHU served to inform how conventional health promotion activities within the unit could be reoriented

into contributing to the achievement of the PHU's outcomes and what new activities could be developed. The outcomes for the HPU were outcomes that the unit intended to achieve within 10 years. This time frame was specified to encourage a sustainable approach to program design and delivery. The HPU's outcomes were developed with outcome indicators and (where appropriate) output indicators. The outcome indicators (also know as impact indicators) were short-term measures (i.e. annual) assessing the health achievement or gain attributable to the HPU's activities. Outcome indicators (e.g. improvement in oral health behaviours, changes in housing policy, body mass index changes) ensure that outcomes can be meaningfully related to program effectiveness; they also give approximations of health gain without needing to rely solely on epidemiological data, which can be problematic when timely results are critical for informing further practice.

The HPU's outcomes were used to inform the development of its activities (discussed in the following section) and served as measures of the success of those activities; this increases the effectiveness of outcomes-focused work.2 Figure 1 provides an overview of how the outcomes for the HPU were developed. The HPU's outcomes were also informed by regional gaps in health promotion services, for example as family violence prevention was not being delivered by any other service in the region it was set as an outcome area. Output indicators were informed by current literature and available data sources as they related to the outcomes.

Implementing an integrated structure

The structure of the HPU prior to reorientation is outlined is Figure 2. The structure was developed around four topics: tobacco, alcohol, nutrition and social environments. Individuals were recruited to work within a specific team and to focus on a single topic. The difficulties with this structure were that it did not encompass an ecological view of health, it prevented the HPU from undertaking work in emerging health issues, and it encouraged a single discipline approach to activities; a new structure was required to address these problems.

The new structure needed to fulfil the following requirements: to foster an multidisciplinary approach to programs; to allow concurrent work on population health gain and health inequalities; to support programs that would address major risk factors for poor health while encouraging flexibility as to what risk factors were addressed and when; and to encourage the development of programs that acknowledged both a lifecourse and social determinants perspective to health and well-being.21,22

Initially, several positions changes were made to bring a greater variety of skills and disciplines into the HPU. Key new positions that were established included a Mâori policy adviser, a health strategist and planner, dedicated project managers, health promotion practitioners with a focus on strategic relationships, a social marketer and a trainer facilitator. Changes were also made to the minimum competencies that were required in existing positions to support evidenced-based planning and practice. Table 1 contains a list of all the original positions and those in the newly configured HPU.

Following the position changes, a new unit and program delivery structure was developed. It was guided by systems dynamics theory23 and recommendations from relevant public health reports.11,12 The aim of the new structure (outlined in Figure 3) was to allow a multidisciplinary and flexible approach to public health issues primarily by moving away from roles that were single topic focused. Specific health topic teams were also removed to ensure there was room for responsive activities when existing health issues changed, new ones emerged, or funding was altered.

The HPU of approximately 40 individuals was divided into three multidisciplinary reporting groups. The first group was primarily focused on health gain for the general population, the second group focused on groups at high risk of poor health, while the third group was a technical advisory group with evaluation, public health medicine, Mâori policy and public health planning expertise. To ensure that all programs would have a multidisciplinary and varied population group approach, unit members representing all three of the reporting groups were assigned to work on each program. As mentioned, the program areas are informed by the HPU outcomes and are reviewed regularly. The structure allows changes to be made to the program areas on the basis of need, evidence of effectiveness of the program, and policy requirements, without leading to funding complications or further restructures.

The new structure was also designed to allow individuals to have some flexibility and variety in their work areas, to discourage a single-topic focus from developing, and to build the knowledge capacity of the team. This structure and the outcomes-focused service delivery framework were implemented concurrently.

Results 

The changes that have been described above occurred over a six-month period in late 2005. During implementation several barriers were encountered. As is commonly the case,24 these barriers existed at multiple levels ranging from individual through to organisational and political.

The individual-level barriers that were encountered related primarily to a lack of information and knowledge about the benefits of evidence and research. This led to unfavourable attitudes to changes that were aiming to ensure evidence and research were a part of normal, everyday activity. To address this issue, we used the existing social networks within the workplace to communicate the benefits of evidence-based practice.7,24 Following recommendations,25 we identified knowledge stewards within the HPU who were more receptive to the use of evidence in practice. These stewards were used to provide leadership, collaboration and collegial support for evidence-based practice.

Individual capability to undertake required research and evaluation activities and to identify emerging health issues within the context of government policy and direction was another barrier to the change. Capacity building was addressed through financial and resource commitment to further training. A basic guide and workshops were provided on

how to review and synthesise research evidence, a seminar series exploring various public health issues including effective partnerships, program planning, Mâori health gain and health inequalities was established, and evaluation workshops were provided. The commitment to capacity building is ongoing.

During the realignment, other organisational bodies did use the situation to attempt to drive structural changes that had little or no supporting evidence regarding their contribution to activity effectiveness. It was found that explicit frameworks explaining the changes, alongside summaries of the research detailing the specific aims and intended results of the realignment, needed to be provided prior to implementation to ensure management and funding bodies understood and supported the changes in the required format.

Political expediency and contractual requirements required that changes be implemented and in place as quickly as possible. This allowed few opportunities to explore different models of practice or to rigorously evaluate systems change. As has been pointed out, organisational change is primarily put in place for more effective service delivery, not for knowledge improvement purposes.14 This issue leads to two concerns: first, a lack of available evidence regarding effective organisational structures (a problem we faced in the public health and health promotion literature); and, second, a lack of support from health care management to see benefit in taking time to both research and properly evaluate realignments. It has been suggested that in documenting and reporting barriers to any health systems change important contextual information is provided and wider support for changes (such as those we implemented) is brought about through knowledge transfer.25 A number of recognised mechanisms were used in an attempt to disseminate information about the changes made to our HPU to government funding bodies, other public health and health promotion services and research bodies interested in health systems.

At a systems level, there also existed some barriers to the realignment. The primary issue was a dearth of synthesised evidence on health promotion interventions. Putting in place structures and systems that encourage evidence-based practice is relatively meaningless if the user cannot access research or find relevant knowledge to inform their decisions. To this end, encouraging systematic reviews of public health interventions, focusing on carrying out evaluations on existing health promotion and public health activities using appropriate methodologies and outcomes-based measures, should be encouraged. The changes implemented in our HPU aim, in part, to address the lack of evaluation in the practice environment.

Conclusions and Implications 

The reconfiguration discussed in this report occurred within a context of a changing public health and health promotion service environment in New Zealand. It is an environment with multiple players; new professions and organisations are increasingly having an important part to play in the delivery of population health gain. Health promotion services face accountability for their contribution to population health gain

and there is pressure for the production of evidence of effectiveness. Such an environment requires a different way of working; it also requires a new way of viewing health promotion delivery. This paper does offer a strong, evidence-based model for other public health and health promotion units when they are considering changes to improve the effectiveness of their activities.

What is signified by such changes is a move away from health promotion as a profession. Increasingly, health promotion is being viewed and used as a tool delivered by multiple professions and organisations. This move has resulted in uncertainty for conventional health promotion providers as they struggle to understand their place. Research, debate, and discussion on the issue, which may help to alleviate some of this uncertainty, are scarce at the practice level. Our experiences indicate that changes implemented to keep pace with the evolving public health environment have important implications for health promotion services. These need to be discussed and considered at the practice level.

One of the most critical issues for health promotion, within an environment of multiple players and multiple disciplines, is how to maintain and marry the experiences, knowledge, ethics and values of practitioners from different professional backgrounds (e.g. marketing, research, policy) with conventional health promotion ethics and values. A multidisciplinary approach has major implications for training, workforce development planning and the development of professional structural status. Certainly, it is important that the skills of conventional health promoters are not lost or overlooked in the process.

Within a multidisciplinary environment many of the new practitioners absorbed into the practice have had successful professional and academic careers in other spheres of the public and private sector. Valuing different perspectives (we certainly didn’ t bring them on board to change them) and acknowledging their worth within specific and set employment structures has its challenges, the implication being that contracts and employment agreements can influence the structure, delivery and outcomes of health promotion and in ways that may not always support increased effectiveness in health promotion.

At a systems level, the multiple partner environment requires a comprehensive health promotion delivery approach, yet current contracting environments often focus on the individual organisation, making it very difficult to develop a sector-wide approach. Health funders need to explore new ways of financing in light of the changing environment. Health promotion services can initiate these explorations.

The issues and challenges discussed here are not unique to the discipline of health promotion. A changing approach to service provision and delivery and organisation accountability in all areas of health and social care mean other disciplines face similar issues; findings from this paper may be generalisable to them.

How we in health respond to these issues will determine the future role of health promotion in public health. What is clear is that those in positions to make changes and respond to the challenges from outside the practice do so in a vacuum of debate, research

and evidence, both locally and internationally. The challenge is for public health and health promotion itself to address these issues and initiate much-needed debate and research.

References 

1.WiseM, SignalL. Health promotion development in Australia and New Zealand. Health Promot Int. 2000; 15(3):237–48.CrossRef, ISI2.NutbeamD, WiseM. Structures and Strategies for Public Health Intervention. In: DetelsR, McEwanJ, BeagleholeR, TanakaH, editors. Oxford Textbook of Public Health. Oxford (UK): Oxford University Press; 2004. p. 1873–88.3.World Health Organization. World Report on Knowledge for Better Health: Strengthening Health Systems. Geneva (CHE): WHO; 2004.4.JonesS, DonovanR. Does theory inform practice in health promotion in Australia? Health Educ Res. 2004; 19: 1–14.CrossRef, Medline, ISI5.BeroL, GrilliR, GrimshawJ, HarveyE, OxmanA, ThomsonM. Getting research findings into practice. Br Med J. 1998; 317: 465–8.6.KingL, HaweP, WiseM. From Research into Practice in Health Promotion: A Review of the Literature on Dissemination. Sydney (AUST): National Centre for Health Promotion; 1995.7.NHS. Getting evidence into practice. Eff Healthc Bull 1999; 5: 1–16.8.ClarksonJ. Getting research into clinical practice-barriers and solutions. Carries Res. 2004; 38: 321–4.CrossRef, Medline, ISI9.RetsasA. Barriers to using research evidence in nursing practice. J Adv Nurs. 2000; 31: 599–606.Synergy, Medline, ISI10.MarchJ, OlsenJ. Elaborating the "New Institutionalism". Oslo (NOR): Centre for European Studies; 2005.11.National Public Health Partnership. Background Paper on Integrated Public Health Practice: Supporting and Strengthening Local Action. Melbourne (AUST): NPHP; 2000.12.National Public Health Partnership. Preventing Chronic Disease: A Strategic Framework. Melbourne (AUST): NPHP; 2001.13.HaynesR, HaywardR, LomasJ. Bridges between health care research evidence and clinical practice. J Am Med Inform Assoc. 1995; 2(6):342–50.

Medline, ISI14.LavisJ, PosadaF, HainesA, OseiE. Use of research to inform public policymaking. Lancet. 2004; 364: 1615–21.CrossRef, Medline15.The European Observatory on Health Systems and Policies [HiT country profiles page on the Internet]. Brussels (BEL): WHO European Centre for Health Policy; 2005 [cited 2006 Feb]. The Observatory's Health Systems Glossary. 2005. Available from: http://www.euro.who.int/observatory/glossary/toppage.16.Centers for Disease Control. Promising Practices in Chronic Disease Prevention and Control: A Public Health Framework for Action. Atlanta (GA): US Department of Health and Human Services; 2003.17.National Health Services. Winning the War on Heart Disease: A Progress Report. London (UK): Department of Health Publications; 2004.18.State Services Commission [work programs – state services research page on the Internet]. Wellington (NZ): The Commission; 2006 [cited 2006 Feb]. Managing for Outcomes. State Services Commission; 2006. Available from: http://io.ssc.govt.nz/pathfinder/information.asp.19.Strategic Evaluation [home page on the Internet]. Auckland (NZ): Parker Duignan Limited; 2004 [cited 2006 Feb]. Duignan P. Principles of Outcome Hierarchies: Contribution Towards a General Conceptual Framework for Outcomes Systems (Outcomes Theory). Available from: http://www.strategicevaluation.info/se/documents/122pdff.html.20.CramptonP, PereraR, CrengleS, DowellA, Howden-ChapmanP, KearnsR, et al. What makes a good performance indicator? Devising primary care performance indicators for New Zealand. N Z Med J. 2004; 117: 820–32.21.PowerC, HertzmanC. Social and biological pathways linking early life and adult disease. Br Med Bull. 1997; 53: 210–21.Medline, ISI22.MarmotM. Multilevel approaches to understanding social determinants. In: BerkmanL, KawachiI, editors. Social Epidemiology. Oxford (UK): Oxford University Press; 2000. p. 349–67.23.HomerJ, HirschG. Systems dynamics modelling for public health: background and opportunities. Am J Public Health. 2006; 96(3):19–25.CrossRef24.GrolR, WensingM. What drives changes? Barriers to and incentives for achieving evidence-based practice. Med J Aust. 2004; 180 Suppl: 57–60.Medline, ISI

Leadership styles in nursing management: preferred and perceived

STINA SELLGREN MSc, RN11 Deputy Nursing Director, Karolinska University Hospital, Stockholm and PhD Student, Medical Management Center (MMC), Karolinska Institute, Stockholm, ,

GÖRAN EKVALL PhD22 Professor Emeritus, Institution of Psychology, University of Lund, Lund, Sweden and and

GÖRAN TOMSON MD, PhD33 Professor, MMC and Division of International Health (IHCAR), Karolinska Institute, Stockholm

1Deputy Nursing Director, Karolinska University Hospital, Stockholm and PhD Student, Medical Management Center (MMC), Karolinska Institute, Stockholm, 2Professor Emeritus, Institution of Psychology, University of Lund, Lund, Sweden and 3Professor, MMC and Division of International Health (IHCAR), Karolinska Institute, Stockholm

Stina SellgrenDepartment of NursingKarolinska University Hospital17176 StockholmSwedenE-mail: stina.sellgren@karolinska.sesellgren s., ekvall g. & tomson g. (2006) Journal of Nursing Management14, 348–355Leadership styles in nursing management: preferred and perceived

Abstract

Aim The aim was to explore nursing leadership regarding what nurse managers and subordinates see as important and to explore subordinates' opinions of their nurse manager's performance in reality.

Background The manager's style can be fundamental for subordinates' acceptance of change and in motivating them to achieve stated visions and goals and high quality of care.

Methods Nurse managers (n = 77) and 10 of each included nurse manager's subordinates received a questionnaire to assess 'preferred' leadership behaviour in three dimensions: change, production and employee/relation orientations. The same questionnaire was used to assess subordinates' opinions of their manager's leadership behaviour.

Results There are statistically significant differences in opinions of preferred leadership between managers and subordinates, especially related to production and relation orientation. The subordinates' perception of real leadership behaviour has lower mean values than their preferred leadership behaviour in all three dimensions.

Conclusions Subordinates prefer managers with more clearly expressed leadership behaviour than managers themselves prefer and demonstrate.

Introduction 

Leadership style

Leadership ability is fundamental in influencing a group to achieve the stated vision and goals (Bass 1985, Yukl 2002). During times of dramatic organizational changes in health systems, nursing management is both a challenging and difficult task. The style of the manager can be important for subordinates' acceptance of change and in motivating them to achieve high quality of care (Bass & Avolio 1985).

Leadership style in the sense of a manager's way of influencing the subordinates arose during the 1940s at the universities of Ohio and Michigan in the USA. The research focused the behaviour and attitudes of managers and supervisors in contrast to earlier research that mainly had been looking for inborn personality and intellectual traits, which paved the way for leadership positions.

Research on leadership styles is mostly based on a theory that there are specific behaviours, which together build leadership style dimensions (Ekvall 1992). The individual leader has a basic general operating style, emanating from personality, experiences and learning of leadership (Ekvall 1992). Leadership style was described in the early studies as consisting of two broad and independent behaviour dimensions, the one production-/task-oriented, the other with focus on employees and relations. Leadership behaviour can be learned, but some researchers believe that personal attributes such as intelligence and temperament sets limits for the learning (Smith & Petersson 1988).

The Michigan and Ohio researchers studied leadership styles in relation to outcome criteria such as productivity, motivation and morale (Michigan, Likert 1967) and turnover (Ohio, Fleishman & Harris 1962). The Michigan researchers identified two 'orientations of supervision', production centred and employee centred, while the Ohio researchers identified two styles which they called, initiating structure and consideration. Both Ohio and Michigan researchers came to the conclusion that effective leadership is dependent on an interaction between employee orientation (consideration) and production orientation (initiating structure); (Fleishman & Harris 1962, Likert 1967).

Today change is the natural state in many private companies as well as in the public sector and leadership is more focused on renewal and change and less on stable efficiency (Ekvall 1992).

New leadership behaviour has developed, more focused on change within the company. This style, called change-oriented leadership behaviour, was not required before the middle of the 1980s (Ekvall 1988, Ekvall & Arvonen 1991). The leadership style is seen as a combination of the three dimensions: change, production and employee/relations (Ekvall & Arvonen 1994, Yukl 2002). Representative behaviours for the three leadership dimensions are:

Production (task)-oriented

  Plans carefully

  Gives clear instructions

  Is very exact about plans being followed

  Defines and explains the work requirements

Employee (relation)-oriented

  Shows regards for the subordinates as individuals

  Is considerate

  Is just in treating subordinates

  Relies on subordinates

  Allows subordinates to decide

Change-oriented

  Offers ideas about new ways of doing things

  Pushes for growth

  Initiates new projects

  Gives thoughts about the future

  Likes to discuss new ideas.

Source: Ekvall and Arvonen (1991).

Cook (2001) identified five attributes that characterize effective nursing leaders: highlighting, respecting, influencing, creativity and supporting. Cook (2001) also identified five different types of effective leaders: discoverer, valuer, enabler, modifier and shaper. Cook's (2001) research points out a component of leadership style, creativity and two leader types, discoverer and shaper; findings that indicate the need for the dimension of change even in nursing leadership.

In other research, the classical leadership styles, i.e. production-/task-oriented and employee-/relation-oriented have been transposed into new dimensions called transactional contra transformational leadership styles (Burns 1978, Bass 1985).

Burns (1978) described transformational leadership as a process that motivates subordinates by appealing to higher ideals and moral values. The transformational leadership style can be seen as a combination between the employee relation-oriented and the change-oriented leadership styles. A transformational leader can be characterized as a 'gardener' who shapes a developing and growing culture through stimulating and empowering the staff in creative thinking and gives freedom for innovation and individual growth. The following four components are highly valued in transformational leadership: inspirational motivation, idealized influence, intellectual stimulation and

individualized consideration (Bass & Avolio 1985, Ward 2002). An American study shows that this leadership style is a little more common among women leaders (Bass et   al. 1996 ). A transactional leader is more focused on structure, role expectations and possibilities to reward the staff. A key criterion is that every extra effort has to be rewarded, as you will not get anything from anybody if you do not give him or her something in exchange (Bass & Avolio 1985).

Nursing management

Nursing as a profession is people-oriented with an emphasis of humanism and this is probably influencing leadership in the area. The nature of health care at a university hospital where life and death, every day probably has its own demands within leadership compared, for example, with industrial industries.

Nursing management is today seen as a profession of its own with special training and skills. To be able to deal with everyday management where behaviour is adapted to the situation (situational leadership), the manager needs to be aware of their own leadership profile, the system and task. Managers who are able to combine these in their leadership have the greatest potential for success (LaMonica 1990).

Nurse managers' tasks, as all managerial positions independent of area, represent different competencies. One is the managing role including competencies such as analytical thinking, knowledge in management, work environment analysis, business knowledge, leadership and visioning (Wallick 2002). These competencies relate to the production dimension. The continuous status of change in health care places demands on nursing managers in competencies such as, social awareness, ability to see the 'big picture and interpersonal relationship building' (Wallick 2002). These last competencies relate to the dimensions of change and relation. Based on Bass's (1985) theory, Prenkert and Ehnfors (1997) studied whether nurse managers who expressed both transactional and transformational behaviour are more organizationally effective. They did not find any evidence for this hypothesis but noticed a higher correlation between transformational leadership and nursing quality and a lower correlation between transactional leadership and nursing quality.

With exception of the above studies there is a lack of research on leadership style and preferred leadership in nursing management providing the rationale for this study.

The aim of this study was to explore nursing leadership regarding what nurse managers and subordinates see as important and to explore subordinates' opinions of their nurse manager's performance.

Research questions

The research questions were:

•  What kind of leadership behaviour do managers and subordinates prefer?

•  How is the manager's real leadership behaviour compared with the preferred?•  Is it possible to identify different leadership profiles (combinations of change,

production and employee orientations) in nursing management.

Method

The study was conducted at the Karolinska Hospital in Stockholm, Sweden in November 2003.

Study population

The criteria for including the nurse manager in the study were: responsibility for budget and human resources and 10 subordinates or more, having been in charge at least 6 months and not tendered resignation. It takes time for a new manager to get to know the workplace and to build a good relation with the subordinates. In this study we decided that 6-months would be a reasonable time for building this relationship. In Sweden, you have to work 3 months after tendering your resignation. During this time it may be difficult to be enthusiastic for the work and to perform effectively. At the time of the study there were 92 nurse managers at the hospital of which 77 corresponded to the inclusion criteria. These managers represented all kinds of units.

The number of subordinates of the 77 nurse managers ranged between 10 and 80 in total. Seven hundred and seventy, 10 per nurse manager, were asked to participate in the study. If the nurse managers had 10 subordinates all were asked to participate. When the staff consisted of more than 10 subordinates every subordinate on the staff list got a number and an assistant independent from the hospital and the study, randomly drew numbers from a box.

Included subordinates were registered nurses, assistant nurses and various administrative staff. Excluded were subordinates with time-based employment because they mostly work nightshifts or weekends when the manager is not in charge.

Questionnaires

A questionnaire, based on the change, production, employee (CPE) model, was used to assess 'preferred' leadership behaviour. This questionnaire, developed and validated by Ekvall and Arvonen (1991, 1994), consists of 30-items covering the three dimensions, change/ development, production/task/structure and employee/relations, with 10-items for each dimension. These three fundamental dimensions can be combined into leadership profiles.

The same questionnaire was used with instructions to respondents to assess perceived leadership behaviour in reality. The questionnaire is reliability tested with Cronbach's-α with coefficients between 0.86 and 0.94 (Arvonen & Ekvall 1999) and its validity is demonstrated in several large studies (Arvonen 2002, Ekvall 2002).

The answers are rated from 1 to 6 in a Likert scale (from 'do not agree at all' to 'agree totally').

Examples of items are:

•  initiate new projects (change dimension);•  trusts the subordinates (employee/relation dimension);•  creates order and clarity (production/task/structure dimension).

Bass (1995) developed a tool for measuring leadership styles, multifactor leadership questionnaire (MLQ). This tool relates to transformational and transactional leadership style. The CPE tool was chosen because it measures leadership from three fundamental dimensions (Yukl 2002) that could be combined into leadership profiles; is reliability tested and validated in the Swedish language and has been widely used both in Sweden and in other countries (Ekvall & Arvonen 1994, Arvonen & Ekvall 1999).

The questionnaires were distributed to all participants at their home addresses and one reminder was distributed after 2 weeks to the participants who did not answer.

Statistical analyses

Significance testing was applied with t-tests of mean differences between perceived and preferred leadership style and between managers' and subordinates' ratings on each of the three dimensions. The analysis was performed using spss.

The perceived leadership style was also analysed (mean scores of the subordinates ratings on each of the three dimensions) to identify specific leadership profiles. In this part only leaders who had five or more subordinates that responded to the questionnaire were included (n = 52).

The scores on each dimension of every single manager were compared with the mean value and standard deviation for the whole population of 52 nurse managers as carried out in earlier studies with the CPE instrument. These analyses were partly performed using spss and partly manually.

Ethics

Confidentiality and anonymity was guaranteed. Participation was voluntary and informed consent was obtained. The anonymity and the confidentiality were particularly important as the first author was working at the hospital as nursing director at the time of the study. The study was approved by the Ethical committee of the Karolinska Institute (Dnr 03-348).

Results 

Respondents

The total number of respondents in the whole study was 492 of 847 (58%). Sixty-six of the 77 (86%) nurse managers answered the questionnaire and 426 subordinates (55%) responded. The total number of non respondents (subordinates and nurse managers) was 355. Most (217) did not give any explanation as to why they did not respond, 138 gave some explanation such as being on the sick leave (six), were pregnant or on maternity leave (10), on leave for other reasons (15) and nine had just resigned. Six gave the explanation that the questionnaires were just too extensive to go through.

Five of the subordinates had not answered all of the questions and their answers could therefore not be used in the study. Units where five or more subordinates responded were 52. Basic facts of the respondents are presented in Table   1 .

All of the 66 responding nurse managers were nurses, of the subordinates 268 (62.9%) were nurses/midwifes, 126 (29.5%) assistant nurses or child assistant nurses, 13 (3%) were secretaries, four (<1%) were technicians or porters, six (1.4%) had another profession and nine were not specified. In total 5% of the subordinates were not working directly as care providers.

From 25 of the 77 units (32%) there were <5 respondents among the subordinates. From three units (4%) there were <3 respondents. From eight (47%) of the 17 units with >50 employees there were <5 answers from the staff.

There was no difference in staff turnover between units where the nurse manager did not respond and units where the nurse manager did respond. The average staff turnover among the studied units was 10% for 2003. The units where the nurse manager did not respond had an average staff turnover of 5.45% (0–18%). For the units with <5 respondents among the staff the average was 6.88 (0–24%) and for the units with five or more respondents it was 6.55 (0–19%).

Preferred leadership behaviour

The comparison between managers' and subordinates' ratings of preferred leadership behaviour is presented in Table   2 . The preferences of leadership behaviour differed between managers and subordinates. The subordinates tended to value every dimension higher than the managers. However, the differences in statistically significant means are fairly modest. The most statistically significant differences between managers and subordinates (P < 0.001) are in the dimensions production orientation and employee orientation. Whereas for the dimension change orientation was P < 0.05.

Perceived leadership behaviour compared with preferred

The answers of the subordinates on the questionnaires of preferred leadership behaviour were compared with the answers of perceived leadership behaviour. The total number of respondents that could be compared was 420. The mean values perceived leadership of

the managers are, as rated by subordinates, far below the level of their preferred leadership. The difference between preferred and perceived leadership behaviour can be found in all three dimensions and are statistically significant (P < 0.001; Table   3 ).

Perceived leadership profiles

The mean values for the whole population (n = 52) in the three dimensions are presented in Table   4 . In earlier studies with the CPE instrument it had been possible to identify 10 different leadership profiles, although five of them were only found in between 2.3% and 7.3% of the population (Ekvall & Arvonen 1994, Ekvall 2002). The most common styles were, Middle of the road, Super leader and Management by Objectives (MBO) leader while the least common were Dominating entrepreneur and Idea squirt (Table   5 ). In our study we could identify seven of the above most common leadership profiles. The Super leaders in our study were 12 (23.1%). Nine managers (17.3%) got low scores in all three dimensions and are identified as invisible leaders. These managers are vague in their leadership profiles. The third most common identified profile, 26 managers (50%), were the Middle of the road leaders with scores inside one half standard deviation from mean values in all three dimensions. In addition to these three common profiles we identified five managers with other profiles (Table   6 ).

Discussion 

Our result with the most evident difference between subordinates and nurse managers in preferred leadership about production orientation, could indicate that subordinates want a leader with a clearer leadership style than the manager themselves think is accurate. This supports the findings of Morrison et al . (1997 ) in their study of nursing staff, using the MLQ scale (Bass 1995). They found that the staff preferred their leaders to take a more active leadership role.

In this world of change it can be safe to have one person who points out the direction and lead the way. But it could also be an expression of lack of demands and a desire to have more structure. There is a risk of loose structure in an environment of constant change.

Both nurse managers and subordinates express high preferences in the dimensions employee and change. In a study among nursing managers of their perceptions of the highest ranking among their responsibilities, communication was shown to be the highest ranked issue and thereafter followed in order, facilitation of goal achievement, effective interpersonal relationships, in fourth place came decision-making and in 10th change agent (Purnell 1999).

The differences in all three dimensions might to some degree arise from the fact that the managers understand the reality of nursing management. They are facing the difficulties and complexities of the first line leader role daily.

The mean value of perceived leadership behaviour was lower than the preferred in all three dimensions. There is a lack in mean values between the leadership behaviour that

the subordinates prefer and the managers can perform. Although it seems to be possible to reach the preferred levels as there are 12 nurse managers who are rated near the preferred mean values in all three dimensions.

The two highest valued dimensions by the subordinates in our study (employee and change), both in preferred and in perceived leadership, represent the basis of transformational leadership style. In some earlier leadership theories a leader that was high performing in both task and relation orientation was supposed to be the most effective in all kind of situations (Blake & Mouton 1982). The advocates for transformational leadership prefer high performance in relation and change to 'garden' the followers (Bass & Avolio 1985, Prenkert & Ehnfors 1997). Boumans and Landeweerd (1993) found that the Netherlands nurses were most satisfied if the nurse manager had a combination of high-social/high-instrumental (task and production) leadership. In that research only two dimensions of leadership were studied and the dimension change orientation was not included.

It was not possible in our study to identify all of the 10 leadership profiles that have been identified in the other studies carried out with the CPE instrument (Ekvall & Arvonen 1994, Ekvall 2002). These studies comprised large samples of managers from different organizations (industry, trade, transportation, service, care, education, media and consultancy). Both male and female managers were included. In our study only five managers had values that were unequal in the three dimensions according to standard deviation for the mean value. All the others had equal values in all three dimensions. This could depend on the fact that the nurse managers are mostly fostered in the nursing profession and this pattern becomes a part of their behaviour. Their way to promote leadership is also as a role model, which influences others to behave in a similar way (Eagly & Johannesen-Schmidt 2003). Fanslow (1984) described that leadership style was related to a personal value system that has been formulated by culture, society and life experience. Cook (2001) identified five different types of effective nursing leaders. In our study we have not investigated how effective the different identified styles are.

Nursing is also a woman-dominated profession and it is therefore natural that nurse managers are mostly women because they are recruited from the profession. In our study there were only three men among the respondent nurse managers. In earlier research it is shown that leadership style could be a gender issue and that women are more inclined to use the transformational leadership style (Bass et   al. 1996 , Eagly & Johannesen-Schmidt 2003). On the contrary, in this research none of the managers in our study were identified as a transformational leader.

In our study there were nine managers that expressed a more vague leadership style.

Hersey and Blanchard (1982) postulated that as the level of maturity among followers increased, leadership required less task orientation and less socio-emotional support (Goldenberg 1990). That is, the more experienced and motivated, the more independent the subordinates will be of leader's direction and support. Bass (1985) calls this style 'laissez-faire' and states that such leadership style is not adequate in any situation.

In a recently published study, nursing managers were asked what competencies they thought where needed for nursing management in 2020 (Scoble & Russel 2003). The key competence was identified as leadership behaviour and specific items in the analysis were transformational leadership, visioning and perseverance.

The educational training in nursing leadership is about 5 weeks in Swedish nursing programmes (Sverigesriksdag 1993). This 5-week education includes leadership theories, laws and other regulations, quality work, supervision, economy and organization (Sverigesriksdag 1993).

At several universities there are health management courses up to 60 weeks in duration. In these courses the student learns about the political and organizational system, about economics, quality improvement and scientific methodology. Leadership behaviours suitable for health care organization are poorly explored during education and our study shows that there is a potential for improvement.

Methodological considerations

Questionnaires have limitations (Ekvall 1992, Arvonen 2002). An advantage of the one used in the present study is that both construct and predictive validity of the instrument are demonstrated (Arvonen 2002). Behaviour description questionnaires devised to study leadership have been questioned by several researchers since this tradition began. The main claim has been that they measure the attitudes of subordinates towards the leader and not real behaviour. The research group at Ohio met the critique by presenting studies which showed significant correlations between subordinates who described the same leader (Ekvall 1992). The CPE questionnaire has been tested in relation to influence of attitude. The change and production dimension showed no correlations with attitude. The employee dimension had a medium size (0.40) coefficient, which is logical, because being accepted and liked is a psychological drive in relation-oriented behaviour (Ekvall & Arvonen 1994). The dropout rate was normal for this type of study and the dropout analysis showed no selection bias.

Conclusions 

The results of this study show that subordinates wish nurse managers to be more distinct about demands in relation to work. It also shows that there are managers with a vague leadership profile. These characteristics of leadership behaviour should be considered in the selection process of nurse managers as well as in the continually professional development programme. Forthcoming work studies the role of leadership in relation to working climate, staff satisfaction and turn over.

References 

•ArvonenJ. (2002) Change, Production and Employees – An Integrated Model of Leadership. Department of Psychology, Stockholm University,

Stockholm, Sweden•ArvonenJ.&EkvallG. (1999) Effective leadership style: both universal and contingent? Creativity and Innovation Management 8 (4), 242–250.Synergy•BassB.M. (1985) Leadership and Performance Beyond Expectations. Free Press, New York, USA•BassB.M. (1995) The Revised MLQ 5X. Mind Garden, Palo Alto, CA, USA•BassB.M.&AvolioB.J. (1985) Improving Organizational Effectiveness through Transformational Leadership. Sage, Thousand Oaks, California, USA•BassB.M., AvolioB.J.&AtwaterL. (1996) The transformational and transactional leadership of men and women. International Review of Applied Psychology 45, 5–34.CSA•BlakeR.R.&MoutonJ.S. (1982) Comparative analysis of situationalism and 9,9 management by principle. Organizational Dynamics 10, 20–43.CrossRef, ISI•BoumansN.P.G.&LandeweerdJ.A. (1993) Leadership in the nursing unit: relationship with nurses well-being. Journal of Advanced Nursing 18 (5), 767–775.CrossRef, Medline, ISI, CSA•BurnsJ.M. (1978) Leadership. Harper & Row, New York, USA•CookM.J. (2001) The attributes of effective clinical leaders. Nursing Standard 35 (1), 33–36; Nursing Management 8, 77–81.•EaglyA.H.&Johannesen-SchmidtM.C. (2003) Transformational, transactional and laissez-faire leadership styles: a meta analysis comparing women and men. Psychological Bulletin 129 (4), 569–591.CrossRef, Medline, ISI, CSA•EkvallG. (1988) Förnyelse och friktion. Natur och Kultur, Stockholm, Sweden•EkvallG. (1992) Ledarskap teorioch forskining. In Ledarskap och arbetsmiljö (J.Schaller&J.A.Johansson eds), pp. 16–26. Akademiförlaget, Stockholm, Sweden•EkvallG. (2002) Ledarstilen är avgörande för arbetsklimat och effektivitet. Psykologi Tidningen 8, 4–8.•EkvallG.&ArvonenJ. (1991) Change centered leadership. An extension of the two dimensional model. Scandinavian Journal of Management 7, 17–26.CrossRef•EkvallG.&ArvonenJ. (1994) Leadership profiles, situation and effectiveness. Creativity and Innovation Management 3 (3), 139–161.Synergy•FanslowN. (1984) Personal values. An influence on leadership. Point of View 2 (2), 8.•FleishmanE.A.&HarrisE.F. (1962) Patterns of leadership behaviour related to employee grievance and turnover. Personnel Psychology 15, 43–56.Synergy, ISI

•GoldenbergD. (1990) Nursing education leadership. Effect of situational and constraint variables on leadership style. Journal of Advanced Nursing 15, 1326–1334.Synergy, Medline, ISI, CSA•HerseyP.&BlanchardK. (1982) Management of Organization Behaviour. Utilizing Human Resources, 4th edn. Prentice-Hall, New Jersey, USA•LaMonicaE. (1990) Management in Healthcare: a Theoretical and Experimental Approach. Springer, New York, USA•LikertR. (1967) The Human Organization. McGraw-Hill, New York, USA•MorrisonR.S., JonesJ.&FullerB. (1997) The relation between leadership style and empowerment on job satisfaction of nurses. Journal of Nursing Adminstration 27(5), 27–34.CrossRef, Medline, ISI•PrenkertF.&EhnforsM. (1997) A measure of organizational effectiveness in nursing management in relation to transactional and transformational leadership: a study in a county hospital. Journal of Nursing Management 5, 279–287.Synergy, Medline, CSA•PurnellL.D.T. (1999) Health care manager's and administrator's roles, functions and responsibilities. Nursing Administration Quarterly 23 (3), 26–37.Medline•ScobleK.B.&RusselG. (2003) Vision 2020: Part 1. Profile of the future nurse leader. Journal of Nursing Administration 33 (6), 324–330.CrossRef, Medline, ISI•Sverigesriksdag (1993) SFS 1993:100 Högskole förordingen Rixlex, Stockholm, Sweden, p. 100.•SmithP.B.&PeterssonM.F. (1988) Leadership Organisation and Culture. Sage, London, UK•WallickW.G. (2002) Healthcare managers roles, competencies and outputs in organizational performance improvement. Journal of Healthcare Management 47 (6), 390–401.Medline, ISI