The leader within: self-leadership in diabetes nursing

The concept of leadership in nursing has often been attributed to those individuals who have a high political profile but who seem remote from the real world. However, in the last few years several styles of leadership have been identified. The theory of transformational leadership (Bass and Avolio, 1994, cited in Wedderburn Tate, 1999; Kouzes and Posners, 1995) suggests, amongst other things, that contributions from each individual are welcomed and valued. This is linked to the concept of shared governance, which aims to actively involve the whole workforce and encourages and enables collaborative ownership of power and decision-making. This involves a paradigm shift, which may not only be difficult for nurse leaders but also for nurses on the front line who often do not recognise their own contributions or that they can influence decision making. The concept of self-leadership encourages individuals to recognise that their experience, expressed through their beliefs and values, can shape the inevitable evolution of patient care.

Leadership in nursing
Leadership skills for nurses have never been more important than they are in the current NHS. This government’s vision appears to be a nurse-led NHS including much wider roles (and more power) for nurses. As Alan Milburn stated in the NHS Plan:

‘For the first time nurses and other staff, not just in some places but everywhere, will have greater opportunities to extend their roles.’ (Milburn, 1997)

The development of NHS Direct, triage nurses, minor injuries units and NHS drop-in centres are all nurse-led initiatives and are examples of this vision. Nurses are becoming the gateway to the NHS.

The nursing strategy document, Making a difference, highlighted the need for nurses to develop leadership skills:

‘We need visionary leadership to help build modern dependable services and to inspire and sustain the commitment of nurses, midwives and health visitors during a period of significant change.’ (Department of Health, 1999)

Despite these visions there has been complacency in preparing nurses for the leadership skills necessary to deliver these services. The Royal College of Nursing Ward leadership project and the King’s Fund initiative, Leading empowered organisations, have been steps in the right direction. However, leadership has not been high on nurses’ agendas as a topic of study, nor have nurses taken leadership skills seriously enough (Wedderburn Tate, 1999).

When Harriet Harman was Minister for Health (2000), she suggested that a successful nurse leader:

‘…is authentic and well informed with real life concerns and issues related to their day-to-day practice as a clinical nurse – someone who can tell me what it is like to care for patients and can also tell me what it is they want me to do for them by relating their issues to my policy agenda.’

Perhaps this is what Wedderburn Tate (1999) refers to as ‘political savvy’.

The current NHS and the implementation of the NSF for Diabetes will need transformational leaders; nurses will often fulfil this role. The fundamentals of transformational leadership include:

• Inspiring a shared vision: creating a vision for the future.
• Modelling the way: acting with integrity as a role model.
• Challenging the process: being experimental, challenging the status quo, stepping out of comfort zones.
• Encouraging the heart: celebrating success visibly, valuing and rewarding others and providing feedback.
• Enabling others to act: enlisting support and encouraging others to lead. 
  (Kouzes and Posner, 1995)

In order that nurses fulfil the fundamental principles of transformational leadership we have to consider our leadership style and current skills, ensuring that we view every opportunity as a learning experience. If we succeed in what we do we should increasingly be able to handle uncertainty and rapid change. Self-development must create a capacity for reflection, which is a powerful source of insight and inspiration. Learning to reflect requires a willingness to be objective and honest with ourselves. Reflection on how we as individuals lead may result in a need to change what we do. Reflecting and recognising our own values and beliefs can help this process, not forgetting that every change, however minor, started as somebody’s vision.

Leadership initiative
A number of models support existing leadership initiatives in nursing and provide an opportunity for collaboration between healthcare professionals and industry. The original vision for the leadership initiative was developed by Joe Marsh (National Sales Manager, Lilly Diabetes Care) whose role is to develop models of collaborative working between healthcare professionals and the pharmaceutical industry. This initiative provided an excellent opportunity for such collaboration.

Eleven diabetes nurses from the UK were approached to pilot a range of leadership models. They were asked to assess the relevance and effectiveness of the models in terms of their own clinical areas. Over three 2-day workshops, this initial group were exposed to a range of tools including the use of metaphors, systems thinking tools, time lining, developing mission statements, visioning exercises, a feedback model and logical levels.

Aims of the leadership initiative
The initial aim was for the pilot group to select any appropriate models, incorporate them into their own self-development and clinical practice (with support) and ultimately to cascade them out to colleagues and friends. 

To increase the numbers of nurses exposed to this learning, a programme of 1 day self-leadership workshops was developed. The group selected the elements from the original pilot that had the greatest impact on their own development. The eleven nurses facilitated six subsequent workshops held in Birmingham, Glasgow, London, York, Manchester and Bristol. These workshops allowed approximately 200 nurses to practice, take away and hopefully share with others, the models of self-leadership that the original pilot group had found most useful. This formed the content of the day.

The workshops were oversubscribed so an additional satellite workshop for 40 nurses was run at the 2003 annual Diabetes UK conference in Glasgow.

Self-leadership workshops
The content of the 1-day course was Dilts’ logical levels (Figure 1), the behavioural feedback model, value elicitation and Disney’s goal setting strategy. This article gives a brief overview of the background to these models; the process used in the workshops will be detailed in the second article.

Numerous metaphors and quotes related to leadership were used to support learning and to encourage us on our journey, for example: 

‘I am my message.’ (Mahatma Gandhi)

‘More important than how fast you are going is where you are headed.’ (Stephen Covey)

Feedback is important to us all, and it is important that it is given constructively. The behavioural feedback model suggests using the following recommendations about feedback:

• It should only be given about observed behaviours, not about the individual as a person.
• Always seek permission before giving feedback, and base it in reality (i.e ‘…when I saw you/heard you…’).
• Then describe the impact of your thoughts and feelings (i.e. ‘…I thought/felt…’).
• Finally, give a recommendation (i.e. ‘I recommend that you continue…’). If you cannot think of a recommendation, do not give the feedback.

There are other situations in which giving feedback should be avoided, for instance if you feel emotional. In this case, calm down, and then give the feedback.

What are values and why are they important?
Values are the social principles, goals or standards held by an individual, class or society (Collins Concise English Dictionary, 2001). Values shape our decisions – the partners, friends and jobs we choose and the relative weight we place on these relationships and tasks. Conflict in organisations can result from a clash of values.

People are motivated to achieve that which they value. However, we are sometimes unaware of the values that influence our judgments. By becoming aware, we are able to make more effective conscious decisions about what route to take, e.g. managing careers.

Dissatisfaction in any situation may be because important values are not met. People’s values change with time, experience and in response to external factors, (e.g. the birth of a child). Discovering and ranking values is therefore an important exercise and may provide invaluable insight into an individual’s behaviours.

The Disney goal setting strategy: ‘imagineering’ the future or knowing better where you are going
‘Imagineering’ is a term coined by Walt Disney to describe the process he used to ‘create the future’ by forming dreams and turning them into realities. The imagineering process essentially involves chunking, or sequencing, the dream into all of the steps that are necessary to manifest it.

There are three of these steps or phases. The first step is the dream or imagination, which focuses on the big picture with the attitude that anything is possible. This is the ‘what’ of the plan. Engineering the dream to become reality makes up steps two and three. Step two, the ‘how’ of the implementation of the plan, comprises reality. Constructive criticism makes up the final step. This focuses on the ‘why’ of the plan and evaluation of whether it holds up under the ‘what if’ conditions (Dilts, 1996).

A personal journey
The workshops were generally well evaluated. The following is a piece of reflective writing by one of the pilot nurses. It portrays how powerful the workshops were for this particular individual; feedback from participants indicated similar experiences.

‘The leadership initiative has been challenging and on occasion threatening to many participants. The opportunity to participate in the leadership initiative was appealing to me from the beginning, without appreciating the illuminating journey about to be undertaken.

Understanding the models and particularly the importance of individual values and beliefs has probably been the most profound learning experience on the journey. Our values, both personal and professional, make us in many ways who we are. The values exercise forms a solid base to the learning undertaken and has proved to be a valuable tool that is easily replicated in both personal and professional situations. In particular, awareness of our own values and the values of those close to us enables us to identify and understand potential areas of conflict, but more importantly, provide a clear guide to identify the focus for individual motivation. 

Exploration and understanding of Dilts’ logical levels provided considerable insight into the appropriate focus of feedback at the behavioural level. Feedback appears to be something we all crave and require, but delivering feedback in a constructive manner is a major challenge. A feedback model explored by the group clearly appeared to provide a framework that facilitated feedback in a non- threatening and constructive manner. This model became an integral component of our interactions throughout the rest of our journey.

Having established an understanding of values and beliefs, leadership styles were explored through a process of modelling. Several different modelling exercises were undertaken, each providing different but informative insights. This process enabled the group to identify the behaviours and characteristics we admired and respected in people we considered to be leaders. It may have been earlier in the journey but by this stage what was becoming very clear to us all was the realisation that everyone has the potential to lead. We will not all lead in the same way and many leaders may not be aware of the leadership they demonstrate but the potential is there in us all. The challenge then facing the group was how could we share the insight we had gained? This is the point when the leadership journey became clearly about self-leadership! 

The ability to clearly identify our own values can support us in identifying where we want to go. This is where Walt Disney provided us with guidance. ‘Imagineering the future’ is an exercise that enables us to ‘dream the dream’, but at the same time identify what needs to be done to enable the dream to become reality. Although at times the questions asked during this exercise may provide answers that are hard to accept, the clarity provided demonstrates clearly where we are going.

To enable other diabetes nurses to benefit from the learning we had gained, exposure to key exercises in a non-threatening environment was facilitated.’

Conclusion
Many of us identify with the themes explored in this personal journey and have been both challenged and enabled to learn and implement new tools. The content of the workshops was important and effective planning and preparation for the day was essential to its success. Reflection was necessary after each study day to assess what had gone well and what needed to be changed. This allowed participants’ recommendations to be included where appropriate and demonstrates the dynamic nature of the workshops, which will continue to evolve to meet participants’ needs. This model of reflective practice also enabled those nurses facilitating each workshop to develop their own skills in organising and delivering effective study days. The process of these workshops and the evaluation from participants will be discussed in the second article.

Acknowledgements
We would like to acknowledge the other members of the leadership group: Mags Bannister; Sue Cradock; Heather Daly; Louise Dodd; Debbie Hicks; Di Garwood-Hughes; Lesley Mills; Jane Pennington. Robert Dilts supported the development of the vision and introduced Tim Hallborn (an American neurolinguistic programming (NLP) trainer) who delivered part of the pilot training.