All organizations, be it in healthcare or in any other sector(s) of society, strive for effective, potentially transformational leadership.
In any health-care system, infants receiving care in neonatal intensive care units are often the most vulnerable patients, with very high severity levels of illness.
The first step in analyzing the impact of leadership in any organization is to observe the interactions of the leaders and the workforce in that specific microenvironment.
The skill sets of a leader have a significant bearing on his/her ability to deliver safe, effective, integrated, and well-coordinated care.
We describe various leadership styles, which can be authoritative, transformational (collaborative), transactional, contingent, and participative. In our own review and discussions, we noted that a “SEAT” paradigm may be something to consider—there may be four main options available to a leader: to support, entrust, administer, and train.
We have also summarized workplace cultures, challenges, communication needs, and practice models for large organizations, including those focused on healthcare.
In any healthcare system, infants receiving care in neonatal intensive care units (NICUs) are often the most vulnerable patients, with very high severity levels of illness. Consequently, the staff members working in these sections of hospitals work under high levels of stress. To provide the best possible clinical care and to retain the most skilled professionals, there is a need for careful, continuous examination of not only the policies and procedures but also the work environment in these units. The leadership and organizational culture are important determinants to ascertain that medical, nursing, and other professionals can work together to achieve these goals. Interestingly, the principles of leadership are similar across any sector, be it in healthcare or in industries with large-sized workforces. In this chapter, we discuss the traits needed for effective leadership, the leadership styles seen in these high-risk operations, and the importance of maintaining an organizational culture that would be most conducive for retaining the best staff members and improving the quality of care. In addition to our own experience, we have drawn from an extensive literature search in the databases PubMed, Embase, and Scopus. To avoid bias in the identification of studies, keywords were short-listed a priori both from anecdotal experience and PubMed’s Medical Subject Heading thesaurus.
The first step in analyzing the impact of leadership on the work culture in any organization is to observe the interactions of both in that specific microenvironment. In healthcare, including in NICUs, these steps will enable the evaluation of patient safety and quality, staff well-being, and health outcomes. A leader, as defined by Peter Drucker, is “someone who has followers.” Leadership may need larger goals; it may entail the virtue of navigating through turbulent times. Interestingly, it may require a modified catechistic approach with prudence to see ahead, justice in dealing with others, fortitude with brave endurance, temperance to bring down the expectations for immediate gains, faith in the abilities of the team, humility, authenticity, maintaining the hope of eventual success, and charity to forgive errors when charting new territories.
Warren Bennis defined leadership as a “function of knowing yourself, having a vision that is well articulated, building trust in colleagues, and taking effective action to realize your own leadership potential.” A leader who demonstrates these abilities needs to take a preeminent role to shape the culture, defined as “the values, behaviors, goals, attitudes, practices and beliefs shared across an entire organization.” At a panoramic level, the executive leadership with expertise and specialized training can promote the organizational culture by clearly defining and authentically living out the mission, vision, and values. However, the microenvironment in the individual units may also affect the outcomes positively or negatively, be it on patient outcomes, perceptions of staff, or in their emotional well-being.
As in any specialized, critically important units in an organization, a NICU is a complex microenvironment that provides care for high-risk patients. The staff members interface with a host of specialists from various disciplines ranging from obstetrics, maternal-fetal medicine, pediatric subspecialists, members of palliative care teams, and others. Many other streams of staff members with different levels of experience, including nurses, pediatric resident trainees, nurse practitioners, physician-assistants, and neonatologists, are also involved. In this paradigm, the basic tenet of a physician leader with the overall responsibility in the unit is to involve/engage the team to render targeted, safe, effective, efficient, and timely care to optimize outcomes. The most important questions about the type of leadership and skill sets remain.
Just as in any complex organizational microenvironment, the skill sets of a leader in a NICU have a significant bearing on his/her ability to deliver safe, effective, integrated, and well-coordinated care to the patients and their families. There are also new, evolving needs, and a leader today should be able to create a social culture of trust and consensus about the needs of tiny babies with involvement of other health systems and social media.
Physician leaders need different types of leadership styles depending on the context, and they need flexibility to adapt in a timely fashion. In the literature, six different leadership styles have been described. We have expanded on three styles that seemed most relevant to healthcare. The other three did not seem to be as pertinent/applicable in the NICU environment, so we mention those only briefly. As we developed this section, we reached out to leaders in various sectors of society; the needs to chart out the plans, inspire, evaluate, and intervene are similar.
Authoritative leadership involves the leader laying down expectations, clear guidelines, and defined outcomes. This model can be successful if the leader is a renowned, respected expert and facilitates efficiency in tasks that require quick turnarounds with few mistakes in implementation. However, it does not promote the growth of associates, and there may be less creativity and synergy. Leaders who base their leadership style solely on personal attributes such as appeal, intellect, and knowledge may lack empathy, emotional intelligence, and situational and social awareness (Great man theory). In some situations, there may be higher dissatisfaction in the group and higher turnover rates of subordinates.
Transformational (Collaborative) Leadership
Transformational (collaborative) leadership is where a leader motivates team members through vision, shares control, serves as a change agent, exhibits concern and development of others, highly engages the team, delegates others to lead a process change, embraces resistance and proposes ways to deal with it, shows emotional intelligence, leads by example, and supports a nurturing and developing culture in the unit ( Fig. 101.1 ). Transformational leadership, particularly when it is character-based, may also include elements of both authentic leadership and servant leadership. The behavior of authentic leaders is congruent with their beliefs—beliefs that prize high moral and ethical standards. Additionally, they are willing to let their colleagues view their flaws. Servant leadership encompasses authentic leadership with the added components of self-sacrifice and service to others. The concept of servant leadership was popularized by Robert Greenleaf in the 1970s. Since that time numerous books and articles have been written about the topic, and research has been conducted that has shown a positive correlation between servant leadership, employer satisfaction, and customer/patient loyalty. A bedside nurse leading patient safety and quality initiatives, a neonatal nurse practitioner responsible for central line insertion and maintenance, a trainee developing clinical practice guidelines to reduce the variation in clinical practice, and a neonatologist leading the team are all examples of a transformational leader.
Transactional leadership seeks to meet operational and financial targets and may leverage reward or punitive measures to achieve the desired goal. The resources for the reward may include verbal praise and recognition (intangible) and could include annual monetary incentives for meeting quality metrics. Negative feedback could include disciplinary actions that progressively increase with the frequency or implications of a specific act of commission/omission. The role of transactional leadership in service improvement is limited.
Contingent leadership varies depending on the context, needs, and attributes of the team members, which has been described as being based on the Trait Theory. Many experts have described this model as based on delegative “laissez-faire” interaction. Effective leaders take into consideration not only the situation but important qualities of each team member to make informed decisions regarding the role he/she needs to play. They may delegate, support, coach, direct, or use other strategies based on the motivation and competency of the team member. It works well in a group that is limited in size and is composed of friendly experts who have worked together for some time. If it works, it can promote innovation and creativity. However, disagreements among senior experts may also cause loss of harmony and morale. This is a difficult model to use in the present day because workplaces are progressively becoming more complex, with increasing emphasis on financial and temporal efficiency.
Participative leadership is rooted in democratic models and can work well in a relatively small team of well-engaged, equally qualified experts who may have to deal with unexpected situations (situational theory). It builds an engaging environment in the medium- and long-term, but the implementation of tasks can be time-consuming with the need for consensus development. This model may not work well with relatively less well-trained employees because there may be an appearance of a lack of consistency, and this may make it harder for them to project the most likely path that will be taken.
We have observed our own teams, and after extensive review and discussions, we found that we use an administrative strategy that could be named the “SEAT” paradigm, with four main options available to a leader: to support, entrust, administer, or train ( Fig. 101.2 ). This strategy combines elements from different models because we have found qualified leaders in our team in some but not in all situations. In each of these possibilities, the leader is ultimately responsible for the outcome and needs to continuously observe the team for single-time-point events and for longitudinal patterns in performance.