The art of leader maintenance

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Pract. Dev. Health Care 5(2) 105–114, 2006Copyright © 2006 John Wiley & Sons, Ltd DOI: 10.1002/pdh

The art of leader maintenance

Contemporary public health facilities seem unable to meet the expectations of either the communities they serve or the governments that operate them. Those expectations include a high standard of care with continually improving practice and outcomes; that is, what we might re-gard as practice development. The inabil-ity to satisfy these expectations is cur-rently attributed, at least in part and somewhat simplistically, to a perceived failure of leadership. The immediate re-sponse to remedy this perceived failure has been a proliferation of leadership de-velopment and support programmes. Not surprisingly, these programmes are yet to have any significant effect on complex problems deeply rooted in the structures and cultures of the health systems.

Clinical leadership is fundamen-tal to practice development, and practice development teams have been character-ized by high profile leaders who tend to move onwards and upwards so there is a high turnover of leaders among these teams. A re-examination of the notion of leadership development and maintenance is both timely and necessary, as is some consideration of the place of leadership in the dynamics of clinical teams. The cre-ation of transformational leaders can be highly effective in changing culture and performance but the task of doing this in a context that is hostile to its principles

may be more than most leaders can en-dure and still survive intact. There is a great need for leadership maintenance practices but there is little evidence that this maintenance exists in contemporary health facilities.

Introduction

While we have all become accustomed to a continual state of crisis in health ser-vices, there is strong evidence to suggest that these services are afflicted with deep-ly embedded and potentially terminal problems that necessitate immediate in-tervention. The evidence for this asser-tion has been building for a long time but currently it centres around a number of scandals in the world that have provided a clear indication that the systems are fail-ing in their basic charter of care. This has predictably and legitimately eroded not only public confidence but also the morale of practitioners, as evidenced by a recent survey of nurses conducted in the UK by the Royal College of Nursing (2006) that reported higher levels of work-related stress among nurses than the general population. Put simply, the delivery of care is compromised by noxious work environments.

Solutions have focused on the as-sumption that good leaders will change culture and environments in positive ways that will facilitate the improvement of practice and outcomes. On this basis, leadership programmes are promoted and considerable resources assigned to help

Practice Development in Health CarePract. Dev. Health Care 5(2) 105–114, 2006Published online in Wiley InterScience(www.interscience.wiley.com) DOI: 10.1002/pdh.187

Ideas and opinions106


people in leadership positions become transformational. However, while the theory may be adopted by the individual and skills learned, living as a transforma-tional leader in the health service is com-plicated by a whole raft of variables not least of which is the philosophical per-spective of personnel in the organization at every level. If progress is not made fol-lowing reform programmes, leaders can fast become the scapegoat for the ills of the organization. There is a pressing need to assay our expectations of leaders in clinical teams and to consider what is re-quired to enable them to satisfy those expectations.

While leadership styles may be learned and developed by individuals through leadership support programmes these leadership styles are unlikely to have more than minor impact unless those ‘transformed’ leaders are able to operate in environments conducive to the partic-ular leadership style. The ‘chicken and egg’ circularity of the expectation that the ‘transformed’ leader should construct an environment that is conducive to trans-formational leadership is one that will inevitably bring undone all but the excep-tional few. It should come as no surprise that many leaders in such difficult operat-ing conditions move on or simply give up the unequal struggle. It is our contention that there is a need for maintenance (in the sense used by Persig, 1974) and that this is a responsibility of both the team and the organization. It is also linked in-extricably with quality. Without wishing to be at all mechanistic, there are some parallels here. It is important for the clini-cal team to run like a well-oiled machine, and there are certain interventions re-quired to keep the machine well-oiled and

running. Just as a machine needs atten-tion at regular intervals to make sure its parts are running and that it is not being over-stressed, so too does the clinical team.

There is many a leader in the health system that has bitten the dust on account of a lack of maintenance.

Clinical teams share other characteristics with motorcycles. For instance, as Persig (1974: 42) says,

Each machine has its own personality

which probably could be defined as the

intuitive sum total of everything you

know and feel about it. This personali-

ty constantly changes, usually for the

worse, but sometimes surprisingly for

the better, and it is this personality

that is the real objective of motorcycle

maintenance. The new ones start out

as good-looking strangers and, depend-

ing on how they are treated, degener-

ate rapidly into bad-acting grouches or

even cripples, or else turn into healthy

good-natured, long-lasting friends.

This description could as easily be refer-ring to a clinical team as a motorcycle. To continue the analogy (or to labour the point, depending on your perspective), the clinical team is a lot like a motorcycle in a desert rally. It has a great deal of work to do in the most hostile of environments where almost every element seems to work against the success of the undertaking. There are different approaches that can be adopted to such challenges. For exam-ple, one way of completing the rally is to

The art of leader maintenance 107


thrash the motorcycle to death in the hope of completing the journey before it dies. It is exhausting and chancy be-cause it maximizes the likelihood of the machine failing to finish the course, but it might win the race. An alternative way is to pace yourself and plan for regu-lar routine maintenance stops, thereby maximizing the likelihood of complet-ing, and, by the way, enjoying the expe-rience of the race.

There is a further choice to be made here between regarding the main-tenance sessions as an imposition or an opportunity to invest time in an impor-tant component of your life. It seems trite to point out that clinical teams in health services need regular mainte-nance. During each service, all of its elements, including leadership, need to be critically reviewed, problems diag-nosed and repairs made as a normal and skilful part of the team’s work. However, there is little evidence that this main-tenance exists in contemporary health facilities and this deficit is detrimental to transformational leadership and prac-tice development because they are high maintenance endeavours.

For those readers old enough to remember Robert Persig, it may be obvi-ous that the title of this paper is in-spired by his classic philosophical trea-tise, Zen and the Art of Motorcycle Maintenance (Persig, 1974), and its con-tent also reflects his influence. The pa-per loosely draws on the considerable wisdom embedded in his work that re-flects his sense of the natural ebb and flow of the human condition, because it seems highly pertinent to those who dwell in the conundrums of the health systems. His ability to accept the tra-

vails of life with equanimity and his articulations of that ability resonate as a stark contrast to the crisis manage-ment so frequently adopted in health services. While the reader may think the motorcycle analogy has been stretched too far, there is much about Persig’s approach to motorcycle mainte-nance that can be extrapolated. Most people readily accept that a poorly maintained motorcycle is a death-trap. The same is true of a health system (al-though this seems less obvious to some who ought to know better). There is many a leader in the health system that has bitten the dust on account of a lack of maintenance.

The world is a much changed place since Persig first published Zen but the changes may well make his com-mentary on life even more relevant now than when it was written. Some things are constants. Health services will al-ways have greater demand than supply; there will never be enough resources to do all that we want to do; and there will never be enough time. There will always be competing wishes and desires of staff; there will always be those who want power, promotion, authority, etc. at the expense of others. There is nothing new in any of this – every leader that ever lived had to contend with the like. What is changing, however, is the in-tensity of these pressures. This intensity is a function of time. It is not that there is any less time now but expectations and perceptions around time have changed and many more things are now time-critical. Responses to issues must be immediate and no one is prepared to wait for anything. Problems have to be fixed yesterday and just as this type of



pressure causes mechanics to rush jobs and enable bits to fail in a motorcycle, so too does pressure create failures in components of the clinical team and in health services generally.

It is contended here that main-tenance at every level is critical, that maintenance is a responsibility of all parties and that all parties have a vested interest in the performance of mainte-nance. Without wanting to open up the debate about professionals in bureaucra-cies, it is the case that all members of a professional team have a responsibility for leadership. That responsibility may lie in the sphere of contributing to the maintenance of the leader by contribut-ing to an environment that sustains the leadership.

bility of both leaders and their teams. Harking back to the well-oiled machine, it seems that once the warranty period after the programme expires, newly transformational leaders are on their own with just an ever-so-trendy toolkit to ensure their survival.

Contextual challenges

Competing world views

Despite a flourishing of mission or vision statements with the intent and the po-tential to draw workers together, health services seem to be philosophically con-fused. The aspiring transformational leader is most closely aligned to a profes-sional way of thinking and emancipatory philosophy ‘. . . emphasizing collective purpose and mutual growth and develop-ment’ (Huber, 1996: 68). It is hard to maintain these ideals in a bureaucracy bent on making clinical leaders minions rather than leaders of service or care. Heads roll so often in the most senior positions that insecure managers place pressure on middle management (clinical leaders) to create vast quantities of infor-mation and pass it upwards so that it may be used to account for the equally vast sums of money spent on health service efficiencies. Lip service may be paid from the most senior people in the health ser-vice to a transformational leadership style but there is little opportunity for them to model such leadership styles in their economic rational world of efficien-cy. This of course is a well-worn com-plaint about health service managers that will persist as long as does economic rationalism.

Inadequate attention is giv-en to ensuring the durability of both leaders and their teams.

Transformational leadership is an in-herently attractive theory. It is compel-ling logic that the production of leaders who can in turn produce teams will lead to improved practice and care. A prob-lem for the delivery of care, and a po-tential flaw in the notion of leadership development programmes, seems to be an inordinate preoccupation with the production of the leader. In many cases the process seems to stall at this point because even if the person involved learns to be a transformational leader there is no guarantee that they will be able to execute this type of leadership in current health services. Inadequate attention is given to ensuring the dura-



There is, however, another philosophical outlook that also ob-structs transformational leadership that is pervasive in society and comes pre-dominantly from below the leader/s. This is the modern rise and rise of in-dividualism described and examined by Taylor (1989) and more recently by Ralston Saul (1997). This is a move-ment that drives a selfish (or perhaps egocentric) view in society. This view runs counter to a professional ethos and allows for decisions by nurses that en-able them to avoid becoming part of collective and corporate efforts to im-prove the service provided by either the team or nursing as a whole. This is epit-omized by nurses who just want to come in, keep their heads down, do a job and go home. Given lifetimes of poor rates of pay and working environments for nurses there is some sympathy for this view, indeed it may well be held by clinical leaders – particularly those who are yet to enrol in a leadership support programme. It would appear that the poor old clinical leader is the person who is expected to live by the rhetoric of mission statements and strive for cul-tural change in an organization where the real and most dominant philoso-phies that drive values and behaviour serve only to obstruct and confound their endeavours.

Just to confound the problem still further there are mixed messages from society. Some factions seek longev-ity through ‘hi-tech’ medicine, some seek merciful release, some want con-tinuing care and others want the right to wreck their health and then be reha-bilitated. Healthcare is construed as a right and, when regarded as a right, it is

a service that is regarded as failing whenever anyone does not get what they want straight away. Death is seen as failure of the health service to cure. As technology becomes more sophisti-cated there is more that we can do and this leads to progressively increas-ing expectations by consumers of healthcare.

Persig (1974) brings to bear a somewhat different world view. He is not a great believer in theory or experts. He is a process person and he likes to experience or use the motorcycle and maintain it himself. He knows how it works and how to keep it in the best possible condition; what is more, he val-ues and enjoys the process of keeping the motorcycle in optimum running or-der. Many nurses would like to savour their work in the way that he describes and be able to view the clinical team and its environs with such familiarity. He advocates the notion of good time – which can be equated with conscious time, and that raises once again this troublesome concept that is, like Tolkien’s ring (1966), at once an asset and a burden.

Time

Besides competing views of work, the nursing leader needs to contend with a lack of resources within an organization that consumes a large proportion of the gross domestic product. The most ex-pensive and precious resource that we have is time and it already seems to be in shortest supply. Even so, the pressure to do more in less time is incessant. Resort has already been made to one of



the ancients (Persig) so no further dam-age can be incurred by reference to an-other. Alvin Toffler (1971) was prescient in his comments on time. He assured us that we can adapt to enormous change. He reassured us that we could even adapt to rapid change – and then he cautioned us that what we cannot cope with is the constant acceleration in the rate of change. Toffler’s concept of fu-ture shock has become a contemporary reality – developed societies are at a point where technology has overtaken (and perhaps left behind) the average individual. Strategies are necessary to accommodate this reality in the work-place and that presents its own set of challenges for clinical teams and their leaders.

Leadership

There remain many issues for leadership in nursing. Some commentators such as Thyer (2003) argue that in nursing the style of leadership remains transactional and she maintains that transformation-al leadership remains the great hope for nursing. Presumably there is an assump-tion that a shift to transformational leadership would liberate nurses and nursing notwithstanding the persistence of the many contextual exigencies that militate against this notion. The fact that there has been a significant shift to transformational leadership over the past two decades that has not produced the particular transformation sought by these commentators might suggest that there are other factors at work here.

In any team the expectations of the leader are significant. Usually they involve such elements as development

of the vision for the team; motivation of the team including maintenance and development of morale; integration of the team; construction of the culture of the team; ethical direction of the team including management of service quali-ty; and development of team members. There are many other formulations of leadership but in essence these are the core expectations. The leader also needs to be capable of steering a clear passage through turbulent times and that is most of the time in contemporary health systems. These are certainly the core competencies that organizations expect of their staff who hold leadership posi-tions; that is, anyone who is charged with the responsibility of achieving the organization’s objectives through the work of another. In the context of this paper another set of expectations of the leader may be more important even than that of the organization. This is the set of expectations held by the members of the leader’s team. It is in-structive to consider such expectations and to examine how the team members themselves might contribute to the re-alization of the expectations. This could be construed as the contribution of team members to leader maintenance.

By way of example, if the indi-vidual members of the team expect the leader to establish a culture that values all members of the team and assures their development, the corollary of this is a set of questions as to how they see their own contribution to the achieve-ment and maintenance of that culture. In our highly individualistic, egocentric contemporary culture, there is a ten-dency for this to be something of a one-way street. Leaders, too, can exhibit a



similar manifestation of the same cul-ture. The contention here that trans-formed leaders tend to move onwards and upwards without leaving a legacy of a sustainable team may well be an ex-pression of precisely this culture. An example can be seen in a paper lauding the potential of transformational lead-ership for nursing. Ironically, Dixon’s (1999) paper epitomizes the problem: she uses a case study of one of the lead-ers that did not stay. As she says, her ‘case example demonstrates how a for-mer nurse executive, now a chief operat-ing officer of one of the nation’s top 100 integrated health systems, puts these concepts [of transformational leader-ship] into action’ (Dixon, 1999: 17). This is obviously very good for the lead-er as an individual but it raises questions as to how good it might be for the team. As Dixon points out, the idea is that the stakeholders are empowered to become leaders and build a culture that supports the vision of the team. The reality is that this is precisely what does not happen.

A similar situation results if the members of the team hold an expecta-tion that the leader bears responsibility for the motivation of the team. If a team is dependent upon an inspirational leader for it success – and there are many examples of such teams – what happens to the team when the leader moves on? Equally importantly, what – if anything – can the members of such a team contribute by way of mainte-nance activities that might sustain the leader in the role? Even more impor-tantly, if the nature of leadership is that the leader evolves in the role and moves on to bigger and better challenges,

should the maintenance of leaders extend to maintenance of the team? Should succession planning form as much a part of the team’s responsibility as of the leader? These questions have profound implications for the reliance on leadership and its failure as a root cause of the state of our healthcare systems.

When it comes to issues of mo-rale, Bakker et al. (2000) argue that nurses at the level of middle manage-ment, such as head nurses or nursing unit managers, can minimize the effects of a demanding work environment on staff nurses by thoughtfully maintaining a leadership style that is supportive of the needs of staff nurses. The fact that so many nurses are jaded and exhausted presumably indicates that nursing lead-ers at this level have failed in this re-sponsibility. Surely this is a collective responsibility. It is not reasonable to rely solely on the leader to make everybody else feel all right about themselves and their work. Here there is a clear and compelling case for all members of the team to assume some responsibility for leader maintenance and maintenance of the team.

Practice development

Just as it has been argued here that transformational leadership has been subject to ‘failure to thrive’ syndrome because of less than conducive circum-stances, the same may be said of prac-tice development. However, practice development does at least focus on teamwork, and leadership is put in per-spective as an important (but not domi-nant) feature of practice development



work. Indeed it is often the case that leadership is only an issue in practice development teams when it is a prob-lem; and when it is a problem it can scupper the endeavours of the whole team. Responsibility for the success of practice development should rest with the entire team even though the reality is that, except in rare circumstances, champions tend to emerge and get most of the attention.

Critical social theory is the guiding theory of emancipatory clinical practice development as described by McCormack and Manley (2004: 43). These authors explain that through emancipatory clinical practice develop-ers do . . .

not pretend to overcome barriers

that are beyond the influence of

group members (for example, limit-

ed financial resources and govern-

ment influence). Instead emancipa-

tory practice development enables

group members to realize the influ-

ence they hold, how to use that in-

fluence most appropriately and ef-

fectively and to recognize aspects

of direct decision making that are

beyond direct influence.

Practice development done well in cir-cumstances that are conducive to open-ness and critique is akin to motorcycle maintenance. The leader within prac-tice development should be cocooned within a raft of professional activity. Of course this is an idealistic representa-tion of practice development and one that is pursued more often than achieved, but if the process can be ap-

preciated it becomes, like motorcycle maintenance, intrinsically worth while and beneficial.

There are areas where leader-ship support programmes have been launched in tandem with practice devel-opment precisely to avoid leaders finding themselves in a no win situation (FitzGerald and Solman, 2003). The fine balance between too much or too little leadership in practice development is an art that only the moment can define.

Conclusion

With appropriate mainte-nance, the leaders will hold up and the practice develop-ment process will have the opportunity to become en-trenched culture. Members of clinical teams need to under-stand that for this to happen, they carry responsibility for the survival of their leader.

For clinical teams, practice develop-ment and leadership – especially trans-formational leadership – are inextrica-bly linked. Neither has lived up to expectations but that may be because the expectations are unrealistic. Health service organizations have embraced practice development as a means of im-proving practice and outcomes. They have embraced the notion of transfor-mational leadership as a mechanism for



leading the practice development pro-cess, including the team-building com-ponent. In each case the innovation was doomed to failure because the pro-cess was predicated on a flawed assump-tion that this was a low-maintenance (and hence, inexpensive) exercise. In each case, there was no provision for maintenance as has been argued in this paper. No maintenance and operation in a wearing, high-stress environment inevitably leads to large-scale failure both of leadership and practice develop-ment. The machine seized for want of maintenance.

There is no intended criticism here of either genuine transformational leadership or practice development. However, those charged with respon-sibility for implementation at the in-stitutional level need to review the implementation process and try to stay faithful to processes for the mainte-nance of both. There is a need to acknowledge the failures and to look to potential solutions and in some instanc-es live with the perceived failures as a part of life. With appropriate mainte-nance, leaders will hold up and the practice development process will have the opportunity to become entrenched culture. Members of clinical teams need to understand that for this to hap-pen, they carry responsibility for the survival of their leader. Here again, maintenance is critical but here it is mechanisms for the maintenance of the team that need to be implemented. This is a difficult notion in a highly individu-alistic society. However, it is this that affords the strongest opportunity for the leader to survive and for practice devel-

opment to become established. In theo-ry, it should then be self-perpetuating, as should the team. With appropriate maintenance, the machine should run for ever.

ReferencesBakker AB, Killmer CH, Siegriest J, Schaufeli

WB (2000). Effort–reward imbalance and burnout among nurses. Journal of Advanced Nursing 31: 884–91.

Dixon DL (1999). Achieving results through transformational leadership. Journal of Nursing Administration 29(12): 17–21.

FitzGerald M, Solman A (2003). Clinical prac-tice development: Central Coast Health. Collegian 10(3): 8–13.

Huber D (1996). Leadership and Nursing Care Management, Philadelphia, PA: Saunders.

McCormack B, Manley K (2004). Practice devel-opment: Purpose, methodology, facilita-tion and evaluation. In McCormack B, Manley K, Garbett R (eds). Practice Development in Nursing (pp. 33–50). Oxford: Blackwell Publishing, Oxford.

Persig RM (1974). Zen and the Art of Motorcycle Maintenance. London: Vintage.

Ralston Saul J (1997). The Unconscious Civiliza-tion. Victoria: Penguin Books Australia.

Royal College of Nursing (2006). At Breaking Point: A survey of the wellbeing and work-ing lives of nurses in 2005. London; Royal College of Nursing.

Stordeur S, D’Hoore W, Vandenberghe C (2001). Leadership, organizational stress, and emotional exhaustion among hospital nursing staff. Journal of Advanced Nurs-ing 35(4): 533–42.

Taylor C (1989). Sources of Self: The Making of the Modern Identity, Cambridge: Cambridge University Press.

Thyer GL (2003). Dare to be different: Transfor-mational leadership may hold the key to reducing the nursing shortage. Journal of Nursing Management 11: 73–9.

Toffler A (1971). Future Shock. London: Pan Books.



Tolkien JRR (1966). Lord of the Rings. London: Allen & Unwin.

John FieldMary FitzGerald

Address correspondence to John Field, Senior Lecturer, James Cook University, Thursday Is-land, Queensland, Australia. Email: [email protected]

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The art of leader maintenance