Expertise Leadership and Collaborative Working E-Book

Soo Downe

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Serie: Essential Midwifery Practice
• Sprache: Englisch

Seitenzahl: 435

Veröffentlichungsjahr: 2010

Beschreibung

Leadership, expertise, and collaborative working are fundamental aspects of efficient and effective healthcare. This book offers a comprehensive overview of the general theories, principles and points of good practice in each of these three areas. This general literature is then contextualised by theoretical and practical implications for maternity care, and illustrated with in-depth case studies of successful innovation and change in practice.

Essential reading for all midwives, midwifery students, and others working in or studying maternity care, this book helps readers understand the theoretical underpinnings of effective leadership, expertise and collaborative ways of working.

Special features:

• Part of the acclaimed Essential Midwifery Practice series
• A theoretical and practical exploration of the nature and application of leadership, expertise and collaborative working in midwifery
• Provides inspirational case studies of change and innovation
• Brings together national and international experts in the field

Leseprobe

Contents

Cover

Title Page

Copyright

Dedication

Contributors

Foreword

Introduction

Leadership

Expertise

Collaborative Working

Conclusion

Part I: Leadership: Introduction to Part I

Chapter 1: Midwifery Leadership: Theory, Practice and Potential

Introduction

Leadership and Leaders: Theory, Styles and Traits

Leadership and Health Services: The UK Example

Maternity Care and Midwifery Leadership

Developing Midwifery Leadership: Planning for the Future

Community Leadership and Maternity Care

Conclusion

Chapter 2: Transformational Leadership and Midwifery: A Nested Narrative Review

Introduction

Background to Concepts of Leadership

The Focus of this Chapter

Methods and Findings

Discussion

Conclusion

Chapter 3: What Do Leaders Do to Influence Maternity Services? Midwifery Leadership As Applied to Case Studies

What is Leadership?

Midwifery Leadership

Discussion

Chapter 4: Leadership for Effective Change in Mother and Infant Health: Lessons Learned from a Programme of Work on Breastfeeding

Introduction and Background

The Case of Infant and Young Child Feeding

Creating Effective Change

Future Developments

Conclusion

Acknowledgements

Part II: Expertise: Introduction to Part II

Chapter 5: The Notion of Expertise

Introduction

General Concepts of Expertise

Expertise in the Context of Healthcare

Discussion

Conclusion

Chapter 6: Expertise in Intrapartum Midwifery Practice

Introduction

Aims, Methods and Emerging Themes

The Nature of Midwifery Expertise

Synthesis of the Findings

Conclusion

Chapter 7: Enhancing Expertise and Skills Through Education

Introduction

The Context for Normal Birth Workshops

Attitudes and Beliefs

Birth Environment

Enhancing Skills for Normal Labour and Birth

Expertise and Group Work

Audit Project

Conclusion

Chapter 8: What is a Skilled Birth Attendant? Insights from South America

Introduction

The Context of Expertise

Integrating Competition in Expertise

Definitions of Authority

The Translation of Authoritative Knowledge into Policy

Traditional Midwifery, Expert Midwifery

Conclusion

Part III: Collaboration: Introduction to Part III

Chapter 9: Collaboration: Theories, Models and Maternity Care

Introduction

The Nature of Collaboration

Multidisciplinarity and Interdisciplinarity in Health and Social Care

Collaboration in the Maternity Care Context

Considerations for a Theory of Interdisciplinary Collaboration

Conclusion

Chapter 10: Case Studies of Collaboration in the UK and China

Introduction

Collaboration in East Lancashire, England

Collaboration in China

Conclusion

Chapter 11: Using Collaborative Theories to Reduce Caesarean Section Rates and Improve Maternal and Infant Well-being

Introduction

Reforming the NHS Through Increasing Collaboration

Maternity Reforms and Collaboration

Moving Policy into Practice

The NHS Institute's Delivering Quality and Value Programme

Focus On: Caesarean Section

Pathways to Success – a Self-Improvement Toolkit

Discussion

Conclusion

Chapter 12: Bringing It All Together

Leadership

Expertise

Collaboration

Conclusion

Index

This edition first published 2011

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Library of Congress Cataloging-in-Publication Data

Essential midwifery practice. Leadership, expertise and collaborative working/edited by Soo Downe, Sheena Byrom, and Louise Simpson.

p.; cm.

Other title: Expertise, leadership, and collaborative working Includes bibliographical references and index.

ISBN 978-1-4051-8431-1 (pbk. : alk. paper)

1. Midwifery. I. Downe, Soo. II. Byrom, Sheena. III. Simpson, Louise, RM. IV. Title: Expertise, leadership, and collaborative working.

[DNLM: 1. Midwifery. 2. Cooperative Behavior. 3. Leadership. 4. Professional Competence. WQ 160 E779 2011]

RG950.E64 2011

618.2–dc22

2010022795

A catalogue record for this book is available from the British Library.

Dedication

This book is dedicated to all the midwives, students, colleagues, doctors, healthcare assistants, women and partners who have taught us all we know about leadership, collaboration and expertise

Contributors

Janet Baldwin is seconded to the NHS Institute of Innovation and Improvement UK as Clinical Lead on the Caesarean Section Team. In this role she works with midwifery and service improvement colleagues on a range of maternity improvements. She recently retired from clinical practice as a consultant obstetrician and gynaecologist at the West Middlesex University Hospital in London where she also held a succession of board-level posts, culminating in the Medical Directorship. In addition to Fellowships of the Royal College of Obstetricians and Gynaecologists and the Royal College of Physicians, she has a Master's degree in Healthcare Administration. She remains actively involved in clinical governance and undergraduate teaching for Imperial College London.

Alison Brodrick is a consultant midwife in normality at the Jessop Wing Sheffield Teaching Hospitals NHS Foundation Trust, UK. Prior to this she worked nationally as a midwife consultant to the Caesarean Section Team at the NHS Institute for Innovation and Improvement on projects in England and Wales, working with maternity service staff and users to optimise opportunities for normal birth. Having trained initially as a nurse, she qualified as a midwife in 1994 at Kingston upon Thames. Since then she has also worked as a lecturer practitioner with Nottingham University and as a midwife and supervisor of midwives with United Lincolnshire NHS Trust. Her strong focus on promoting normality and enabling change within maternity services was reflected in her Master's degree in Midwifery and in achieving an RCM award with a colleague in 2006.

Anna Byrom has worked within maternity services in the UK, as a midwife, for the past 6 years. She has worked around the UK within a range of midwifery care models, including a birth centre, working as a Sure Start caseload midwife and her present role as an infant feeding co-ordinator. Throughout her career, she has developed a philosophy of midwifery that embraces women's physical, emotional and social needs within the context of their family environment. She has a passion for social research and is currently undertaking a PhD with the University of Central Lancashire and the Maternal and Infant Nutrition and Nurture Unit. This research will involve exploring how macro-interventions impact on microcultures, looking specifically at UNICEF's Baby Friendly Hospital Initiative.

Sheena Byrom is Head of Midwifery at East Lancashire Hospitals Trust, UK. She qualified as a nurse and midwife in the 1970s, and has worked in the north of England since that time. Her past clinical practice encompasses 10 years within a GP unit, and then a combination of hospital and community midwifery, both clinical and managerial. Sheena worked as a consultant midwife for 6 years, in a role that encompassed the refocusing of maternity services in response to need, leading midwives in the public health agenda, and developing peer support networks and user involvement in service provision. Her post was part funded by the University of Central Lancashire where she contributed to the research capacity building strategy. Sheena was nominated twice to meet the Prime Minister, has been involved in several national projects with NICE and the Department of Health. She has published and presented nationally and internationally on topics such as addressing inequalities in health and promoting true woman-centred philosophies of care.

Ngai Fen Cheung is the professor and head of the first Chinese Midwifery Research Unit of the Nursing College of Hangzhou Normal University in China. Her main research interest is in the area of childbearing women's well-being and the development of Chinese midwifery. Her PhD, completed in the University of Edinburgh in 2000, compared the childbearing experiences of Chinese and Scottish women. Since then she has continued to design and organise international collaborative research projects studying Chinese midwifery. Her research aims to document and explain the practices of midwifery both in China and abroad, promoting normal birth and modern maternity care in China.

Sophie Cowley is an Associate with the NHS Institute for Innovation and Improvement, working on clinical pathway improvement. For the past 5 years she has supported NHS organisations delivering improvements in several pathways including promoting normal birth and reducing caesarean section rates, day surgery, radiology and ophthalmology. Previous to this Sophie was an information analyst with the NHS Modernisation Agency where she went on to become an improvement practitioner. Her main interests are service improvement tools and techniques, she has a Black Belt in Six Sigma and is currently studying for a Master's in Managing Quality in Health Care.

Ann Davenport A nurse since 1976 and midwife since 1991, Ann has been hired by organisations to live and work in more than 13 countries around the world – from the mountains of Nepal and Bolivia and the jungles of Brazil and Indonesia to the deserts of Ethiopia and western Mexico. She has worked with the University of Johns Hopkins Program for International Education in Gynecology and Obstetrics since 2001, along many other international organisations involved in the promotion of women and newborn health and well-being. She is the author of Babies in the Cornfield: Stories of Maternal Life and Death from Around the World, and lives in Chile, where she writes for a website promoting humanised childbirth (www.nuestroparto.cl).

Soo Downe leads the Research in Childbirth and Health (ReaCH) group at the University of Central Lancashire (UCLan) in England. Soo spent 15 years working as a midwife in various clinical, research and project development roles at Derby City General Hospital. In 2001 she joined UCLan, where she is now the Professor of Midwifery Studies. She currently chairs the UK Royal College of Midwives Campaign for Normal Birth steering committee, and she co-chairs the ICM Research Standing Committee. She has been a member of a number of national midwifery committees, and has held a number of visiting professorships, most recently in Belgium, Hong Kong, Sweden and Australia. Her main research focus is the nature of, and culture around, normal birth. She is the editor of Normal Birth, Evidence and Debate (2004, 2008), and the founder of the International Normal Birth Research conference series.

Kenny Finlayson has been working as a research assistant in the Research in Childbirth and Health (ReaCH) group at the University of Central Lancashire (UCLan) for the last 4 years. Although his background is in biochemistry and the pharmaceutical industry, Kenny has been involved in the research and practice of complementary medicine for much of the last decade. His research interests revolve around the integration of holistic approaches to healthcare, interprofessional boundary work and access to healthcare services by marginalised communities, all within a maternity context. For most of the last year Kenny has been deeply engaged in the design and development of a collaborative training programme for midwives and doctors. The programme is now entering its second phase of development and is being used as a regional initiative to foster a culture of collaboration within the maternity services.

Anita Fleming trained as a nurse and midwife in Blackburn, Lancashire, and has continued to work in East Lancashire since. After gaining all-round midwifery experience, Anita became a midwifery team leader in 2001. Having developed a particular interest in public health, she became a Sure Start midwife and in 2003 set up and led a midwifery group practice providing a caseload model of care to women from vulnerable groups. Anita is particularly interested in promoting normal birth and facilitating positive birth experiences for women, especially those deemed to be ‘high risk’, and this often involves working in collaboration with obstetricians to help enable this. She completed both a BSc(Hons) and MA in Midwifery at the University of Central Lancashire, and since February 2009, she has been working as a consultant midwife at East Lancashire Hospitals Trust and the University of Central Lancashire.

Sue Henry is Infant Feeding Co-ordinator at East Lancashire Hospitals NHS Trust, UK. Her current role focuses on leadership in the local maternity unit and primary care trust in reaching and maintaining full Baby Friendly Initiative standards, developing innovative ways to increase breastfeeding rates, and working closely with all partners and service users. Sue has represented her local trusts and shared her breastfeeding management experience via presentations and publications both regionally and nationally.

Lesley Kay is Lecturer in Midwifery at Anglia Ruskin University, UK. She previously worked as a midwifery team leader in a community-based team in the Cambridgeshire area. She completed a Master of Studies degree at the University of Cambridge in 2007, which incorporated the Postgraduate Certificate of Medical Education. She qualified as a midwife in 2000 after completing a direct-entry midwifery programme. In her current role, she is responsible for a ‘Birth and Beyond’ module, a ‘Complexities’ module and an ‘Obstetric Challenges in Midwifery’ module for the BSc(Hons) Pre-Registration Midwifery Pathway and the BSc(Hons) for Registered Nurses Pathway.

Nicky Mason is a midwife consultant seconded to the NHS Institute for Innovation and Improvement Caesarean Section Team in the UK. She has been a midwife since 1991 and has a background in clinical education and practice development. She has experience of facilitating large-scale change in both the south east of England and in Auckland, New Zealand through providing innovative coaching and support programmes to clinical staff. In her current role, Nicky has been working closely with maternity service staff and users across England and Wales to optimise opportunities for normal birth. Nicky is passionate about user involvement in service improvement and research. She has facilitated a women's focus group at her local unit since 2001 and is working with an advisory group of women who are supporting her in her PhD looking at women's narratives of planned caesarean birth.

Mary Newburn is Head of the NCT's Research and Information Team (RAIT). She is editor in chief of the NCT's continuing professional development journal, New Digest, and an advisor to the National Perinatal Research Unit. She trained as an NCT antenatal teacher before becoming a member of the NCT staff in 1988. Mary has a degree in sociology from the London School of Economics and a Master's degree in Public Health: Health Services Research from the London School of Hygiene and Tropical Medicine. She was made an honorary professor by Thames Valley University in 2004, awarded for services to midwifery and women's health.

Mary J. Renfrew is Professor and Director of the Mother and Infant Research Unit at York University. She is a graduate of the Department of Nursing Studies in the University of Edinburgh. She qualified as a midwife in 1978 and gained her PhD in Edinburgh in 1982 while working with the Medical Research Council Reproductive Biology Unit. She has since worked in Oxford, Alberta, Canada, Leeds and York. She established and led the Midwifery Research Initiative at the National Perinatal Epidemiology Unit, and has been co-editor of the Cochrane Pregnancy and Childbirth Group. She established the multidisciplinary Mother and Infant Research Unit (MIRU) in 1996. Her research has been funded by the Medical Research Council, the Department of Health, the National Institute for Health Research, the National Institute for Health and Clinical Excellence and the ESRC, among others. In addition to more than 90 academic journal publications, she has written widely about maternity care, and is author or editor of seven books, including A Guide to Effective Care in Pregnancy and Childbirth with Murray Enkin, Marc Keirse and Jim Neilson. She has an active interest in the integration of research, education, policy and practice, and has worked closely with service users and consumer groups for many years. She has sat on committees at national and international level including Chair of the WHO Strategic Committee for Maternal and Newborn Health. She has been awarded inaugural Senior Investigator status by the National Institute for Health Research.

Louise Simpson is Practice Education Facilitator, Women's, Children and Sexual Health Division, Mid Cheshire NHS Trust, Crewe. She has been a practising midwife for 10 years. She has also worked as a labour ward co-ordinator. Her current role is to promote leaning within the clinical environment, and to support midwives in a clinical capacity. Her philosophy of care is to promote pregnancy, labour and birth as a normal, natural process placing emphasis on birth as a whole, and supported through attending to the physical, social and emotional needs of the woman and her family. Louise is passionate about midwifery and research. She was involved in the data collection for the RCM ‘Campaign for Normal Birth’. Her Master's by research explored midwives' accounts of intrapartum expertise. Through this research, she identified the skills, practices and personal attributes required to promote expertise in practice. She has presented the findings of this research at local, national and international conferences, and published her findings in leading journals.

Denis Walsh is Associate Professor in Midwifery, University of Nottingham, UK. He was born and brought up in Queensland but trained as a midwife in Leicester, UK, and has worked in a variety of midwifery environments over the past 25 years. His PhD was on the birth centre model. He lectures on evidence and skills for normal birth internationally and is widely published on midwifery issues and normal birth. He authored the best seller Evidence-Based Care for Normal Labour and Birth.

Cathy Warwick CBE is General Secretary of the Royal College of Midwives (RCM), one of the world's oldest and largest midwifery organisations, representing the majority of the UK's midwives. She has written and published widely on midwifery issues and lectures and speaks nationally and internationally. She was awarded a visiting professorship by King's College, London in 2004. She received a CBE for services to healthcare in 2006, and was awarded an Honorary Doctorate from St George's and Kingston University, London, in 2007.

Foreword

This book addresses three aspects of midwives' work: leadership, expertise and collaboration. Individually, each is important to describing midwifery practice; collectively, they are a dynamic package that can elevate the health of women and babies locally and across the broad global community.

Midwives are called upon to be many things to many people. They must be first-rate practitioners who use their knowledge, skill and expertise to care effectively for women and babies. Some would say that is enough and all that really counts. But it is not! Students and junior midwives often funnel their energy into developing skills, as they should. However, their vision should not be so narrow as to block out other important aspects of midwifery practice. They must realise that their practice reflects the environment in which they work and the world in which we all live. They have the potential to influence both for the good of mothers and babies. This requires commitment to developing expert clinical skills, but also to broadening their expertise as collaborators and leaders.

As we all know, there are many paths, venues, roadblocks and bridges in the birth journey. Navigating that ‘travail’ (journey/the work of labour) is something a woman does in concert with others and she deserves the very best artists who are in harmony with her in the process. Her midwife should be a practitioner who artfully collaborates with others to ensure that the woman's needs are met. Skilled collaboration fosters seamless care transitions when required, integrates complex healthcare systems and opens closed doors. Collaboration among practitioners involved in childbearing care is essential, but collaboration with the woman and family and the broad community also is important. It is a skill and not always easy, especially within daunting hierarchal institutions. It requires the recognition that all who enter a collaborative relationship are human beings with individual beliefs and values shaped by their culture, education and experiences. If we pride ourselves (as we often contest) that we are listeners and value each woman as an individual then it is incumbent upon all of us to apply those same communication skills and beliefs to the development of our collaborative professional and community relationships.

Leadership is perhaps the part of the job description that is shunned by many midwives who think, 'I just take care of women – I don't need to be a leader!'. But you are and you do – you just may not realise the form it takes or the far-reaching impact it can have. Leadership goes further than the common misperception of a leader as the lofty head of a group, institution or country. Rather, it is the everyday work that demonstrates strength, knowledge and ethical behaviour to others. Your actions should be those that others want to emulate. This means being engaged in work to further the health of mothers and babies, as an individual and as a member of the broader community – you are part of the solution!

This book will help you learn about and reflect on these vital aspects of our work and how you can develop each of them as a midwife. As I reflect on my own midwifery path, I have come to realise that all of these have added to the joy and challenges of my work. Although the path was never easy, the forward journey and navigating the pitfalls have added to the richness of my professional life. If we all embrace these aspects of our work, the world will become a better place for mothers, babies, families and the broader global community.

Holly Powell Kennedy PhD, CNM, FACNM, FAAN

Helen Varney Professor of Midwifery

Yale University School of Nursing

New Haven, Connecticut, USA

[email protected]

Introduction

Soo DowneSheena ByromLouise Simpson

Leadership, expertise and collaborative working are fundamental aspects of efficient and effective healthcare. These three aspects have been recognised in governmental and health agency documents across the world (WHO 2005; DH 2007a). While there has been some exploration of these areas in the nursing literature, there is a paucity of theoretical and practical exploration of the nature and application of these characteristics in the context of maternity care. This book offers a comprehensive overview of the general theories, principles and points of good practice in each of these three areas. This general literature is then contextualised by theoretical and practical implications for maternity care. Each section is illustrated with in-depth case studies of successful innovation and change in practice based on the theories and concepts discussed in earlier chapters.

Leadership

The World Health Organization (WHO) recognises the importance of strong leadership for effective healthcare. The WHO has also developed a programme for potential dynamic leaders in an attempt to combat poverty and health inequalities (WHO 2005). In the UK, the Department of Health has developed a leadership centre as part of the NHS Modernisation Agency, in the belief that leaders within the NHS could motivate staff and improve patient care (DH 2003).

Examination of the literature on leadership and that relating to midwifery reveals some evolutionary similarities. The dominant theories in both areas appear to be moving away from hierarchical models and towards those based on relationship. In the case of leadership, this has led to a concentration on transformational philosophies, in contrast to earlier approaches based on command and control (Conger 1991; Barker 1994; Carless 1998). In midwifery, woman-centred care has become the ideology of choice, theoretically replacing hierarchies built on professional power bases (WHO 1997; DfES 2004; DH 2007b). The leadership section of the book examines the theoretical synergies between these two movements and provides examples of effective leadership in practice.

Expertise

It is not uncommon for midwives to call themselves ‘the experts in normal childbirth’. The statement appears to see both ‘expertise’ and ‘normality’ as unproblematic concepts. In many countries across the world, the majority of women giving birth with trained midwives currently do not experience a physiological birth. This raises questions about the nature and provenance of expert or exemplary practice in midwifery. The section on expertise will draw on general theories of expertise, on established usage of the term in nursing and medicine, on emerging theories in midwifery, and on practical examples of expertise in practice through in-depth case studies Given the fact that most women in the world are not attended by trained midwives, this section also addresses the topic of maternity care expertise for practitioners without formal midwifery qualifications.

Collaborative Working

The concept of increased inter- and/or multidisciplinary collaboration is advocated by various governing bodies. In a recent document entitled Safer Childbirth: Minimum Standards for Service Provision and Care in Labour (RCOG, RCM, RCA, RCPCH 2007), a range of UK professional bodies comment that national audits and reviews of maternity services have continued to highlight poor outcomes related to multiprofessional working, staffing and training (Foreword). The NHS Institute for Innovation and Improvement has defined four levels of collaboration (DH 2007b). This section will explore the roots of effective and ineffective collaborative working, summarise the key theories, concepts and policy documents in this area, and present case studies from the UK and China to illustrate how collaboration across professional and agency boundaries can be improved, and the implications this has for practice and for outcomes.

Conclusion

Strategic and clinical leadership, the application of expertise and effective intra- and interprofessional collaboration are essential components in the provision of high-quality healthcare. We hope that this book will assist midwives, midwifery students at all levels, and others working in or studying maternity care to understand the theoretical underpinnings of effective leadership, expertise and collaborative ways of working. We also aim to inspire positive changes in practice, through the provision of inspirational case studies of change and innovation. We hope this text is a practical guide to such change for the future.

References

Barker AM (1994) An emerging leadership paradigm: transformational leadership. In Hein EC, Nicholson MJ (eds) Contemporary Leadership Behavior: Selected Readings, 4th edn. Philadelphia, J B Lippincott.

Carless SA (1998) Gender differences in transformational leadership: an examination of superior, leader, and subordinate perspectives. Sex Roles: A Journal of Research39 (11-12). www.findarticles.com (accessed June, 2010).

Conger JA (1991) Inspiring others: the language of leadership. Academy of Management Executive5 (1).

Department for Education and Skills (2004) National Service Framework for Children, Young People and Maternity Services. London, Department for Education and Skills. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4089114 (accessed June, 2010).

Department of Health (2003) The Leadership Centre. http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Managingyourorganisation/Humanresourcesandtraining/Modelcareer/DH_4080689 (accessed June, 2010).

Department of Health (2007a) Maternity Matters: Choice, Access and Continuity of Care in a Safe Service. London, Department of Health.

Department of Health (2007b) Institute for Innovation and Improvement. Delivering Quality and Value: Focus on Caesarean.www.institute.nhs.uk/quality_and_value/introduction/toolkits_for_high_volume_care_pathways.html (accessed June, 2010).

Department of Health (2007c) Institute for Innovation and Improvement. www.nhsleadershipqualities.nhs.uk/ (accessed June, 2010).

RCOG, RCM, RCA, RCPCH (2007) Safer Childbirth: Minimum Standards for Service Provision and Care in Labour.www.rcog.org.uk/files/rcog-corp/uploaded-files/WPRSaferChildbirthReport2007.pdf (accessed June, 2010).

World Health Organization, Department of Reproductive Health and Research (1997) Care in Normal Birth: A Practical Guide. Geneva, World Health Organization.

World Health Organization (2005) The Health Leadership Service. www.who.int/health_leadership/en/ (accessed June, 2010).

Part I

Leadership

Introduction to Part I

Sheena Byrom

The subject of leadership in general has received much attention throughout the world. Although there is a significant amount of research and expert opinion in relation to leadership and health professionals, there has been less examination of the issues relating to leadership and the midwifery profession.

Examination of the literature on leadership and that relating to midwifery reveals some evolutionary similarities. The dominant theories in both areas appear to be moving away from hierarchical models and towards those based on relationship. The emotional focus of midwifery work, and the philosophy of women-centred care where midwives support and nurture women, could be linked with transformational style leadership theory. While it has been suggested that there is a lack of effective midwifery leadership across the world, there are examples of midwifery leaders who are challenging that belief, through their dynamic leadership styles, in strategic development, midwifery research, education, academia and service provision.

In Chapter I, Sheena Byrom and Lesley Kay examine the general and specific literature relating to leadership theory. They provide a brief overview of various leadership styles and traits. The subject of whether leaders are born or made is debated, in addition to various approaches to leadership development. There is an agreement within the literature that leadership is an essential element of organisational success, and for maternity services leadership has been identified as a critical factor when considering optimum safety for mothers and babies. The chapter suggests that all midwives have a responsibility to ‘lead’ in certain circumstances – for example, they ‘lead’ women during the childbirth continuum in their daily work, they lead parent education sessions, and they facilitate birth. The chapter proposes that the way midwives ‘lead’ women or other midwives needs to be considered at all times if quality of care is to be improved.

Sheena Byrom, Soo Downe and Anna Byrom take a more theoretical approach in Chapter 2, in which they describe a ‘nested narrative review’ of the literature pertaining to midwifery, woman-centred care and transformational leadership theory. Midwives and midwifery have always championed a holistic approach to childbirth. Even though transformational leadership has been closely linked to feminine traits by some authors, there appears to be little in the literature about the possibility of adopting transformational leadership approaches in midwifery. The chapter reviews the literature of woman-centred care and transformational leadership separately. On the back of the findings, it is suggested that the two approaches have much in common. The authors suggest that adoption of transformational leadership styles may be welcomed, at least in some midwifery settings.

A series of case studies and personal reflections are set out in Chapter 3. Contributions include personal reflections from midwifery leaders working at various levels. Sue Henry, Sheena Byrom and Cathy Warwick offer insights from the UK as midwives working at local level, as a consultant midwife and as a national leader, respectively. Ngai Fen Cheung gives an example of leading radical change in China, and a service user leader, Mary Newburn, describes how she came to a position of national influence in maternity care. Individuals frequently describe being inspired by leaders. The chapter provides personal insights into how such people achieve their vision and their ultimate success. Their skill and capacity to develop others to succeed and their influence on maternity service development offer encouragement and inspiration to all midwives, now and in the future.

Chapter 4, written by Mary Renfrew, uses the subject of breastfeeding as a case study to examine ways of creating change at a wide range of levels, from the very local to the international. Mary describes ways in which her work has attempted to address challenges faced in terms of research, practice, policy, education and strategy. Crucially, she draws out lessons for leadership in creating change at scale. The chapter highlights the fact that success depends on all members of the team, each bringing their contribution, skills, expertise and talents. Mary is clear that successful leadership includes having the confidence to ask others to follow, and the ability to work in collaboration and to follow others in turn.

All the chapters in this section illustrate the need for courage, vision and conviction if leaders are to be effective. They set out the theoretical basis for leadership and provide examples of where good leadership has led to important changes at all levels. As such, they provide a set of principles and a series of templates for midwifery leaders in the future.

Chapter 1

Midwifery Leadership: Theory, Practice and Potential

Sheena Byrom and Lesley Kay

Introduction

In 2008 the World Health Organization (WHO 2008) highlighted consistent leadership as a vital element to improve maternal, newborn and child health, and as a crucial component for progress towards Millennium Development Goals 4 and 5. Whilst this is a global strategy, many countries are also individually promoting positive leadership as key to promoting safe and appropriate maternity care.

This chapter will provide an overview of theory underpinning the concept of leadership, with a particular focus on maternity services and midwifery care. It provides the reader with a basic insight into the current position of leadership within maternity services, and into the potential for improvement and aspirations for the future. Whilst reference is made to other countries, the majority of the examples of current practice apply to the UK.

Leadership and Leaders: Theory, Styles and Traits

Leadership theory has been debated for centuries throughout the world, and yet it remains difficult to give a precise and agreed definition to the word 'leadership' (Mullins 2009). Put simply, it could be described as a relationship through which one person influences the behaviour or actions of other people in the accomplishment of a common task (Mullins 2009).

The concept of leadership is related to motivation, communication and interpersonal skills (Tack 1984) and has been suggested as the critical variable in defining the success or failure of an organisation (Schein 2004). Successful leaders have emerged within community groups, religious circles, political arenas and armed forces, and their talents have ranged from leading a few individuals to leading whole countries.

It could be useful to consider the following suggestions from Anderson et al. (2009) when trying to navigate the leadership phenomenon.

Leadership (and management) is about dealing with the boundary between order and chaos – management leans more towards the order side and leadership more towards the chaos/complexity side. The issue is to balance the maintenance of what is useful (unless it is dysfunctional) while developing the new, and managing the transitions from one state to another.Leadership has become much more prevalent as a word and concept and has taken over from management, important in the era of manufacturing.Good management is added to, not replaced, by leadership. Well-led change needs good management to implement and maintain it.Leadership as an activity has in recent years been seen to be more distributed. Although it is still seen as the responsibility of a significant few, it is also a concern of the many who can have significant impact. Leadership is in part about human capital, contained in individuals, but also partly about social capital, embedded in collectives and their relationships: teams, networks, whole organisations and even sectors and regions. This presents real challenges for leadership development.

Leadership is an integral part of the social structure and culture of an organisation (Mullins 2009). When contemplating organisational culture, consideration should be given to how leaders create culture, and how culture defines and creates leaders (Schein 2004). Interestingly, and relevant to this chapter, the Care Quality Commission (2008), in its survey of all UK maternity services, reported that poor morale and ineffective or authoritarian leadership are commonly linked. The Commission noted that this is likely to contribute to a less effective service. It recommended that hospital organisations (trusts) need to consider the culture within their maternity services.

The so-called ‘Great Man’ and ‘Trait’ theories were the basis for most leadership research until the mid-1940s (Bednash 2003) These theories suggest that leaders are born and not made, and that leaders possess certain innate qualities or characteristics such as interpersonal skills, judgement and fluency (Bass 1990). Contemporary opponents of these theories (Cook 2001; Gould et al. 2001) argue that leadership skills can be developed and are not necessarily inborn. Handy (1993) describes a major flaw of the trait theories: they disregard the influence of others or the situation on the leadership role. Trent (2003) agrees, maintaining that leadership requires collaborators more than charisma.

Vroom & Yetton (1973) and later Vroom & Jago (1988) developed a model called situational contingency theory. This theory considers how and the degree to which the leader engages his or her team members in the decision-making process (Vroom & Jago 2007). It suggests that the same leader can use different group decision-making approaches depending on the characteristics of each situation. ‘Style’ theory succeeded both trait and situational theories and concentrates on what effective leaders actually do as opposed to what sort of person they are. Leadership in this context is understood as a set of behaviours rather than a set of traits.

Lewin et al. (1990) undertook seminal work on leadership styles. They considered some leaders' need to demonstrate a degree of dictatorial authority as opposed to the readiness of other leaders to assume a more democratic role. Leaders taking an autocratic stance make decisions without consulting others. Ralston (2005) describes this type of style as ‘authoritarian’. Communication is top-down and staff are not expected or encouraged to take the initiative. In contrast, in the democratic style, the leader involves others in decision making and is often described as ‘participative’. This is usually appreciated by people and improves staff morale and ownership; however, problems can arise when there is a wide range of opinions and there is no clear way of reaching an equitable decision. In another approach, the laissez-faire style of leadership minimises the leader's involvement in decision making. Those of this ilk tend to lead by virtue of their position in the organisation, without necessarily displaying leadership skills (Ralston 2005).

Burns (1978) conceptualised leadership in terms of a leadership–member exchange model, a two-directional process between follower and leader. This differentiates between transactional and transformational leadership styles. Transactional leadership occurs when one person takes the initiative in making contact with others for the purpose of making an exchange (Conger & Kanungo 1994), whereas transformational leaders communicate positive self-esteem and empowerment of followers (Davidhizar 1993).

Transformational Leadership

The leadership style that is increasingly advocated in the healthcare literature is that based on the transformational model (Kouzes & Posner 2007). Ralston (2005, p.35) defines transformational leadership as ‘inspirational and empowering, challenging thinking and offering informal rewards at every opportunity’. Coggins (2005) suggests that leaders using this model tend to motivate others to apply their own leadership behaviours. The transformational leader attempts ‘to engage the full person as the follower’ (Ralston 2005, p.35).

Some have argued that transformational leadership styles have parallels with feminist theories, specifically where they act to empower women (Helgesen 1990; Coggins 2005). Indeed, Helgesen describes a set of feminine principles which are argued to guide women's typical leadership behaviour: caring, being involved, helping, being responsible, making intuitive decisions and structuring organisations as networks rather than hierarchies.

Transformational leadership is well established in the literature. One of the most clearly articulated and rigorously tested contributions is the ‘five practices of exemplary leadership’ model (Table 1.1) (Kouzes & Posner 2007). In 1983, Kouzes and Posner set out to establish what it was that leaders did when they realised their personal best in leading rather than managing others (Van Maurik 2001). The five key elements Kouzes and Posner describe are elemental practices that enable leaders to get things done. According to Kouzes and Posner, leadership starts where management ends and where ‘systems of control, reward, incentive and overseeing give way to innovation, and where individual character and courage of convictions can achieve great things’ (Van Maurik 2001, p.109). Leadership, they argue, is not about personality but about behaviour and relationships.

Table 1.1 The five key elements of transformational leadership (Kouzes & Posner 2007). Descriptors added by Kay (2007)

ElementDescriptorChallenging the processBreak new groundSearch for the potential to progress and evolvePrepared to take the risk of failingModelling the wayAct as a role modelBe transparent about vision and valuesAct consistently within those valuesInspiring a shared visionExhibit belief and enthusiasmEnlist and motivate othersEncouraging the heartAcknowledge contributionsCelebrate achievementsEnabling others to actEstablish trustBuild strong relationshipsEngage everyone involvedEmpower others

Leadership Characteristics and Traits

Pashley (1998) suggests that, on the basis of research, theory and practice, the range of prescriptive characteristics, qualities and skills that can be attributed to a leader is vast. Kouzes and Posner's (2007) research, for example, single-handedly recognised 255 characteristics of leadership. In their study profiling nursing leaders, Antrobus and Kitson (1999, p.750) identified common themes from the interview data which enabled them to outline the ‘skills repertoire’ of the ‘future nurse leader’ (Box 1.1).

Box1.1 Leadership traits identified by Antrobus and Kitson (1999)

A powerful influential operator – empowering relationships created with othersA strategic thinker – creating meaning and supporting learningA developer of nursing knowledge – assimilating research evidence with practiceA reflexive thinker – having a clear understanding of values, purpose and personal meaningA process consultant – working through and with others to achieve transformational change

Although it is not clearly stated in the research report, the inference is made that leadership relates to occupying a certain hierarchical status within an organisation. On the other hand, Christian and Norman (1998) identified ten elements that are central to the clinical leader role at all levels. This core set of attributes was considered applicable across clinical settings and specialties. In addition to co-ordinating and managing abilities, the core characteristics included encouraging staff ownership of changed practices as well as enabling staff development, supporting and motivating the team, networking, and acting as a change agent. In their report, the authors summarize the data by outlining a ‘profile’ of a nurse development unit clinical leader. Although this makes for an interesting read, there is no clear explanation in the text of how this profile was determined; it is therefore difficult to see how the core set of attributes can be applicable across settings and specialties.

An understanding of the constraints on clinical leaders, especially in relation to their position in the organisational hierarchy, emerged from Christian and Norman's (1998) study. Those without managerial responsibility who had the potential to produce a vision for the future lacked authority to make it happen, and those who had managerial authority at a strategic level could not extricate themselves from administration to be creative in clinical practice.

Conversely, Stanley's study of clinical leaders in paediatric nursing (2004, p.42) determined that clinical leadership, in this specific setting, was not tied to a hierarchical position and that clinical leaders are seen as nursing staff who are ‘able to be supportive, cope well with change in the clinical environment … guide, motivate, act as an advocate, inspire confidence, think critically and remain clinically competent’. According to Stanley (2004), the study demonstrates that clinical nurse leaders exist across the gamut of nursing grades, principally in relation to nurses with a strong clinical focus. Stanley does acknowledge, however, that the study findings could be limited by the fact that the participants were settling in to new surroundings (which could have affected their responses).

Leadership and Health Services: The UK Example

Both leadership and quality improvement are high on the National Health Service (NHS) agenda in the UK. Appropriate and effective leadership is critical to the transformation and improvement of health care (Reinertsen et al. 2008; Health Foundation 2009a, 2009b), with consideration given to both clinical and strategic leadership. For healthcare organisations in particular, leadership capabilities need to be nurtured and expanded at all levels, and within all professions. Indeed, David Nicholson, Chief Executive Officer for the NHS (NHS 2009), proclaimed:

We are extremely lucky to already have fantastic leaders throughout the National Health Service. But if we are to realise our vision of an NHS that puts quality at the heart of everything it does, we need to embrace more leaders from all levels in the service and from a wider range of backgrounds.

For midwives, other professionals and citizens of the UK, there are programmes of learning for aspiring leaders, and established pathways to recognise those who demonstrate exceptional capabilities (Cabinet Office 2009; NHS 2009). In 2009, the UK's Department of Health established a National Leadership Council (DH 2009a) to assist with implementing actions from the final report of Lord Darzi's Next Stage Review (DH 2009b). This document is clear in its support for, and championing of, leadership in the NHS and has a clear framework for delivering the agenda (Dawson et al. 2009). Part of the remit for the Council is to seek transformational change in the culture of leadership, with much emphasis on encouragement, support and mentoring.

Maternity Care and Midwifery Leadership

It has been suggested that there is a lack of midwifery leadership in other countries too, and the International Confederation of Midwives (ICM) has set up a Young Midwifery Leadership Programme to address this (ICM 2010). Specifically, the UK Department of Health has suggested that the lack of midwifery positions at a senior level within some UK hospitals may have contributed to poor quality of care (DH 2009b).

The ability of midwives to be strategic leaders in service, policy and higher education requires that these roles are there to start with; and that midwives have the expertise, credibility and leadership skills to represent our profession and its contributions.

(DH 2009c, p.32)

This statement is taken directly from a recent UK midwifery directive, and captures in one paragraph the current situation in relation to UK midwifery leadership. The document describes the importance of the midwifery contribution to the maternity governance agenda, and suggests that when there is midwifery influence at board level, it enhances the opportunity for midwifery leaders to engage in decisions about strategies and systems that meet the needs of women and their families. Within the UK, midwifery leaders are evident to some degree in strategic, academic and direct service positions. Professors of midwifery, consultant midwives, heads of midwifery and the General Secretary position at the Royal College of Midwives are strategic roles, and many of the individuals in those roles have influence at a national and international level. In addition, midwives lead teams, including those that are multidisciplinary, and there are others demonstrating leadership capabilities through their clinical work as midwives. Even so, there is a perceived lack of leadership in maternity services in the UK, and this has been highlighted in reports relating to the safety agenda (Care Quality Commission 2006; King's Fund 2008).

As with general healthcare, leadership within maternity services needs to occur at all levels and within each element of the multidisciplinary team. For maternity services, the evidence in relation to the safety of maternity services highlights difficulties with leadership and management, stating that maternity teams are not always clear about leadership and are not always well managed (King's Fund 2008). In addition, in 2006 a report on the investigation into ten maternal deaths in one UK maternity service revealed a distinct lack of leadership (Care Quality Commission 2006).

As midwifery-led care expands within the UK, there is increasing debate as to who ‘leads’ the management of maternity care overall. The Care Quality Commission (2008) asked members of maternity teams throughout the UK who led maternity care. Rather worryingly, both midwives and medical staff perceived that it was their professional group (Figure 1.1). This result could be viewed as lack of defined leadership or a deficit in understanding of roles in general. It could also be the result of lack of team work, collaboration and shared goals, and suggests a continuation of the historical pursuit of power and control between professional groups and hierarchies (Donnison 1988).

Figure 1.1 Perceptions of sources of leadership in the maternity unit by professional group. HCC (2008) survey of Maternity staff 2007

The recent King's Fund Safe Births document (King's Fund 2008) maintains that healthcare is in the process of moving away from a traditional hierarchical model of organisation and leadership towards a team approach, which should include midwifery supervisors, managers, consultant midwives, educationalists and other professionals. A strong, integrated team enhances the capacity of clinical midwives to offer flexible and relevant woman-centred care. In her seminal book on effective teamwork, West (2004) suggests that traditional leaders tend to direct rather than facilitate and support, to give rather than seek advice and to determine rather than integrate views. Current UK policy on maternity services reminds maternity care workers of the excellent opportunities to work in partnership with the leads of other professional groups, such as non-clinical managers and midwives, and in leadership positions in other sectors, such as policy bodies and universities (DH 2009a). Ralston (2005) is of the opinion that this is happening in practice, and that the delivery of midwifery care is changing from a task-oriented approach to a team approach, where midwives collaborate with others to provide holistic care. Chapter 9 debates the benefits of collaborative working in maternity services in more detail.

The Care Quality Commission's (CQC) monitoring of maternity services (Care Quality Commission 2008) highlights considerable variations in quality of care received by women across the UK. Pressure groups such as the Association for Improvements in Maternity Services (AIMS: see www.aims.org.uk) and the National Childbirth Trust (see www.nctpregnancyandbabycare.com/home) are continually striving to improve quality within maternity care systems. It is imperative that all midwives understand their leadership role in the delivery of high-quality care, on a day-to-day basis. It could be argued that midwives ‘lead’ women during the childbirth continuum in their daily work, leading parent education sessions, for example, and facilitating birth. The way midwives ‘lead’ women or other midwives needs to be considered at all times if quality of care is to be improved. Byrom and Downe's (2010) research suggests that to become effective clinical leaders and to empower themselves and their organisations, midwives need to discover and utilise certain philosophies that underpin midwifery in relation to the women and families they care for. That is, a midwife who successfully empowers women could, as a leader, have the capability of empowering his or her followers. Chapter 2 debates this theory in more detail, and Chapter 3 gives some examples from local case studies.

There are midwives in successful leadership positions influencing services at local, national and international levels, from academic and strategic positions (for example, see Chapter 4).

What Does this Mean for Midwifery?

Leadership characteristics, traits and philosophies have been briefly outlined above, but how does this relate to the progression and expansion of midwifery leadership? The early ‘trait’ theories of leadership that suggest leaders have inborn qualities, rather than acquired skills, could be related to some midwifery leaders who possess a natural ability to lead others. It could be argued, however, that those midwives ‘learnt’ the skill by working closely with positive role models, which would conform with the views of Handy (1993), who firmly believed in the influence of others on the leadership role.

Theories such as those based on ‘situational contingency’ describe particular characteristics for dealing with situations, and ‘style’ theory relates to what the leader actually does. In the complexity of maternity care, it could be suggested that midwives need to utilise some aspects of each of these theories. This would reflect the need to be flexible and responsive to changing situations, and to accommodate the fact that actions may need to change from time to time according to a particular situation.

Historically, midwifery leadership followed the health service model of authoritarian ‘top-down’ approaches to leading services. Curtis et al. (2006) have elaborated on the effects of institutionalised bullying in maternity care, as a reason for midwives leaving the profession. Whilst there may be occasions when it is necessary for midwifery leaders to assume responsibility and make decisions without consultation, a democratic style of leadership may be more acceptable. Pashley (1988) suggests that transactional leadership, described as a process of mutual influence and coalition building, is important for midwives, as they are required to work in partnership with an array of other professionals. In a metasynthesis of the qualitative literature relating to the ‘good’ leader, Byrom and Downe (2010) note that the traits associated with such leaders could be described as transformational. It could be suggested that leadership traits and characteristics might usefully be identified within individual midwives and then nurtured, supported and developed accordingly.

Developing Midwifery Leadership: Planning for the Future