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

Jessica Berentson-Shaw11Auckland Regional Public Health Service, New Zealand and err! Price11Auckland Regional Public Health Service, New Zealand 1Auckland Regional Public Health Service, New Zealand Correspondence to: r !essica "erentson#Shaw, Auckland Regional Public Health Service, 11 orking Road, "rookl$n, %ellington, New Zealand& 'a(: )*+ ++,1 -*.,/ e# 0ail: 1essicaberentson2g0ail&co0

Abstract
"b#ectives$ Health %ro&otion is a core 'unction o' %ublic health services and i&%roving the e''ectiveness o' health %ro&otion services is an essential %art o' %ublic health service develo%&ent( )his re%ort describes the rationale, the %rocess and the outco&es o' a realign&ent designed to i&%rove the e''ectiveness o' health %ro&otion activities in a %ublic health unit *PH+, in New Zealand( -ethods$ A %ractice environ&ent anal!sis revealed several 'actors that were hindering the e''ectiveness o' the health %ro&otion unit.s *HP+, activities( )wo %ri&ar! change &echanis&s were i&%le&ented( )he 'irst was an outco&es-'ocused &odel o' %lanning and service deliver! *to su%%ort evidenced-based %ractice,, the second was the reorganisation o' the HP+ 'ro& a to%ics-based structure to an integrated one based on a &ulti-risk 'actor %aradig& o' %o%ulation health( Results$ /uring the realign&ent barriers were encountered on &ulti%le levels( At the individual level, un'avourable attitudes to changes occurred because o' a lack o' in'or&ation and knowledge about the bene'its o' evidence and research( At higher levels, barriers included resourcing concerns, a lack o' organisational co&&it&ent and understanding, and tensions between the %olitical need 'or e0%edient change and research and develo%&ent need 'or ti&el! consideration o' the i&%act o' di''erent &odels o' %ractice( 1onclusions and 2&%lications$ )his realign&ent took %lace within the conte0t o' a changing %ublic health environ&ent, which is signi'icantl! altering the deliver! o' %ublic health and health %ro&otion( Realign&ents designed to 'acilitate &ore e''ective health %ro&otion and %ublic health %ractice will continue, but need to do so in the light o' others3 e0%erience and debate( Health %ro&otion in New Zealand has traditionall! been a core activit! o' health services( Although not alwa!s %h!sicall! located within %ublic health units *PH+,, health %ro&otion is beco&ing &ore aligned with conventional %ublic health %ractice( As a result, the disci%line o' health %ro&otion has been re4uired to %rove its contribution to %o%ulation health gain(

Health %ro&otion theor! is robust and scienti'ic5 research has revealed, however, that the theor! is not alwa!s translated into %ractice( 1 )he challenge 'or the larger %ublic health disci%line is to 'ind wa!s to ensure that health %ro&otion theor! is 'ull! integrated into health %ro&otion %ractice and that health %ro&otion activities are contributing to %o%ulation health gain( Public health structure in New Zealand 2n New Zealand, health %ro&otion services *and other %ublic health services, are contracted %ri&aril! b! the -inistr! o' Health and are delivered b! a co&bination o' govern&ental and non-govern&ental organisations(1 )he largest govern&ent-based %roviders o' health %ro&otion services are the regionall! based PH+s( 2n the 'uture, the recentl! established, govern&ent-'unded %ri&ar! health organisations &a! assu&e this role( )he PH+ that is the 'ocus o' this %a%er serves the &ost heavil! %o%ulated and ethnicall! diverse region in New Zealand( 2t has 'our business units that deliver services relating to$ health %ro&otion, co&&unicable disease %revention and investigation, %ublic health intelligence, and environ&ental health( 2t is changes &ade to the health %ro&otion unit *HP+, that are the 'ocus o' this re%ort( )he conte0t 'or these changes is %rovided b! structural changes that were occurring in the PH+ at the ti&e( Implementing effective health promotion practice )he broad ai& o' the changes discussed in this %a%er was to i&%le&ent &ore e''ective %ractice in the HP+5 &ore s%eci'ic ai&s, however, were re4uired to achieve this end( A wide review o' several discrete and varied bodies o' literature relating to health %ro&otion, %ublic health and organisational structures and s!ste&s was undertaken to in'or& these &ore 'ocused ai&s( Relevant issues drawn 'ro& each bod! o' literature are discussed below in brie' detail( 6hile the health %ro&otion literature identi'ies several general 'eatures o' health %ro&otion %ractice, evidenced-based %ractice *which we take to &ean the use o' evaluation and research to design, deliver and &easure the i&%act o' health %ro&otion activities, is dee&ed critical 'or e''ectiveness( 1ruciall!, the use o' evidence in health %ro&otion %ractice in New Zealand or Australia is not a%%reciabl! e&%hasised( 1 7 A large bod! o' clinical and non-clinical literature has e0%lored reasons as to wh! evidence-based %ractice is not e&%hasised in health settings and within health %ro&otion s%eci'icall! it has been suggested that there &a! be a lack o' disse&ination o' evidence and a %oor understanding o' evidence and research in general( However, i&%le&entation research has 'ound that disse&inating evidence &ore widel! and &aking it &ore accessible has not been 'ound to 'acilitate evidence-based %ractice( 8 9 )he organisational literature &a! o''er so&e answers as to wh! this &a! be the case( Research has 'ound that the use o' research and evaluation in %ractice *in all health settings including health %ro&otion, is hindered b! organisational resources and

in'rastructures that do not %ro&ote and su%%ort evidence-based %ractice( : ; <0a&%les o' this include an organisation 'ailing to co&&it 'inancial resources to activel! undertake research, not i&%le&enting role-s%eci'ic structures that su%%ort sta'' in the develo%&ent o' their research skills, and not encouraging or e&%hasising research %artnershi%s( )he literature suggests that organisational s!ste&s and structures &a! need to be changed or develo%ed when the! i&%inge u%on the success or e''ectiveness o' activities and outco&es o' that organisation, in this case evidence-based and e''ective health %ro&otion %ractice(9,1= 2n light o' the literature, the 'irst ai& o' the changes was to identi'! an organisational s!ste& that would %rovide a conte0t and su%%ortive environ&ent 'or evidence-based health %ro&otion %ractice( A review o' the organisational literature *relating s%eci'icall! to %ublic health %ractice, identi'ied that, in addition to an organisation.s s!ste&s, certain service deliver! structures are %rohibitive 'or %ublic health %ractice e''ectiveness and organisational develo%&ent( S%eci'icall!, vertical or to%ics-based structures are %roble&atic( 11,1> )o%ics-based or vertical structures have been identi'ied as contributing to structural in'le0ibilit! and the! also reduce a health s!ste&.s abilit! to u%scale activities and &eet conte&%orar! health challenges, due in %art to the 'unding restrictions that can occur in to%ics-based structures(?,11 A review o' health s!ste&s in Australia indicated that to%ics-based structures %roduce %rogra&s that have little re'erence to one another and this creates an inabilit! to addresses &ulti%le health issues(11 )o%ics-based structures can also lead to single-disci%line a%%roaches to health issues, where &ultidisci%linar! a%%roaches are &ore e''ective and at worst the! &a! %roduce %oorer outco&es and higher costs(1?,17 )here are, however, structures that have been identi'ied as bene'icial5 structures %lanning and deliver! s!ste&s that generate 'le0ible, integrated and res%onsive health %ro&otion activities and that enco&%ass ecological a%%roaches to %ublic health are increasingl! recognised as having the %otential to achieve the &ost traction 'or health gain( 1> <cological a%%roaches recognise and work to i&%rove health within a s!ste& o' disease, health and risk behaviours, environ&ental 'actors, and health and social s!ste&s( )he second ai& o' changes &ade to the HP+ and discussed in this %a%er was to investigate and identi'! the s%eci'ic structural issues in the deliver! o' services that were i&%eding the e''ectiveness o' the HP+, and to i&%le&ent an i&%roved s!ste&(

Method

Analysis of current practice and structure )he 'irst stage o' the %rocess was an anal!sis o' the HP+.s %ractice environ&ent, as is reco&&ended(9 @or i&%artialit!, the anal!sis was undertaken b! an e0ternal consultant( )he anal!sis included a stocktake o' current activities in the HP+ and an e0a&ination o' the %rogra& %lanning, deliver! and re%orting %rocesses( )he consultant was asked to look

s%eci'icall! at organisational and structural issues( )he results called two issues to attention( )he 'irst issue related to the out%uts-'ocused 'ra&ework o' deliver!( "ut%uts-'ocused service deliver! 'ocuses on re%orting on the i&&ediate %roduct or services o' the %ublic health activit!,18 'or e0a&%le the nu&ber o' health %ro&otion %rogra&s being delivered( "ut%uts-'ocused service deliver! 'ra&eworks are t!%ical 'or &ost PH+s in New Zealand5 however, the! do not su%%ort evidence-based %ractice as evaluating health i&%rove&ent is not a %rere4uisite o' re%orting( )he second issue that was called to attention was that the current structure did not enco&%ass a &ulti%le deter&inants and &ulti%le outco&es view o' %ublic health( )he HP+ was continuing to engage in historical work with little or no view to e&erging health issues, and there tended to be a single disci%line a%%roach to activities5 all this was due in %art to the to%ics-based structure o' the tea&( )he anal!sis indicated that changes to the service deliver! 'ra&ework and the HP+ structure were necessar!( Implementing outcomes-focused service delivery )o address issues with the out%uts-'ocused service deliver! 'ra&ework, an outco&es'ocused &odel o' deliver! was %ro%osed not #ust 'or the HP+, but 'or the entire PH+( )he outco&es-'ocused service deliver! &odel had e0isting reco&&endations internationall!1:,19 and within New Zealand(1A,1; 6ithin outco&es-'ocused &odels o' deliver!, re%orting is done on the 'inal result *or outco&e, o' %roducts and services delivered b! the PH+(18 2n the case o' PH+s, these 'inal results are wider health targets or outco&es, 'or e0a&%le the rate o' cancer in a target %o%ulation( "utco&es-'ocused re%orting ensures that the evaluation o' health outco&es occurs and is related to service activities and service review( > <valuation beco&es a s!ste&atic and organisation-driven activit!( As activities &ust be linked to health achieve&ent, during %lanning there is an increased 'ocus on research concerning the likel! success o' %rogra&s( "utco&es-'ocused service deliver! re4uires that organisations engage in onl! a li&ited nu&ber o' activities( )hese activities are in'or&ed b! a Bvital 'ew3 health outco&es or targets( <ach vital health outco&e has an indicator 'or evaluation and re%orting %ur%oses(1A Reducing %er'or&ance indicators to a vital 'ew is seen to assist organisations in &ore e''icientl! assessing their own e''ectiveness( >= /escribed in @igure 1 are so&e o' the sources that were used to identi'! the vital 'ew outco&es 'or our PH+( )heses sources can and o'ten do include activities that have been or are success'ul in the PH+5 the setting o' the vital 'ew allows 'or a new or di''erent e&%hasis to be %laced on these activities and how their e''ectiveness is &easured( @urther in'or&ation on outco&es'ocused deliver! and &anage&ent is available in &ore detail(1A,1; 6hen setting the outco&es 'or the HP+, the vital 'ew outco&es o' the PH+ served to in'or& how conventional health %ro&otion activities within the unit could be reoriented

into contributing to the achieve&ent o' the PH+.s outco&es and what new activities could be develo%ed( )he outco&es 'or the HP+ were outco&es that the unit intended to achieve within 1= !ears( )his ti&e 'ra&e was s%eci'ied to encourage a sustainable a%%roach to %rogra& design and deliver!( )he HP+.s outco&es were develo%ed with outco&e indicators and *where a%%ro%riate, out%ut indicators( )he outco&e indicators *also know as i&%act indicators, were short-ter& &easures *i(e( annual, assessing the health achieve&ent or gain attributable to the HP+.s activities( "utco&e indicators *e(g( i&%rove&ent in oral health behaviours, changes in housing %olic!, bod! &ass inde0 changes, ensure that outco&es can be &eaning'ull! related to %rogra& e''ectiveness5 the! also give a%%ro0i&ations o' health gain without needing to rel! solel! on e%ide&iological data, which can be %roble&atic when ti&el! results are critical 'or in'or&ing 'urther %ractice( )he HP+.s outco&es were used to in'or& the develo%&ent o' its activities *discussed in the 'ollowing section, and served as &easures o' the success o' those activities5 this increases the e''ectiveness o' outco&es-'ocused work(> @igure 1 %rovides an overview o' how the outco&es 'or the HP+ were develo%ed( )he HP+.s outco&es were also in'or&ed b! regional ga%s in health %ro&otion services, 'or e0a&%le as 'a&il! violence %revention was not being delivered b! an! other service in the region it was set as an outco&e area( "ut%ut indicators were in'or&ed b! current literature and available data sources as the! related to the outco&es( Implementing an integrated structure )he structure o' the HP+ %rior to reorientation is outlined is @igure >( )he structure was develo%ed around 'our to%ics$ tobacco, alcohol, nutrition and social environ&ents( 2ndividuals were recruited to work within a s%eci'ic tea& and to 'ocus on a single to%ic( )he di''iculties with this structure were that it did not enco&%ass an ecological view o' health, it %revented the HP+ 'ro& undertaking work in e&erging health issues, and it encouraged a single disci%line a%%roach to activities5 a new structure was re4uired to address these %roble&s( )he new structure needed to 'ul'il the 'ollowing re4uire&ents$ to 'oster an &ultidisci%linar! a%%roach to %rogra&s5 to allow concurrent work on %o%ulation health gain and health ine4ualities5 to su%%ort %rogra&s that would address &a#or risk 'actors 'or %oor health while encouraging 'le0ibilit! as to what risk 'actors were addressed and when5 and to encourage the develo%&ent o' %rogra&s that acknowledged both a li'ecourse and social deter&inants %ers%ective to health and well-being(>1,>> 2nitiall!, several %ositions changes were &ade to bring a greater variet! o' skills and disci%lines into the HP+( e! new %ositions that were established included a -Cori %olic! adviser, a health strategist and %lanner, dedicated %ro#ect &anagers, health %ro&otion %ractitioners with a 'ocus on strategic relationshi%s, a social &arketer and a trainer 'acilitator( 1hanges were also &ade to the &ini&u& co&%etencies that were re4uired in e0isting %ositions to su%%ort evidenced-based %lanning and %ractice( )able 1 contains a list o' all the original %ositions and those in the newl! con'igured HP+(

@ollowing the %osition changes, a new unit and %rogra& deliver! structure was develo%ed( 2t was guided b! s!ste&s d!na&ics theor!>? and reco&&endations 'ro& relevant %ublic health re%orts(11,1> )he ai& o' the new structure *outlined in @igure ?, was to allow a &ultidisci%linar! and 'le0ible a%%roach to %ublic health issues %ri&aril! b! &oving awa! 'ro& roles that were single to%ic 'ocused( S%eci'ic health to%ic tea&s were also re&oved to ensure there was roo& 'or res%onsive activities when e0isting health issues changed, new ones e&erged, or 'unding was altered( )he HP+ o' a%%ro0i&atel! 7= individuals was divided into three &ultidisci%linar! re%orting grou%s( )he 'irst grou% was %ri&aril! 'ocused on health gain 'or the general %o%ulation, the second grou% 'ocused on grou%s at high risk o' %oor health, while the third grou% was a technical advisor! grou% with evaluation, %ublic health &edicine, -Cori %olic! and %ublic health %lanning e0%ertise( )o ensure that all %rogra&s would have a &ultidisci%linar! and varied %o%ulation grou% a%%roach, unit &e&bers re%resenting all three o' the re%orting grou%s were assigned to work on each %rogra&( As &entioned, the %rogra& areas are in'or&ed b! the HP+ outco&es and are reviewed regularl!( )he structure allows changes to be &ade to the %rogra& areas on the basis o' need, evidence o' e''ectiveness o' the %rogra&, and %olic! re4uire&ents, without leading to 'unding co&%lications or 'urther restructures( )he new structure was also designed to allow individuals to have so&e 'le0ibilit! and variet! in their work areas, to discourage a single-to%ic 'ocus 'ro& develo%ing, and to build the knowledge ca%acit! o' the tea&( )his structure and the outco&es-'ocused service deliver! 'ra&ework were i&%le&ented concurrentl!(

esults
)he changes that have been described above occurred over a si0-&onth %eriod in late >==8( /uring i&%le&entation several barriers were encountered( As is co&&onl! the case,>7 these barriers e0isted at &ulti%le levels ranging 'ro& individual through to organisational and %olitical( )he individual-level barriers that were encountered related %ri&aril! to a lack o' in'or&ation and knowledge about the bene'its o' evidence and research( )his led to un'avourable attitudes to changes that were ai&ing to ensure evidence and research were a %art o' nor&al, ever!da! activit!( )o address this issue, we used the e0isting social networks within the work%lace to co&&unicate the bene'its o' evidence-based %ractice(9,>7 @ollowing reco&&endations,>8 we identi'ied knowledge stewards within the HP+ who were &ore rece%tive to the use o' evidence in %ractice( )hese stewards were used to %rovide leadershi%, collaboration and collegial su%%ort 'or evidence-based %ractice( 2ndividual ca%abilit! to undertake re4uired research and evaluation activities and to identi'! e&erging health issues within the conte0t o' govern&ent %olic! and direction was another barrier to the change( 1a%acit! building was addressed through 'inancial and resource co&&it&ent to 'urther training( A basic guide and worksho%s were %rovided on

how to review and s!nthesise research evidence, a se&inar series e0%loring various %ublic health issues including e''ective %artnershi%s, %rogra& %lanning, -Cori health gain and health ine4ualities was established, and evaluation worksho%s were %rovided( )he co&&it&ent to ca%acit! building is ongoing( /uring the realign&ent, other organisational bodies did use the situation to atte&%t to drive structural changes that had little or no su%%orting evidence regarding their contribution to activit! e''ectiveness( 2t was 'ound that e0%licit 'ra&eworks e0%laining the changes, alongside su&&aries o' the research detailing the s%eci'ic ai&s and intended results o' the realign&ent, needed to be %rovided %rior to i&%le&entation to ensure &anage&ent and 'unding bodies understood and su%%orted the changes in the re4uired 'or&at( Political e0%edienc! and contractual re4uire&ents re4uired that changes be i&%le&ented and in %lace as 4uickl! as %ossible( )his allowed 'ew o%%ortunities to e0%lore di''erent &odels o' %ractice or to rigorousl! evaluate s!ste&s change( As has been %ointed out, organisational change is %ri&aril! %ut in %lace 'or &ore e''ective service deliver!, not 'or knowledge i&%rove&ent %ur%oses(17 )his issue leads to two concerns$ 'irst, a lack o' available evidence regarding e''ective organisational structures *a %roble& we 'aced in the %ublic health and health %ro&otion literature,5 and, second, a lack o' su%%ort 'ro& health care &anage&ent to see bene'it in taking ti&e to both research and %ro%erl! evaluate realign&ents( 2t has been suggested that in docu&enting and re%orting barriers to an! health s!ste&s change i&%ortant conte0tual in'or&ation is %rovided and wider su%%ort 'or changes *such as those we i&%le&ented, is brought about through knowledge trans'er(>8 A nu&ber o' recognised &echanis&s were used in an atte&%t to disse&inate in'or&ation about the changes &ade to our HP+ to govern&ent 'unding bodies, other %ublic health and health %ro&otion services and research bodies interested in health s!ste&s( At a s!ste&s level, there also e0isted so&e barriers to the realign&ent( )he %ri&ar! issue was a dearth o' s!nthesised evidence on health %ro&otion interventions( Putting in %lace structures and s!ste&s that encourage evidence-based %ractice is relativel! &eaningless i' the user cannot access research or 'ind relevant knowledge to in'or& their decisions( )o this end, encouraging s!ste&atic reviews o' %ublic health interventions, 'ocusing on carr!ing out evaluations on e0isting health %ro&otion and %ublic health activities using a%%ro%riate &ethodologies and outco&es-based &easures, should be encouraged( )he changes i&%le&ented in our HP+ ai&, in %art, to address the lack o' evaluation in the %ractice environ&ent(

!onclusions and Implications

and there is %ressure 'or the %roduction o' evidence o' e''ectiveness( Such an environ&ent re4uires a di''erent wa! o' working5 it also re4uires a new wa! o' viewing health %ro&otion deliver!( )his %a%er does o''er a strong, evidence-based &odel 'or other %ublic health and health %ro&otion units when the! are considering changes to i&%rove the e''ectiveness o' their activities( 6hat is signi'ied b! such changes is a &ove awa! 'ro& health %ro&otion as a %ro'ession( 2ncreasingl!, health %ro&otion is being viewed and used as a tool delivered b! &ulti%le %ro'essions and organisations( )his &ove has resulted in uncertaint! 'or conventional health %ro&otion %roviders as the! struggle to understand their %lace( Research, debate, and discussion on the issue, which &a! hel% to alleviate so&e o' this uncertaint!, are scarce at the %ractice level( "ur e0%eriences indicate that changes i&%le&ented to kee% %ace with the evolving %ublic health environ&ent have i&%ortant i&%lications 'or health %ro&otion services( )hese need to be discussed and considered at the %ractice level( "ne o' the &ost critical issues 'or health %ro&otion, within an environ&ent o' &ulti%le %la!ers and &ulti%le disci%lines, is how to &aintain and &arr! the e0%eriences, knowledge, ethics and values o' %ractitioners 'ro& di''erent %ro'essional backgrounds *e(g( &arketing, research, %olic!, with conventional health %ro&otion ethics and values( A &ultidisci%linar! a%%roach has &a#or i&%lications 'or training, work'orce develo%&ent %lanning and the develo%&ent o' %ro'essional structural status( 1ertainl!, it is i&%ortant that the skills o' conventional health %ro&oters are not lost or overlooked in the %rocess( 6ithin a &ultidisci%linar! environ&ent &an! o' the new %ractitioners absorbed into the %ractice have had success'ul %ro'essional and acade&ic careers in other s%heres o' the %ublic and %rivate sector( Daluing di''erent %ers%ectives *we certainl! didn3 t bring the& on board to change the&, and acknowledging their worth within s%eci'ic and set e&%lo!&ent structures has its challenges, the i&%lication being that contracts and e&%lo!&ent agree&ents can in'luence the structure, deliver! and outco&es o' health %ro&otion and in wa!s that &a! not alwa!s su%%ort increased e''ectiveness in health %ro&otion( At a s!ste&s level, the &ulti%le %artner environ&ent re4uires a co&%rehensive health %ro&otion deliver! a%%roach, !et current contracting environ&ents o'ten 'ocus on the individual organisation, &aking it ver! di''icult to develo% a sector-wide a%%roach( Health 'unders need to e0%lore new wa!s o' 'inancing in light o' the changing environ&ent( Health %ro&otion services can initiate these e0%lorations( )he issues and challenges discussed here are not uni4ue to the disci%line o' health %ro&otion( A changing a%%roach to service %rovision and deliver! and organisation accountabilit! in all areas o' health and social care &ean other disci%lines 'ace si&ilar issues5 'indings 'ro& this %a%er &a! be generalisable to the&( How we in health res%ond to these issues will deter&ine the 'uture role o' health %ro&otion in %ublic health( 6hat is clear is that those in %ositions to &ake changes and res%ond to the challenges 'ro& outside the %ractice do so in a vacuu& o' debate, research

and evidence, both locall! and internationall!( )he challenge is 'or %ublic health and health %ro&otion itsel' to address these issues and initiate &uch-needed debate and research(

eferences
1(6ise-, SignalE( Health %ro&otion develo%&ent in Australia and New Zealand( Health Pro&ot 2nt( >===5 18*?,$>?9F7A( 1rossRe', 2S2 >(Nutbea&/, 6ise-( Structures and Strategies 'or Public Health 2ntervention( 2n$ /etelsR, -c<wanJ, BeagleholeR, )anakaH, editors( "0'ord )e0tbook o' Public Health( 3(4ord 5678 $ "0'ord +niversit! Press5 >==7( %( 1A9?FAA( ?(6orld Health "rganiGation( 6orld Re%ort on nowledge 'or Better Health$ Strengthening Health S!ste&s( 9eneva 5CH:8 $ 6H"5 >==7( 7(JonesS, /onovanR( /oes theor! in'or& %ractice in health %ro&otion in AustraliaH Health <duc Res( >==75 1;$ 1F17( 1rossRe', -edline, 2S2 8(BeroE, IrilliR, Iri&shawJ, Harve!<, "0&anA, )ho&son-( Ietting research 'indings into %ractice( Br -ed J( 1;;A5 ?19$ 7:8FA( :( ingE, HaweP, 6ise-( @ro& Research into Practice in Health Pro&otion$ A Review o' the Eiterature on /isse&ination( S$dne$ 5A6S;8 $ National 1entre 'or Health Pro&otion5 1;;8( 9(NHS( Ietting evidence into %ractice( <'' Healthc Bull 1;;;5 8$ 1F1:( A(1larksonJ( Ietting research into clinical %ractice-barriers and solutions( 1arries Res( >==75 ?A$ ?>1F7( 1rossRe', -edline, 2S2 ;(RetsasA( Barriers to using research evidence in nursing %ractice( J Adv Nurs( >===5 ?1$ 8;;F:=:( S!nerg!, -edline, 2S2 1=(-archJ, "lsenJ( <laborating the JNew 2nstitutionalis&J( 3slo 5N3R8 $ 1entre 'or <uro%ean Studies5 >==8( 11(National Public Health Partnershi%( Background Pa%er on 2ntegrated Public Health Practice$ Su%%orting and Strengthening Eocal Action( <elbourne 5A6S;8 $ NPHP5 >===( 1>(National Public Health Partnershi%( Preventing 1hronic /isease$ A Strategic @ra&ework( <elbourne 5A6S;8 $ NPHP5 >==1( 1?(Ha!nesR, Ha!wardR, Eo&asJ( Bridges between health care research evidence and clinical %ractice( J A& -ed 2n'or& Assoc( 1;;85 >*:,$?7>F8=(

-edline, 2S2 17(EavisJ, Posada@, HainesA, "sei<( +se o' research to in'or& %ublic %olic!&aking( Eancet( >==75 ?:7$ 1:18F>1( 1rossRe', -edline 18()he <uro%ean "bservator! on Health S!ste&s and Policies KHi) countr! %ro'iles %age on the 2nternetL( Brussels *B<E,$ 6H" <uro%ean 1entre 'or Health Polic!5 >==8 Kcited >==: @ebL( ;he 3bservator$=s Health S$ste0s 9lossar$( >==8( Available 'ro&$ htt%$MMwww(euro(who(intMobservator!Mglossar!Mto%%age( 1:(1enters 'or /isease 1ontrol( Pro&ising Practices in 1hronic /isease Prevention and 1ontrol$ A Public Health @ra&ework 'or Action( Atlanta 59A8 $ +S /e%art&ent o' Health and Hu&an Services5 >==?( 19(National Health Services( 6inning the 6ar on Heart /isease$ A Progress Re%ort( >ondon 5678 $ /e%art&ent o' Health Publications5 >==7( 1A(State Services 1o&&ission Kwork %rogra&s F state services research %age on the 2nternetL( 6ellington *NZ,$ )he 1o&&ission5 >==: Kcited >==: @ebL( <anaging 4or 3utco0es( State Services 1o&&ission5 >==:( Available 'ro&$ htt%$MMio(ssc(govt(nGM%ath'inderMin'or&ation(as%( 1;(Strategic <valuation Kho&e %age on the 2nternetL( Auckland *NZ,$ Parker /uignan Ei&ited5 >==7 Kcited >==: @ebL( /uignan P( Principles o4 3utco0e Hierarchies: Contribution ;owards a 9eneral Conceptual 'ra0ework 4or 3utco0es S$ste0s 53utco0es ;heor$8( Available 'ro&$ htt%$MMwww(strategicevaluation(in'oMseMdocu&entsM1>>%d''(ht&l( >=(1ra&%tonP, PereraR, 1rengleS, /owellA, Howden-1ha%&anP, earnsR, et al( 6hat &akes a good %er'or&ance indicatorH /evising %ri&ar! care %er'or&ance indicators 'or New Zealand( N Z -ed J( >==75 119$ A>=F?>( >1(Power1, HertG&an1( Social and biological %athwa!s linking earl! li'e and adult disease( Br -ed Bull( 1;;95 8?$ >1=F>1( -edline, 2S2 >>(-ar&ot-( -ultilevel a%%roaches to understanding social deter&inants( 2n$ Berk&anE, awachi2, editors( Social <%ide&iolog!( 3(4ord 5678 $ "0'ord +niversit! Press5 >===( %( ?7;F:9( >?(Ho&erJ, HirschI( S!ste&s d!na&ics &odelling 'or %ublic health$ background and o%%ortunities( A& J Public Health( >==:5 ;:*?,$1;F>8( 1rossRe' >7(IrolR, 6ensing-( 6hat drives changesH Barriers to and incentives 'or achieving evidence-based %ractice( -ed J Aust( >==75 1A= Su%%l$ 89F:=( -edline, 2S2

"eadership styles in nursing management: preferred and perceived

S)2NA S<EEIR<N -Sc, RN11/e%ut! Nursing /irector, arolinska +niversit! Hos%ital, Stockhol& and Ph/ Student, -edical -anage&ent 1enter *--1,, arolinska 2nstitute, Stockhol&, , INRAN < DAEE Ph/>>Pro'essor <&eritus, 2nstitution o' Ps!cholog!, +niversit! o' Eund, Eund, Sweden and and INRAN )"-S"N -/, Ph/??Pro'essor, --1 and /ivision o' 2nternational Health *2H1AR,, arolinska 2nstitute, Stockhol& 1 eput$ Nursing irector, 7arolinska 6niversit$ Hospital, Stockhol0 and Ph Student, <edical <anage0ent Center 5<<C8, 7arolinska ?nstitute, Stockhol0, Pro4essor :0eritus, ?nstitution o4 Ps$cholog$, 6niversit$ o4 >und, >und, Sweden and .Pro4essor, <<C and ivision o4 ?nternational Health 5?HCAR8, 7arolinska ?nstitute, Stockhol0 Stina Sellgren epart0ent o4 Nursing 7arolinska 6niversit$ Hospital 1,1,* Stockhol0 Sweden :#0ail: stina&sellgren2karolinska&se sellgren s(, ekvall g( O to&son g( *>==:, !ournal o4 Nursing <anage0ent#$% ?7AF?88 "eadership styles in nursing management: preferred and perceived

Abstract
Ai& )he ai& was to e0%lore nursing leadershi% regarding what nurse &anagers and subordinates see as i&%ortant and to e0%lore subordinates. o%inions o' their nurse &anager.s %er'or&ance in realit!( Background )he &anager.s st!le can be 'unda&ental 'or subordinates. acce%tance o' change and in &otivating the& to achieve stated visions and goals and high 4ualit! o' care( -ethods Nurse &anagers *n P 99, and 1= o' each included nurse &anager.s subordinates received a 4uestionnaire to assess .%re'erred. leadershi% behaviour in three di&ensions$ change, %roduction and e&%lo!eeMrelation orientations( )he sa&e 4uestionnaire was used to assess subordinates. o%inions o' their &anager.s leadershi% behaviour( Results )here are statisticall! signi'icant di''erences in o%inions o' %re'erred leadershi% between &anagers and subordinates, es%eciall! related to %roduction and relation orientation( )he subordinates. %erce%tion o' real leadershi% behaviour has lower &ean values than their %re'erred leadershi% behaviour in all three di&ensions( 1onclusions Subordinates %re'er &anagers with &ore clearl! e0%ressed leadershi% behaviour than &anagers the&selves %re'er and de&onstrate(

Introduction

"eadership style Eeadershi% abilit! is 'unda&ental in in'luencing a grou% to achieve the stated vision and goals *Bass 1;A8, Qukl >==>,( /uring ti&es o' dra&atic organiGational changes in health s!ste&s, nursing &anage&ent is both a challenging and di''icult task( )he st!le o' the &anager can be i&%ortant 'or subordinates. acce%tance o' change and in &otivating the& to achieve high 4ualit! o' care *Bass O Avolio 1;A8,( Eeadershi% st!le in the sense o' a &anager.s wa! o' in'luencing the subordinates arose during the 1;7=s at the universities o' "hio and -ichigan in the +SA( )he research 'ocused the behaviour and attitudes o' &anagers and su%ervisors in contrast to earlier research that &ainl! had been looking 'or inborn %ersonalit! and intellectual traits, which %aved the wa! 'or leadershi% %ositions( Research on leadershi% st!les is &ostl! based on a theor! that there are s%eci'ic behaviours, which together build leadershi% st!le di&ensions *<kvall 1;;>,( )he individual leader has a basic general o%erating st!le, e&anating 'ro& %ersonalit!, e0%eriences and learning o' leadershi% *<kvall 1;;>,( Eeadershi% st!le was described in the earl! studies as consisting o' two broad and inde%endent behaviour di&ensions, the one %roduction-Mtask-oriented, the other with 'ocus on e&%lo!ees and relations( Eeadershi% behaviour can be learned, but so&e researchers believe that %ersonal attributes such as intelligence and te&%era&ent sets li&its 'or the learning *S&ith O Petersson 1;AA,( )he -ichigan and "hio researchers studied leadershi% st!les in relation to outco&e criteria such as %roductivit!, &otivation and &orale *-ichigan, Eikert 1;:9, and turnover *"hio, @leish&an O Harris 1;:>,( )he -ichigan researchers identi'ied two .orientations o' su%ervision., %roduction centred and e&%lo!ee centred, while the "hio researchers identi'ied two st!les which the! called, initiating structure and consideration( Both "hio and -ichigan researchers ca&e to the conclusion that e''ective leadershi% is de%endent on an interaction between e&%lo!ee orientation *consideration, and %roduction orientation *initiating structure,5 *@leish&an O Harris 1;:>, Eikert 1;:9,( )oda! change is the natural state in &an! %rivate co&%anies as well as in the %ublic sector and leadershi% is &ore 'ocused on renewal and change and less on stable e''icienc! *<kvall 1;;>,( New leadershi% behaviour has develo%ed, &ore 'ocused on change within the co&%an!( )his st!le, called change-oriented leadershi% behaviour, was not re4uired be'ore the &iddle o' the 1;A=s *<kvall 1;AA, <kvall O Arvonen 1;;1,( )he leadershi% st!le is seen as a co&bination o' the three di&ensions$ change, %roduction and e&%lo!eeMrelations *<kvall O Arvonen 1;;7, Qukl >==>,( Re%resentative behaviours 'or the three leadershi% di&ensions are$ Production *task,-oriented

Plans care'ull! Iives clear instructions 2s ver! e0act about %lans being 'ollowed /e'ines and e0%lains the work re4uire&ents <&%lo!ee *relation,-oriented Shows regards 'or the subordinates as individuals 2s considerate 2s #ust in treating subordinates Relies on subordinates Allows subordinates to decide 1hange-oriented "''ers ideas about new wa!s o' doing things Pushes 'or growth 2nitiates new %ro#ects Iives thoughts about the 'uture Eikes to discuss new ideas( Source$ <kvall and Arvonen *1;;1,( 1ook *>==1, identi'ied 'ive attributes that characteriGe e''ective nursing leaders$ highlighting, res%ecting, in'luencing, creativit! and su%%orting( 1ook *>==1, also identi'ied 'ive di''erent t!%es o' e''ective leaders$ discoverer, valuer, enabler, &odi'ier and sha%er( 1ook.s *>==1, research %oints out a co&%onent o' leadershi% st!le, creativit! and two leader t!%es, discoverer and sha%er5 'indings that indicate the need 'or the di&ension o' change even in nursing leadershi%( 2n other research, the classical leadershi% st!les, i(e( %roduction-Mtask-oriented and e&%lo!ee-Mrelation-oriented have been trans%osed into new di&ensions called transactional contra trans'or&ational leadershi% st!les *Burns 1;9A, Bass 1;A8,( Burns *1;9A, described trans'or&ational leadershi% as a %rocess that &otivates subordinates b! a%%ealing to higher ideals and &oral values( )he trans'or&ational leadershi% st!le can be seen as a co&bination between the e&%lo!ee relation-oriented and the change-oriented leadershi% st!les( A trans'or&ational leader can be characteriGed as a .gardener. who sha%es a develo%ing and growing culture through sti&ulating and e&%owering the sta'' in creative thinking and gives 'reedo& 'or innovation and individual growth( )he 'ollowing 'our co&%onents are highl! valued in trans'or&ational leadershi%$ ins%irational &otivation, idealiGed in'luence, intellectual sti&ulation and

individualiGed consideration *Bass O Avolio 1;A8, 6ard >==>,( An A&erican stud! shows that this leadershi% st!le is a little &ore co&&on a&ong wo&en leaders *Bass et al& 1;;:,( A transactional leader is &ore 'ocused on structure, role e0%ectations and %ossibilities to reward the sta''( A ke! criterion is that ever! e0tra e''ort has to be rewarded, as !ou will not get an!thing 'ro& an!bod! i' !ou do not give hi& or her so&ething in e0change *Bass O Avolio 1;A8,( Nursing management Nursing as a %ro'ession is %eo%le-oriented with an e&%hasis o' hu&anis& and this is %robabl! in'luencing leadershi% in the area( )he nature o' health care at a universit! hos%ital where li'e and death, ever! da! %robabl! has its own de&ands within leadershi% co&%ared, 'or e0a&%le, with industrial industries( Nursing &anage&ent is toda! seen as a %ro'ession o' its own with s%ecial training and skills( )o be able to deal with ever!da! &anage&ent where behaviour is ada%ted to the situation *situational leadershi%,, the &anager needs to be aware o' their own leadershi% %ro'ile, the s!ste& and task( -anagers who are able to co&bine these in their leadershi% have the greatest %otential 'or success *Ea-onica 1;;=,( Nurse &anagers. tasks, as all &anagerial %ositions inde%endent o' area, re%resent di''erent co&%etencies( "ne is the &anaging role including co&%etencies such as anal!tical thinking, knowledge in &anage&ent, work environ&ent anal!sis, business knowledge, leadershi% and visioning *6allick >==>,( )hese co&%etencies relate to the %roduction di&ension( )he continuous status o' change in health care %laces de&ands on nursing &anagers in co&%etencies such as, social awareness, abilit! to see the .big %icture and inter%ersonal relationshi% building. *6allick >==>,( )hese last co&%etencies relate to the di&ensions o' change and relation( Based on Bass.s *1;A8, theor!, Prenkert and <hn'ors *1;;9, studied whether nurse &anagers who e0%ressed both transactional and trans'or&ational behaviour are &ore organiGationall! e''ective( )he! did not 'ind an! evidence 'or this h!%othesis but noticed a higher correlation between trans'or&ational leadershi% and nursing 4ualit! and a lower correlation between transactional leadershi% and nursing 4ualit!( 6ith e0ce%tion o' the above studies there is a lack o' research on leadershi% st!le and %re'erred leadershi% in nursing &anage&ent %roviding the rationale 'or this stud!( )he ai& o' this stud! was to e0%lore nursing leadershi% regarding what nurse &anagers and subordinates see as i&%ortant and to e0%lore subordinates. o%inions o' their nurse &anager.s %er'or&ance( esearch &uestions )he research 4uestions were$ R 6hat kind o' leadershi% behaviour do &anagers and subordinates %re'erH

R How is the &anager.s real leadershi% behaviour co&%ared with the %re'erredH R 2s it %ossible to identi'! di''erent leadershi% %ro'iles *co&binations o' change, %roduction and e&%lo!ee orientations, in nursing &anage&ent(

Method
)he stud! was conducted at the arolinska Hos%ital in Stockhol&, Sweden in Nove&ber >==?( 'tudy population )he criteria 'or including the nurse &anager in the stud! were$ res%onsibilit! 'or budget and hu&an resources and 1= subordinates or &ore, having been in charge at least : &onths and not tendered resignation( 2t takes ti&e 'or a new &anager to get to know the work%lace and to build a good relation with the subordinates( 2n this stud! we decided that :-&onths would be a reasonable ti&e 'or building this relationshi%( 2n Sweden, !ou have to work ? &onths a'ter tendering !our resignation( /uring this ti&e it &a! be di''icult to be enthusiastic 'or the work and to %er'or& e''ectivel!( At the ti&e o' the stud! there were ;> nurse &anagers at the hos%ital o' which 99 corres%onded to the inclusion criteria( )hese &anagers re%resented all kinds o' units( )he nu&ber o' subordinates o' the 99 nurse &anagers ranged between 1= and A= in total( Seven hundred and sevent!, 1= %er nurse &anager, were asked to %artici%ate in the stud!( 2' the nurse &anagers had 1= subordinates all were asked to %artici%ate( 6hen the sta'' consisted o' &ore than 1= subordinates ever! subordinate on the sta'' list got a nu&ber and an assistant inde%endent 'ro& the hos%ital and the stud!, rando&l! drew nu&bers 'ro& a bo0( 2ncluded subordinates were registered nurses, assistant nurses and various ad&inistrative sta''( <0cluded were subordinates with ti&e-based e&%lo!&ent because the! &ostl! work nightshi'ts or weekends when the &anager is not in charge( (uestionnaires A 4uestionnaire, based on the change, %roduction, e&%lo!ee *1P<, &odel, was used to assess .%re'erred. leadershi% behaviour( )his 4uestionnaire, develo%ed and validated b! <kvall and Arvonen *1;;1, 1;;7,, consists o' ?=-ite&s covering the three di&ensions, changeM develo%&ent, %roductionMtaskMstructure and e&%lo!eeMrelations, with 1=-ite&s 'or each di&ension( )hese three 'unda&ental di&ensions can be co&bined into leadershi% %ro'iles( )he sa&e 4uestionnaire was used with instructions to res%ondents to assess %erceived leadershi% behaviour in realit!( )he 4uestionnaire is reliabilit! tested with 1ronbach.s-@ with coe''icients between =(A: and =(;7 *Arvonen O <kvall 1;;;, and its validit! is de&onstrated in several large studies *Arvonen >==>, <kvall >==>,(

)he answers are rated 'ro& 1 to : in a Eikert scale *'ro& .do not agree at all. to .agree totall!.,( <0a&%les o' ite&s are$ R initiate new %ro#ects *change di&ension,5 R trusts the subordinates *e&%lo!eeMrelation di&ension,5 R creates order and clarit! *%roductionMtaskMstructure di&ension,( Bass *1;;8, develo%ed a tool 'or &easuring leadershi% st!les, &ulti'actor leadershi% 4uestionnaire *-ES,( )his tool relates to trans'or&ational and transactional leadershi% st!le( )he 1P< tool was chosen because it &easures leadershi% 'ro& three 'unda&ental di&ensions *Qukl >==>, that could be co&bined into leadershi% %ro'iles5 is reliabilit! tested and validated in the Swedish language and has been widel! used both in Sweden and in other countries *<kvall O Arvonen 1;;7, Arvonen O <kvall 1;;;,( )he 4uestionnaires were distributed to all %artici%ants at their ho&e addresses and one re&inder was distributed a'ter > weeks to the %artici%ants who did not answer( 'tatistical analyses Signi'icance testing was a%%lied with t-tests o' &ean di''erences between %erceived and %re'erred leadershi% st!le and between &anagers. and subordinates. ratings on each o' the three di&ensions( )he anal!sis was %er'or&ed using s%ss( )he %erceived leadershi% st!le was also anal!sed *&ean scores o' the subordinates ratings on each o' the three di&ensions, to identi'! s%eci'ic leadershi% %ro'iles( 2n this %art onl! leaders who had 'ive or &ore subordinates that res%onded to the 4uestionnaire were included *n P 8>,( )he scores on each di&ension o' ever! single &anager were co&%ared with the &ean value and standard deviation 'or the whole %o%ulation o' 8> nurse &anagers as carried out in earlier studies with the 1P< instru&ent( )hese anal!ses were %artl! %er'or&ed using s%ss and %artl! &anuall!( )thics 1on'identialit! and anon!&it! was guaranteed( Partici%ation was voluntar! and in'or&ed consent was obtained( )he anon!&it! and the con'identialit! were %articularl! i&%ortant as the 'irst author was working at the hos%ital as nursing director at the ti&e o' the stud!( )he stud! was a%%roved b! the <thical co&&ittee o' the arolinska 2nstitute */nr =??7A,(

esults

espondents )he total nu&ber o' res%ondents in the whole stud! was 7;> o' A79 *8AT,( Si0t!-si0 o' the 99 *A:T, nurse &anagers answered the 4uestionnaire and 7>: subordinates *88T, res%onded( )he total nu&ber o' non res%ondents *subordinates and nurse &anagers, was ?88( -ost *>19, did not give an! e0%lanation as to wh! the! did not res%ond, 1?A gave so&e e0%lanation such as being on the sick leave *si0,, were %regnant or on &aternit! leave *1=,, on leave 'or other reasons *18, and nine had #ust resigned( Si0 gave the e0%lanation that the 4uestionnaires were #ust too e0tensive to go through( @ive o' the subordinates had not answered all o' the 4uestions and their answers could there'ore not be used in the stud!( +nits where 'ive or &ore subordinates res%onded were 8>( Basic 'acts o' the res%ondents are %resented in )able 1( All o' the :: res%onding nurse &anagers were nurses, o' the subordinates >:A *:>(;T, were nursesM&idwi'es, 1>: *>;(8T, assistant nurses or child assistant nurses, 1? *?T, were secretaries, 'our *U1T, were technicians or %orters, si0 *1(7T, had another %ro'ession and nine were not s%eci'ied( 2n total 8T o' the subordinates were not working directl! as care %roviders( @ro& >8 o' the 99 units *?>T, there were U8 res%ondents a&ong the subordinates( @ro& three units *7T, there were U? res%ondents( @ro& eight *79T, o' the 19 units with V8= e&%lo!ees there were U8 answers 'ro& the sta''( )here was no di''erence in sta'' turnover between units where the nurse &anager did not res%ond and units where the nurse &anager did res%ond( )he average sta'' turnover a&ong the studied units was 1=T 'or >==?( )he units where the nurse &anager did not res%ond had an average sta'' turnover o' 8(78T *=F1AT,( @or the units with U8 res%ondents a&ong the sta'' the average was :(AA *=F>7T, and 'or the units with 'ive or &ore res%ondents it was :(88 *=F1;T,( Preferred leadership behaviour )he co&%arison between &anagers. and subordinates. ratings o' %re'erred leadershi% behaviour is %resented in )able >( )he %re'erences o' leadershi% behaviour di''ered between &anagers and subordinates( )he subordinates tended to value ever! di&ension higher than the &anagers( However, the di''erences in statisticall! signi'icant &eans are 'airl! &odest( )he &ost statisticall! signi'icant di''erences between &anagers and subordinates *P U =(==1, are in the di&ensions %roduction orientation and e&%lo!ee orientation( 6hereas 'or the di&ension change orientation was P U =(=8( Perceived leadership behaviour compared with preferred )he answers o' the subordinates on the 4uestionnaires o' %re'erred leadershi% behaviour were co&%ared with the answers o' %erceived leadershi% behaviour( )he total nu&ber o' res%ondents that could be co&%ared was 7>=( )he &ean values %erceived leadershi% o'

the &anagers are, as rated b! subordinates, 'ar below the level o' their %re'erred leadershi%( )he di''erence between %re'erred and %erceived leadershi% behaviour can be 'ound in all three di&ensions and are statisticall! signi'icant *P U =(==15 )able ?,( Perceived leadership profiles )he &ean values 'or the whole %o%ulation *n P 8>, in the three di&ensions are %resented in )able 7( 2n earlier studies with the 1P< instru&ent it had been %ossible to identi'! 1= di''erent leadershi% %ro'iles, although 'ive o' the& were onl! 'ound in between >(?T and 9(?T o' the %o%ulation *<kvall O Arvonen 1;;7, <kvall >==>,( )he &ost co&&on st!les were, -iddle o' the road, Su%er leader and -anage&ent b! "b#ectives *-B", leader while the least co&&on were /o&inating entre%reneur and 2dea s4uirt *)able 8,( 2n our stud! we could identi'! seven o' the above &ost co&&on leadershi% %ro'iles( )he Su%er leaders in our stud! were 1> *>?(1T,( Nine &anagers *19(?T, got low scores in all three di&ensions and are identi'ied as invisible leaders( )hese &anagers are vague in their leadershi% %ro'iles( )he third &ost co&&on identi'ied %ro'ile, >: &anagers *8=T,, were the -iddle o' the road leaders with scores inside one hal' standard deviation 'ro& &ean values in all three di&ensions( 2n addition to these three co&&on %ro'iles we identi'ied 'ive &anagers with other %ro'iles *)able :,(

*iscussion
"ur result with the &ost evident di''erence between subordinates and nurse &anagers in %re'erred leadershi% about %roduction orientation, could indicate that subordinates want a leader with a clearer leadershi% st!le than the &anager the&selves think is accurate( )his su%%orts the 'indings o' -orrison et al( *1;;9, in their stud! o' nursing sta'', using the -ES scale *Bass 1;;8,( )he! 'ound that the sta'' %re'erred their leaders to take a &ore active leadershi% role( 2n this world o' change it can be sa'e to have one %erson who %oints out the direction and lead the wa!( But it could also be an e0%ression o' lack o' de&ands and a desire to have &ore structure( )here is a risk o' loose structure in an environ&ent o' constant change( Both nurse &anagers and subordinates e0%ress high %re'erences in the di&ensions e&%lo!ee and change( 2n a stud! a&ong nursing &anagers o' their %erce%tions o' the highest ranking a&ong their res%onsibilities, co&&unication was shown to be the highest ranked issue and therea'ter 'ollowed in order, 'acilitation o' goal achieve&ent, e''ective inter%ersonal relationshi%s, in 'ourth %lace ca&e decision-&aking and in 1=th change agent *Purnell 1;;;,( )he di''erences in all three di&ensions &ight to so&e degree arise 'ro& the 'act that the &anagers understand the realit! o' nursing &anage&ent( )he! are 'acing the di''iculties and co&%le0ities o' the 'irst line leader role dail!( )he &ean value o' %erceived leadershi% behaviour was lower than the %re'erred in all three di&ensions( )here is a lack in &ean values between the leadershi% behaviour that

the subordinates %re'er and the &anagers can %er'or&( Although it see&s to be %ossible to reach the %re'erred levels as there are 1> nurse &anagers who are rated near the %re'erred &ean values in all three di&ensions( )he two highest valued di&ensions b! the subordinates in our stud! *e&%lo!ee and change,, both in %re'erred and in %erceived leadershi%, re%resent the basis o' trans'or&ational leadershi% st!le( 2n so&e earlier leadershi% theories a leader that was high %er'or&ing in both task and relation orientation was su%%osed to be the &ost e''ective in all kind o' situations *Blake O -outon 1;A>,( )he advocates 'or trans'or&ational leadershi% %re'er high %er'or&ance in relation and change to .garden. the 'ollowers *Bass O Avolio 1;A8, Prenkert O <hn'ors 1;;9,( Bou&ans and Eandeweerd *1;;?, 'ound that the Netherlands nurses were &ost satis'ied i' the nurse &anager had a co&bination o' high-socialMhigh-instru&ental *task and %roduction, leadershi%( 2n that research onl! two di&ensions o' leadershi% were studied and the di&ension change orientation was not included( 2t was not %ossible in our stud! to identi'! all o' the 1= leadershi% %ro'iles that have been identi'ied in the other studies carried out with the 1P< instru&ent *<kvall O Arvonen 1;;7, <kvall >==>,( )hese studies co&%rised large sa&%les o' &anagers 'ro& di''erent organiGations *industr!, trade, trans%ortation, service, care, education, &edia and consultanc!,( Both &ale and 'e&ale &anagers were included( 2n our stud! onl! 'ive &anagers had values that were une4ual in the three di&ensions according to standard deviation 'or the &ean value( All the others had e4ual values in all three di&ensions( )his could de%end on the 'act that the nurse &anagers are &ostl! 'ostered in the nursing %ro'ession and this %attern beco&es a %art o' their behaviour( )heir wa! to %ro&ote leadershi% is also as a role &odel, which in'luences others to behave in a si&ilar wa! *<agl! O Johannesen-Sch&idt >==?,( @anslow *1;A7, described that leadershi% st!le was related to a %ersonal value s!ste& that has been 'or&ulated b! culture, societ! and li'e e0%erience( 1ook *>==1, identi'ied 'ive di''erent t!%es o' e''ective nursing leaders( 2n our stud! we have not investigated how e''ective the di''erent identi'ied st!les are( Nursing is also a wo&an-do&inated %ro'ession and it is there'ore natural that nurse &anagers are &ostl! wo&en because the! are recruited 'ro& the %ro'ession( 2n our stud! there were onl! three &en a&ong the res%ondent nurse &anagers( 2n earlier research it is shown that leadershi% st!le could be a gender issue and that wo&en are &ore inclined to use the trans'or&ational leadershi% st!le *Bass et al& 1;;:, <agl! O Johannesen-Sch&idt >==?,( "n the contrar!, in this research none o' the &anagers in our stud! were identi'ied as a trans'or&ational leader( 2n our stud! there were nine &anagers that e0%ressed a &ore vague leadershi% st!le( Herse! and Blanchard *1;A>, %ostulated that as the level o' &aturit! a&ong 'ollowers increased, leadershi% re4uired less task orientation and less socio-e&otional su%%ort *Ioldenberg 1;;=,( )hat is, the &ore e0%erienced and &otivated, the &ore inde%endent the subordinates will be o' leader.s direction and su%%ort( Bass *1;A8, calls this st!le .laisseG-'aire. and states that such leadershi% st!le is not ade4uate in an! situation(

2n a recentl! %ublished stud!, nursing &anagers were asked what co&%etencies the! thought where needed 'or nursing &anage&ent in >=>= *Scoble O Russel >==?,( )he ke! co&%etence was identi'ied as leadershi% behaviour and s%eci'ic ite&s in the anal!sis were trans'or&ational leadershi%, visioning and %erseverance( )he educational training in nursing leadershi% is about 8 weeks in Swedish nursing %rogra&&es *Sverigesriksdag 1;;?,( )his 8-week education includes leadershi% theories, laws and other regulations, 4ualit! work, su%ervision, econo&! and organiGation *Sverigesriksdag 1;;?,( At several universities there are health &anage&ent courses u% to := weeks in duration( 2n these courses the student learns about the %olitical and organiGational s!ste&, about econo&ics, 4ualit! i&%rove&ent and scienti'ic &ethodolog!( Eeadershi% behaviours suitable 'or health care organiGation are %oorl! e0%lored during education and our stud! shows that there is a %otential 'or i&%rove&ent( Methodological considerations Suestionnaires have li&itations *<kvall 1;;>, Arvonen >==>,( An advantage o' the one used in the %resent stud! is that both construct and %redictive validit! o' the instru&ent are de&onstrated *Arvonen >==>,( Behaviour descri%tion 4uestionnaires devised to stud! leadershi% have been 4uestioned b! several researchers since this tradition began( )he &ain clai& has been that the! &easure the attitudes o' subordinates towards the leader and not real behaviour( )he research grou% at "hio &et the criti4ue b! %resenting studies which showed signi'icant correlations between subordinates who described the sa&e leader *<kvall 1;;>,( )he 1P< 4uestionnaire has been tested in relation to in'luence o' attitude( )he change and %roduction di&ension showed no correlations with attitude( )he e&%lo!ee di&ension had a &ediu& siGe *=(7=, coe''icient, which is logical, because being acce%ted and liked is a %s!chological drive in relation-oriented behaviour *<kvall O Arvonen 1;;7,( )he dro%out rate was nor&al 'or this t!%e o' stud! and the dro%out anal!sis showed no selection bias(

!onclusions
)he results o' this stud! show that subordinates wish nurse &anagers to be &ore distinct about de&ands in relation to work( 2t also shows that there are &anagers with a vague leadershi% %ro'ile( )hese characteristics o' leadershi% behaviour should be considered in the selection %rocess o' nurse &anagers as well as in the continuall! %ro'essional develo%&ent %rogra&&e( @orthco&ing work studies the role o' leadershi% in relation to working cli&ate, sta'' satis'action and turn over(

eferences
RArvonenJ( *>==>, 1hange, Production and <&%lo!ees F An 2ntegrated -odel o' Eeadershi%( /e%art&ent o' Ps!cholog!, Stockhol& +niversit!,

Stockhol0, Sweden RArvonenJ(O<kvallI( *1;;;, <''ective leadershi% st!le$ both universal and contingentH 1reativit! and 2nnovation -anage&ent A *7,, >7>F>8=( S!nerg! RBassB(-( *1;A8, Eeadershi% and Per'or&ance Be!ond <0%ectations( @ree Press, New Aork, 6SA RBassB(-( *1;;8, )he Revised -ES 8W( -ind Iarden, Palo Alto, CA, 6SA RBassB(-(OAvolioB(J( *1;A8, 2&%roving "rganiGational <''ectiveness through )rans'or&ational Eeadershi%( Sage, ;housand 3aks, Cali4ornia, 6SA RBassB(-(, AvolioB(J(OAtwaterE( *1;;:, )he trans'or&ational and transactional leadershi% o' &en and wo&en( 2nternational Review o' A%%lied Ps!cholog! 78, 8F?7( 1SA RBlakeR(R(O-outonJ(S( *1;A>, 1o&%arative anal!sis o' situationalis& and ;,; &anage&ent b! %rinci%le( "rganiGational /!na&ics 1=, >=F7?( 1rossRe', 2S2 RBou&ansN(P(I(OEandeweerdJ(A( *1;;?, Eeadershi% in the nursing unit$ relationshi% with nurses well-being( Journal o' Advanced Nursing 1A *8,, 9:9F998( 1rossRe', -edline, 2S2, 1SA RBurnsJ(-( *1;9A, Eeadershi%( Har%er O Row, New Aork, 6SA R1ook-(J( *>==1, )he attributes o' e''ective clinical leaders( Nursing Standard ?8 *1,, ??F?:5 Nursing -anage&ent A, 99FA1( R<agl!A(H(OJohannesen-Sch&idt-(1( *>==?, )rans'or&ational, transactional and laisseG-'aire leadershi% st!les$ a &eta anal!sis co&%aring wo&en and &en( Ps!chological Bulletin 1>; *7,, 8:;F8;1( 1rossRe', -edline, 2S2, 1SA R<kvallI( *1;AA, @Xrn!else och 'riktion( Natur och ultur, Stockhol0, Sweden R<kvallI( *1;;>, Eedarska% teorioch 'orskining( 2n Eedarska% och arbets&il#X *J(SchallerOJ(A(Johansson eds,, %%( 1:F>:( Akade&i'Xrlaget, Stockhol0, Sweden R<kvallI( *>==>, Eedarstilen Yr avgXrande 'Xr arbetskli&at och e''ektivitet( Ps!kologi )idningen A, 7FA( R<kvallI(OArvonenJ( *1;;1, 1hange centered leadershi%( An e0tension o' the two di&ensional &odel( Scandinavian Journal o' -anage&ent 9, 19F>:( 1rossRe' R<kvallI(OArvonenJ( *1;;7, Eeadershi% %ro'iles, situation and e''ectiveness( 1reativit! and 2nnovation -anage&ent ? *?,, 1?;F1:1( S!nerg! R@anslowN( *1;A7, Personal values( An in'luence on leadershi%( Point o' Diew > *>,, A( R@leish&an<(A(OHarris<(@( *1;:>, Patterns o' leadershi% behaviour related to e&%lo!ee grievance and turnover( Personnel Ps!cholog! 18, 7?F8:( S!nerg!, 2S2

RIoldenberg/( *1;;=, Nursing education leadershi%( <''ect o' situational and constraint variables on leadershi% st!le( Journal o' Advanced Nursing 18, 1?>:F1??7( S!nerg!, -edline, 2S2, 1SA RHerse!P(OBlanchard ( *1;A>, -anage&ent o' "rganiGation Behaviour( +tiliGing Hu&an Resources, 7th edn( Prentice-Hall, New !erse$, 6SA REa-onica<( *1;;=, -anage&ent in Healthcare$ a )heoretical and <0%eri&ental A%%roach( S%ringer, New Aork, 6SA REikertR( *1;:9, )he Hu&an "rganiGation( -cIraw-Hill, New Aork, 6SA R-orrisonR(S(, JonesJ(O@ullerB( *1;;9, )he relation between leadershi% st!le and e&%ower&ent on #ob satis'action o' nurses( Journal o' Nursing Ad&instration >9*8,, >9F ?7( 1rossRe', -edline, 2S2 RPrenkert@(O<hn'ors-( *1;;9, A &easure o' organiGational e''ectiveness in nursing &anage&ent in relation to transactional and trans'or&ational leadershi%$ a stud! in a count! hos%ital( Journal o' Nursing -anage&ent 8, >9;F>A9( S!nerg!, -edline, 1SA RPurnellE(/()( *1;;;, Health care &anager.s and ad&inistrator.s roles, 'unctions and res%onsibilities( Nursing Ad&inistration Suarterl! >? *?,, >:F?9( -edline RScoble (B(ORusselI( *>==?, Dision >=>=$ Part 1( Pro'ile o' the 'uture nurse leader( Journal o' Nursing Ad&inistration ?? *:,, ?>7F??=( 1rossRe', -edline, 2S2 RSverigesriksdag *1;;?, S@S 1;;?$1== HXgskole 'Xrordingen Ri0le0, Stockhol0, Sweden , %( 1==( RS&ithP(B(OPetersson-(@( *1;AA, Eeadershi% "rganisation and 1ulture( Sage, >ondon, 67 R6allick6(I( *>==>, Healthcare &anagers roles, co&%etencies and out%uts in organiGational %er'or&ance i&%rove&ent( Journal o' Healthcare -anage&ent 79 *:,, ?;=F7=1( -edline, 2S2