key: cord-0060922-u720ltqg authors: Kemp, Joy; Maclean, Gaynor D.; Moyo, Nester title: Midwifery Leadership date: 2020-09-25 journal: Global Midwifery: Principles, Policy and Practice DOI: 10.1007/978-3-030-46765-4_11 sha: 15bb5a42b085a1bc5ddd7a8879621bbe07ffcf09 doc_id: 60922 cord_uid: u720ltqg This chapter identifies from leadership literature salient aspects of leadership perceived as useful for midwifery leadership development. It learns from corporate organisations and higher education institutions and compiles content to inform the development and exercise of midwifery leadership at all levels. It describes leadership strengths, resilience and versatility required to enable midwifery leaders to face the world in and outside of midwifery. Leadership is a concept easily used in everyday conversation but understood by a few (Bojadjiev et al. 2019 ). The world is rapidly changing, and it is important to determine what is required to lead in a volatile, uncertain, complex and ambiguous environment. Leadership is about providing vision, purpose and direction. It is about aligning thoughts and ideas towards the achievement of a common goal. It involves communicating and motivating others to act, and includes priority setting, analysis of situations and innovations. Leadership is about people (Rathore et al. 2017) . Management involves making decisions to achieve predetermined goals. It focuses on systems, processes, structure and goals. Management exists for operational control, monitoring performance, planning, organising, allocating resources and evaluating processes. Managers ensure that things are done right. Some authors say management is about things (USAID 2015; Management Science for Health 2015) . Administration involves operationalising organisational plans, maintaining bureaucratic policies, implementing and maintaining established rules of procedure in the best way possible, at the most appropriate time for the achievement of objectives, utilising the systems and processes mandated by management. The focus of administration is on efficiency of processes for achievement of results (Yourdictionary 2018) . Effective leaders need to develop capacities from all three areas. They must be good managers able to guide administrative processes in the 11 By the end of the chapter, the reader should be able to: • Define the nature of leadership. Hollander and Julian (1969) defined leadership as a social interpersonal influence relationship between two or more persons who depend on each other to attain certain mutual goals. So did Kanter (1982) , Reid (2016) and Rathore et al. (2017) . Parris and Hart (2013) and Adeyemi and Bolarinwa (2013) added the words 'to work devotedly' and 'to strive willingly' towards the achievement of objectives. Putting all these definitions together, the 'influence' is about providing vision, purpose and direction; aligning thoughts and ideas and steering people towards the achievement of a common goal. In situations of rapid change, intense competition, an explosion of new technologies, chaos, turbulence and high levels of uncertainty, leadership is critical to offer a pathway of confidence and direction, creativity and effective management of change (Bennis and Thomas 2002) . In some cases, leadership involves changing people's thinking, perceptions, character and behaviour, so that they exert themselves 'willingly' in doing something(s) which they would otherwise have not done (Conger 2012) . The twenty-first century turbulence and chaos has led to a rapid change in the composition of the midwifery workforce and the recipients of midwifery care. Hence, midwifery leadership needs special capabilities to respond to these changes (Bennis and Thomas 2007; Conger 2012 ; Lee Iacocca in Bojadjiev et al. 2017 ). Organisations have moved away from the traditional, hierarchical structures to expanding roles of members in decision-making (Elangovan and Xie 2000; Byrom and Doiwne 2010; Carlton and Perloff 2015) . Leaders more readily delegate power to different levels of the organisation (Choy et al. 2016) . Midwifery leaders can learn from this trend especially in professional associa-tions where contributing to the decision-making processes motivates and gives members a sense of belonging. In maternal and child health (MCH) services, midwifery leaders need collaborative leadership practices to navigate the public health systems in which they work (De Pree 2006) . Collaborative leadership practices involve power sharing and are process based (Clarke and Cilenti 2017) . Collaborative leadership is vision based and makes it necessary and possible to convene and engage necessary stakeholders for a systems approach in solving MCH issues in the complex setting in which care is provided (Leadership Academy 2011). Mianda and Voce (2018) , Jarvis and Reeves (2017) and Divall (2015) point out a gap that has persisted in midwifery leadership and clinical leadership. Emphasis has been placed on position leadership to the neglect of leadership on the bedside and in the maternity ward. In the United Kingdom, clinical leadership has been provided as an outreach activity by a District Clinical Specialist Team. This has gradually been supplemented by team leadership where every member develops some leadership capacity and exercises that during care provision. Power is shared among the team. Decision-making is by the clinicians. In addition, clinical leaders have been nurtured who have all the characteristics of a position leader. Their clinical expertise and their application of generic leadership skills to specific clinical settings differentiate them from the position leader. Self-directed learning and maintenance of clinical competence are essential for clinical leaders. The responsibilities of clinical leaders centre around organisation of care processes, ensuring better performance in the ward, wellbeing of women and newborn and staff, quality management and control as well as identifying best practices in care provision (Managament Science for Health 2015). They also serve as clinical mentors, facilitators of professional development of staff and building strong teams, conducive work environment and team building (Fizza et al. 2019 ). Midwifery leaders need power to achieve objectives and to increase the credibility and visibility of the profession. A clear understanding and effective use of power enhance the leader's capacity to contribute to policy and engage intelligently in negotiations and advocacy settings. Power is fluid, expendable and mostly remains potential. Power may be overt or covert, formal or informal and can be possessed by individuals or a group. Power is like a savings account. It has to be earned, saved and used well in order to last and is neutral until exercised (ICM 2014). Midwifery leaders need to recognise their power bases especially because in some countries, it takes a few years for a midwife to rise to a position of power. Power bases are the sources of power. Organizational or institutional power comes from one's position in the organization giving rise to three power bases: position, reward and coercion power. Personal power emanates from the individual's inherent characteristics and personal traits, acquired or potential, giving rise to four power bases: referent (charismatic), expert, information and relationship power (Box 11.1). Leveraging power is a skill (De Pree 2006) (Box 11.2). Technology has enabled the development of vast social networks making relationships and access to knowledge and information easier than ever before (Center for Creative Leadership 2013). Important and extraordinary, highly visible relationships can be forged with stakeholder groups in different parts of the world (Kanter 2002; Wright and Taylor 1994) . Midwifery leaders should invest time and energy in existing relationships and creating new ones; identify persons to learn from and with whom to establish a relationship; repair damaged or neglected relationships, build trust, repair own image when needed, demonstrate confidence and develop their own brand of charisma. With effective use of power, midwifery leaders ensure that priorities of midwifery care are heard at the right levels, that quality care is delivered and that outcomes are improved for women, newborns and families (Read 2019) . Midwives need a means by which they can work in collaboration with nurses and not be subsumed in the nursing agenda (Read 2019) . With adequate awareness of the power they possess, midwives can display significant leadership capabilities, authority and confidence to do things differently. As stated by Richard Buckminster Fuller: You can never change things by fighting the existing normal. To change something, build a new model that makes the existing one obsolete. (Read 2019:7) Box 11.1. Power Bases: Brief summaries Position power: Legitimate power or authority is power bestowed on an individual by her/his position in the organization. Others accept this power and are ready and expected to submit to it. The higher a person is in the organization the more power the person has. Reward power relates to one's capacity to reward others because of control over reward mechanisms and resources (e.g. promotions, salary raise, positive appraisal). This is usually supported by the individual's position in the organization. Coercive power relates to one's capacity to make others do what they might not want to do. It is associated with the capacity to punish others. It is also related to position power but can belong to anyone (e.g. strikes, blackmail)! Coercive power is the least-leveraged source of power (Centre for Creative Leadership 2013). Personal Power Referent power is based on charisma (charismatic power) and good will generated by a leader's style or persona. A charismatic individual's character draws people, captivates and makes them want to This agrees with Powell-Kennedy's statement that: '…leadership goes further than the common misconception 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' (Powell-Kennedy 2011). The midwifery workforce is getting more diverse in terms of race, gender and sexual orientation. So are its beneficiaries, presenting with different needs, concerns and personal ideologies. Given that the contexts in which midwifery care is provided are not static and in some cases are rapidly changing, the midwifery leader needs to be sensitive to diversity and the multicultural expectations and needs among the workforce and the care receivers. In situations of rapid change and stress, work and organisations become major sources of need fulfilment (Conger 2012 follow; is well liked, respected, perceived as a role model, and others are prone to consider her/his point of view. It takes time to develop, has to be earned and can be very effective in some situations. When strong enough, others may ignore the person's failures and seek her/his approval. Relationship power is derived from the individual's relationships and networks that enable the leader to penetrate systems through formal and informal networks both inside and outside of the organization and even outside of the profession (they know people who know people). It is strengthened by the individual's integrity and positive interpersonal relationships. Expert power emanates from the individual's expertise. The more crucial and unusual the expertise and knowledge, the greater the power. This power is sometimes "understood" from the individual's title (Professor, Doctor, Sir, etc.) and, in some cases, is reinforced by society. The individual is trusted and seen as credible because of the expertise. Information power is when one has information valued by others. The greater difference the information makes, the more power one has over those who need it. Information power is common in scientific and technical fields and is available to anyone who seeks it through personal development. Personal attributes are not usually included as power bases. But there are situations when one's colour, gender, age and country of origin are power sources. Sources: ICM Young Midwifery Leaders Programme (2014) build the profession into communities which offer midwives a sense of identity, ownership and belonging. In some countries, despite being key service providers, without leadership, midwives' contribution is not recognised, especially where there are severe staff shortages, weak midwifery education and weak midwifery competencies (Chapter 4). Without leadership, these and the conditions of service, the high workload and poor salaries will remain unchanged. Midwifery leadership is needed to spearhead the development of context-appropriate interventions and solutions (Robert et al. 2000) . Midwifery needs leadership in care provision to treat others as responsible, potential leaders, to earn respect and to learn to be reflective, consistent and self-disciplined (Northouse 2019) . At policymaking level, the leader has to be versatile and resilient and to adopt different personae to meet the demands of each level. The midwifery leader needs to be a visionary in order to shape a vision for the profession; an optimizer to make the best of difficult situations; a builder, superconnecter, warrior, researcher and mentor (Annex 11.1). Midwifery is at different levels of development globally. In some countries, midwives are organised in large professional associations with visible, strong and effective leadership. In some, the associations are small, weak, with no or ineffective leadership; in others the profession does not exist or is not recognised, or there is no association and therefore no leadership (see Chapter. 5 and 6). Yet by its very nature midwifery leadership should cross organisational boundaries because midwifery care is delivered by an interdependent network of organisations. Midwifery leadership should be broad based, i.e. the practice of leadership by clinicians and other frontline staff since, in many countries, it is these frontline staff that have to make decisions (Michael West et al. 2015) . The International Confederation of Midwives (ICM) provides global midwifery leadership through supporting and representing midwives and works closely with other global bodies including United Nations agencies, other professional bodies and non-governmental organisations, bilateral and civil society groups (ICM 2019). ICM provides the midwifery voice and expertise and contributes to the global health agenda. For a detailed description of ICM, see Chapter 2. The hierarchical position, organisational and societal culture, gender and the age of the leader impact on leadership (Gîrneață and Potcovaru 2015) . A midwifery leader in a position of power in the organisation faces different issues when leading the profession compared to a midwifery leader who is in the lower ranks of the organisation (Hochwarter et al. 2000). Leadership is the most influential factor in shaping organisational culture. Organisational culture is a pattern of shared basic assumptions learned by a group, considered valid and therefore, the correct way to perceive, think and feel in relation to problems (Schein 2010; Watkins 2013 ). Because of these basic assumptions, where midwifery is not recognised, the mindsets in organisations impact on how midwifery leaders are perceived and determine their level of involvement in policy making bodies and activities. Most In others they are expected to assume the greater share of the family and homelife responsibilities despite the demands of leadership (Yang 2011; Kong and Zhang 2011; Zhang and Foo 2012; Cho and Ryu 2016) . Some authors posit that women tend to exclude themselves because of their social orientation, thus creating a 'psychological glass ceiling' against themselves (Austin 2009; Eagly 2015; Sandberg and Scovell 2013) . Others believe that gender segregation gives women a professional advantage as they do not have to compete with men in women-only professions like midwifery (Yan et al. 2018; Alsubaie and Jones 2017) . In colleges and universities, women are expected to navigate their own way to leadership (Helgesen and Johnson 2010; Wang and Cho 2013; Jones et al. 2018; Longman 2018) . Midwifery leaders need to recognise and rise above these issues and to prevent the emergence of the queen bee syndrome. Queen bee syndrome describes women who, having achieved success in male-dominated environments, perceive other women as threats and oppose their rise (Staines et al. 1973; Blau and DeVaro 2007) . Midwifery leadership development should acknowledge these struggles. Hofstede and Minkov (Hofstede and Minkov 2010:6) described culture as: the collective programming of the mind that distinguishes the members of one group or category of people from others Societal culture provides the basis for leadership styles and employee behaviours (Hofstede 1991; Dorfman et al. 2006 ). Most well-researched leadership styles are based on the Western (Europe and United States of America) culture (Whitley 1994; Sørensen and Kuada 2001) . Thinking has moved towards examining the concept in other cultures. African culture is mainly based on collectivism, familism and advancing the common good (Gyekye 1997 (Gyekye , 2010 . The philosophy of 'ubuntu' encapsulated in the maxims 'I am because we are' and 'a person is a person through other persons' exhorts the exhibition of humanness, suggesting a life of positive integration with others, with communalism as a goal (Menkiti 2004; Tutu 1999; Shutte 2001; Masolo 2010) . Sharing and treating everyone with respect are important values (Metz 2013 (Metz , 2017 (Metz , 2018 Ndlovu 2016; Ndlovu-Gatsheni and Ngcaweni 2017; Woermann and Engelbrecht 2017) . Whereas western leadership has the end goal of achieving the company's objectives, African leadership has the company's objectives, the individual's goals and benefits as end goals (Fadare 2018; Kuada 2010) . While Western approaches perceive human beings as resources (instruments), the African approach perceives human beings as having value in their own right (Kuada 2009; Metz 2015; Bolden and Kirk 2009 ). In Mexico, Michaud et al. (2019) used Kouzes and Posner's (2012) leadership practices inventory and determined that Mexican leaders typically engage styles that involved both presenting a vision for the future and convincing employees to make this vision their own. Leaders would not engage in creative activities that deviated too far from the status quo. In China, India and Pakistan, gender plays a big role with women in leadership being evaluated with closer scrutiny than men. In the Philippines, among the millennials, 1 age is important (Rathore et al. 2017) . In Macedonia, the size of the company is important (Bonafe and Casimiro 2019). In small and medium enterprises (SME) success depends on the clarity with which the leader shares the vision and motivates people towards achieving a common goal and provides direction (Bojadjiev et al. 2019; Durham et al. 1997; Mihai 2015) . SMEs succeed under leadership which transforms knowledge into action, enhances autonomy and encourages cooperation among employees (Nanjundeswaraswamy and Swamy 2015; Rahman 2012; Kelchner 2016) . This describes the type of leadership required to build a midwives' association (Haron 2015) . Globalisation and population movements have created multicultural societies and a great diversity of beliefs and values among followers (Hofstede and Minkov 2010) , challenging leaders to adapt (Eagly 2015; Bristol 2016) . No one leadership approach fits all circumstances. Midwifery leaders need to be aware of these issues. According to Bojadjiev et al. (2017) older people can be better leaders than younger ones due to their ability to deal with and understand people in a more positive way. Younger ones are different. Table 11 .1 captures some of the differences. Individuals have personal and social identities which form the basis of their goals (Ashford and Cummings 1983; Lord et al. 1999) . Leadership practices must align personal and organisational goals to stimulate commitment and motivation. Otherwise, individuals will find ways of fulfilling their own goals (Jackson 2004; Okpara and Wynn 2007) . Personal and organisational goal alignment constitute a 'psychological' contract between the leaders and the followers (Rousseau 1990; Jackson 2004) . Midwifery leaders should fulfil these 'psychological contracts' through the way they lead. Leadership styles describe how leaders exercise authority and the degree of autonomy they offer to followers. Some authors suggest that men and women lead differently (Patel et al. 2013 in Bojadjiev et al. 2017 . Others feel that stereotypes may prejudice women in leadership (Kaiser and Wallace 2016). Blake and Mouton (1964), Fiedler (1967) , House and Mitchell (1974) , and Stogdill (1974) described behavioural approaches to leadership. Stogdill stated that leadership is situational. Fiedler's path-goal theory suggests that effective leadership provides a path to a Transactional and transformational leaderships are presented in Annex 11.3. Transactional leadership focuses on exchanges of favours between leaders and followers and on reward or punishment for performance. Transformational leadership focuses on binding people around a common purpose through self-reinforcing behaviours. Bass (1985) explained that successful leaders inspire employees to transcend themselves and do more through idealized influence, inspirational leadership, individualized consideration and intellectual stimulation. The four Is are illustrated in Fig. 11 .1 and defined in Box 11.3. Midwifery leadership development programmes should consider including these concepts. Annex 11.4 presents some factors which might either neutralise or substitute leadership. Idealised influence: Leaders act as role models, are able to motivate people around a common purpose through self-reinforcing behaviours gained from successfully achieving a task and from a reliance on intrinsic rewards. Inspirational leadership: Leaders inspire followers by identifying new opportunities, providing meaning and challenge, and articulating a strong vision. They have positive expectations of and can convince members that they are talented and willing to work and can deliver up to their potentials. Individualised consideration: Leaders provide personalised consideration on individual needs for achievement, development, growth and support and adopt coaching and mentoring strategies in their relationships with followers. A leader is expected to have a certain personality, a form of persuasion and power, and the art of inducing compliance (De Pree 2006; Bass and Stogdil 1990) . She/he influences diverse followers to willingly expend energy to achieve the organizational objectives (Winston and Patterson 2006); defines the vision and converts the idea into action (Bolden 2004) . Midwifery leaders need capacity to do these things for them to present midwifery as one united profession. Box 11.4 presents a non-exhaustive list of selected leadership characteristics; while Box 11.5 presents what literature describes as an effective leader. The follower can either reject or accept a leadership activity. The follower's personality and readiness to follow determines the type of leadership style (Hollander 1964) . The midwifery leader needs to be sensitive and respectful of these traits among midwives as followers. Intellectual stimulation: Leaders are enthusiastic, optimistic, communicate clear and realistic expectations and demonstrate commitment to a shared vision. Followers are encouraged to participate in identifying required change, how to achieve it, to see deeper purpose in their work and exceed their own self-interests for the good of the organisation. Source: Conger (2012) . Leadership needs in the twenty-first century. Principles of Management. The twenty-first century demanded strong, versatile, resilient leaders capable of leading in challenging circumstances (Conger 1993) . Leaders needed to be: • Strategic opportunists: To find strategic opportunities. • Globally aware: To cope with environmental demands for flexibility and learning. • Sensitive to diversity: To deal with a racially, gender, sexual orientation diverse workforce and membership. • Interpersonally competent: To be aware of and sensitive to multi-cultural needs and expectations. Where work and organisations serve as major sources of identity and fulfilment of needs and members develop a sense of ownership and identity. Inclusive leadership (Box 11.6), plus effective communication, credibility, being inspirational, fostering acceptance of goals, and being wise, knowledgeable and intelligent should be included in midwifery development programmes. Acts of transformational leadership are highly relevant given their effectiveness in a variety of settings and cultures (Brubaker 2013) . A midwifery leadership development programme should ensure the development of confidence and leadership skills in real-work settings and the creation of leadership teams and networks. Midwifery leadership programmes should move away from heroic leadership based on innate qualities to a set of behaviours that can be developed to produce authentic leaders (Jaye 2017). An effective leader • Is a difference-maker between success and failure. • Knows the way, shows the way and goes the way. • Has a futuristic vision and is positive. • Knows how to turn his ideas into success stories and is oozing with confidence. • Takes a little more than his share of blame and a little less than his share of credit (Arnold S. Glasson Authentic leadership is when the individual seeks to be reflective and develops a high level of self-knowledge to understand others with whom the individual works and to operate and engage in an honest transparent manner, providing reassurance and direction particularly in difficult situations (Ross-Davie et al. 2016 ). The impact of gender, age, culture, organisational politics and societal culture should be included (Eagly and Carli 2003a, b) . Prospective midwifery leaders need capacity to deal with and rise above gender issues. Female midwifery leaders require effective strategies to deal with work-family conflict and to dissipate the 'glass ceiling' in many settings (Cameron and Quinn 2011; Halverson and Tirmizi 2008) . Jackson (2004), Kuada (2006) and Bolden and Kirk (2009) introduced the ideas of cross-vergence or hybridization, suggesting that leadership development must be built on ideas from many cultures and the multifaceted nature of the factors impacting on leadership practices. Midwifery leadership programme developers need evidence on these concepts including concepts on orgnasational politics (Ferris and Hochwarter 2011) for programmes to enhance the individual midwifery leader's intelligence, emotional and political quotients (Owen 2017) . Additionally, for successful leadership development, the programme must include different aspects of teaching and learning including education, coaching and quality improvement to enable participants to learn and then embed whatever key leadership behaviours they will have learnt (Ross-Davie et al. 2016) . The National Health Services of the United Kingdom has developed a leadership framework made up of seven domains for leadership in clinical settings-the Clinical Leadership Framework and Medical Competency Framework (NHS Leadership Academy 2012). This is a useful tool for those developing leadership in the clinical settings. Midwifery also needs leadership at regional and global levels. The competencies for these individuals who have to lead and represent midwifery outside the midwifery settings are much broader as described above Forbes (2018) . The ICM Leadership Programme's vision is: …a future where women, their newborn and families are healthy and receiving optimum midwifery services because the midwifery profession is strong and well led and taking the lead in provision of services within the context of their countries. (ICM 2014) To achieve this vision, midwifery leaders must be primary advocates for women and their families, chart the way and strengthen midwifery by contributing to global health policy. This implies having midwives holding key positions in global bodies dealing with midwifery and reproductive health; driving change in social, political and cultural arenas; promoting the profession and making midwives and midwifery visible; and acting as inspiring role models for midwives globally (ICM 2014). Midwifery leadership is needed in research to produce evidence and new knowledge in care provision and workforce development to match the increasingly changing and expanding role of midwives and provide policymakers with a vision, a strategic path, a set of priorities and a range of suggestions and adaptable strategies for action to improve health, address health inequalities and ensure the health of future generations. WHO Regional Office for Europe (2015) in 'Health 2020' (Box 11.7) described midwives as 'a vital resource for health' and as having key and increasingly important roles to play in society's efforts to tackle the public health challenges of the twenty-first century (WHO 2015). Health 2020, the European health policy framework and strategy, aims to improve Effective leadership makes midwives associations the voice of midwifery. In midwifery education, leadership guides education institutions and programmes based on global guidelines and advocates for resources for the production of competent midwives who provide respectful midwifery care. The ICM brings together leading experts in education, regulation and research into Standing Committees which keep their fingers on the pulse of global health issues and the contribution of midwives. This global leadership needs to be owned, valued and supported by all midwives. 'In practice, effective leadership will provide oversight, advocacy for quality, respectful midwifery care provision and demonstration and promotion of examples of value-added midwifery interventions in addressing people's health needs' (WHO 2015:1). Effective midwifery leaders contribute to workforce development, evidence-based recruitment, deployment and retention of the workforce and discourage the belief that the least qualified members of the healthcare team should work closest to where women live (WHO 2008; Adhikari 2018) , thus inadvertently exonerating governments from and perpetuating the lack of development of badly needed facilities and infrastructure in rural areas. Without water, electricity and other modern amenities (internet, housing, transport and communication systems), women cannot enjoy the care of professionals considered highly qualified. No one leadership style fits all situations. Leaders need to be discerning enough to know when to change styles. Global events have challenged leadership styles. Neither the Western, the African, nor the Asian approaches to leadership fit because populations and organisations consist of neither purely African, Western (European and American) nor Asian cultures. Leaders need characteristics that enable them to function in all settings. Midwifery leaders need to represent midwives on the decision-making table and provide a vision and a path to help individual midwives to develop an identity. Big midwives' associations can learn from the corporate world and adapt some of the approaches to midwifery leadership. The Pakistani example showed that female leaders and female followers are unique and need leaders who understand gender dynamics (Rathore et al. 2017) . Smaller associations can learn from the Macedonian SME example (Bojadjiev et al. 2017) as they attempt to pull midwives together into a coherent professional group. Existing leaders must coach, mentor, support and nurture colleagues into the profession. They must guide care processes, support colleagues to love and value the profession and the women they care for; use transactional approaches to provide order and structure to the work and be transformative enough to enable others to be creative, share ideas and continue to learn, as well as nurture and develop resilience in midwives in the health and well-being of populations, reduce inequalities and ensure peoplecentred health systems. In order to support the realization of the Health 2020 goals, the European strategic directions for strengthening nursing and midwifery towards Health 2020 was developed guiding Member States and the WHO Regional Office to mobilize the potential of the nursing and midwifery workforce. This European compendium was produced to provide operational examples of the new nursing and midwifery roles and new service delivery models currently being employed across the region. The case studies directly relate to the priority areas in Health 2020 and exemplify the types of activities needed to fully implement the objectives within the Strategic Directions framework. Source: WHO European Region (2015) Nurses and Midwives A vital resource: European compendium of good practices in nursing and midwifery towards Health 2020 goals. times of stress. They must be able to use collaborative leadership approaches to navigate the health systems in which they work and for them to manage to work with multiple stakeholders most of whom are neither midwives nor healthcare providers. Team leadership is effective in clinical settings, with clinical leaders who are experts in their field and who can get their hands dirty when needed. Older leaders should support and guide younger leaders using their experience and analytic approach to issues. Cultural sensitivity must be one of the hallmarks of midwifery leadership in order to lead a profession that respects diversity among its members and care receivers. Research on leadership and leadership styles continues. Midwifery research should contribute to these studies and guide the profession in developing its future leaders with a clear vision of what the future holds and to share that vision effectively enough for all midwives to want to follow. Characteristics Visionary • Capable of shaping a vision for those who cannot see the possibilities • Thinks big and conceptualises ideas to motivate others to action • Sees the end before the beginning and able to assess from a bird's eye view • Has a long-term mindset and plots his course accordingly Optimizer • Assesses, analyses and maps out improvements that directly save or make money. (In health we do not make money but life and positive health outcomes) • Some people rely on to make sound decisions • Assesses a situation and immediately sees ways of improving health outcomes • Gains satisfaction from knowing her work makes a difference or makes the business more profitable In the autocratic leadership style, the leader brings all the decisions and orders to the group. Group members' behaviour is controlled through punishment reward and arbitrary rules. There is no room for members' initiative and creativity. The leader, in general, is arrogant, proud and egotistical. This leadership style is useful in situations where there is little time for group decision-making or where the leader is the most knowledgeable member within the group and in times of crisis (Khan et al. 2015) . The benefit of autocratic leadership is that it is incredibly efficient (Amanchukwu et al. 2015) . The democratic style focuses on group relationships and the sensibility of people in the organization. Team members take responsibility for their behaviour. It encourages professional competence prompts quality assuring behaviour (Cummingham et al. 2015:34) . Group members can express their feelings, ideas and give suggestions. The leader proposes ideas, is patient, confident and friendly and offers guidance to the members. The leader perceives her/himself as a member of the group and allows sharing ideas from other members of the group. Group members are involved in the decision-making process, although the leader has the last word (Khan et al. 2015) . This results in increased motivation, creativity and confidence among group members. The main disadvantage is that extended time is required to move forward (Amanchukwu et al. 2015) . It is most suitable for small-and mediumsized groups where the leader can focus on developing highly driven, smaller teams (Fiaz et al. 2017:147) . This style is particularly recommended in cases of innovative organizations or projects which require cooperation between various units (Mohuidin 2017:26-27) . The laissez-faire leadership style is characterized by a lack of real leadership, where every team member can do what he/she wants. There is a disregard of supervisory duties and lack of guidance given to subordinates, which later results in low productivity, resistance to change and low quality of work (Murnigham and Leung 1976) . The team members are not only involved in the decision-making process, but they are also responsible for making the final decision, although the full responsibility goes to the leader. Suitable for situations where employees are highly educated and they are confident enough to bring the right decision. They know how to deal with a specific task and how to use the strategies in order to complete the same task (Khan et al. 2015) . Source: Conger (2012) . Leadership in the twenty-first Century. • Supportive leadership-Leadership that demonstrates concern for the well-being and personal needs of members Transformational leadership involves binding people around a common purpose through selfreinforcing behaviours gained from successfully achieving a task and from a reliance on intrinsic rewards. There are six dimensions of transformational leadership. These are intellectual stimulation, articulating a vision, appropriate role model, and expectations of high performance, group goals and individualized support (Edwards et al. 2016; Speitzer et al. 2005:212) . Transformational leaders act as role models and are able to motivate and inspire their followers by identifying new opportunities, providing meaning and challenge, and articulating a strong vision for the future (Barling et al. 2000; Khaliq et al. 2017) . They are enthusiastic and optimistic, communicate clear and realistic expectations and demonstrate commitment to a shared vision. The leader's responsibility is to convey and communicate a clear vision with clear explanation why and what type of change is necessary (Bass 1999) . Followers are encouraged to participate in identifying required change and how to achieve it (Bass 1997) , to see deeper purpose in their work and exceed their own self-interests for the good of the organisation and to consider the needs of others over their own, share risks with others and conduct themselves ethically. Transformational leaders provide personalised consideration on individual needs for achievement, development, growth and support and adopt coaching and mentoring strategies in their relationships with followers (Bass and Steidlmeier 1999; Dong et al. 2017; Brodbeck et al. 2002) and have positive expectations of the team members (Ogbonnaya and Nielsen 2016). The leader is naturally enthusiastic and capable of convincing members that they can deliver up to their potentials because she/he believes they are talented and willing to work and utilises whatever rewards are available (Ahmad et al. 2014 ). This highly motivates and inspires the team members. Transactional leaders are very consistent in accomplishing the organization goals and objectives made by either the leaders themselves or the top management. Their prime concern is the accomplishment of task by all means through reward and punishment strategy (Tremblay et al. 2013) . The leader makes explicit agreements with the team members about the rewards if they adhere to the policies and the punishment if they fail to do so. The promise of reward and the fear of punishment thus drive the efforts and commitment of the employees and the leader keeps tag of each individual's performance purpose. For an organization, this style maybe useful to keep every working unit in the organization on track (Vera and Crossan 2004) . Source: Conger (2012) . Leadership needs in the twenty-first century. Principles of Management. There are some situations that challenge leadership however well it is exercised. Discuss substitutes for leadership and neutralisers of leadership. Substitutes for leadership are those situations where the role expectations, motivation of organisational members, and some group members characteristics render leadership irrelevant. One example given is when a highly skilled expert performs her/his work according to her/his own standards without needing any outside prompting. A leader is not needed to motivate this person. In some situations, the work itself is motivating. For example, when it involves solving of an intricate problem or when it is familiar and well structured, it is intrinsically satisfying and therefore renders the leader irrelevant. In other situations, the organisational rules are so clear and specific that workers know exactly what is expected of them and do not need help from outside. These situations substitute for leadership. Neutralisers are situations that prevent the leaders from exercising their authority the way they would like to. Examples include computerpaced activities which prevent the leader from initiating structure or behaviour to either speed up or slow down the process. Some organisations' labour conditions and terms do not allow the leader to reward people according to performance or be creative in correcting issues. Instead rewards could be based on seniority and years of work irrespective of quality of work, and disciplinary rules are laid down and have to be followed despite the leaders' desires. This tends to be common in the civil service. So, there is not external motivation from the leader to enhance production. This brings up the issue that allowing oneself to be led is a choice. 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