There are numerous definitions of leadership across all healthcare disciplines, this may be because leadership has been observed to encompass various attributes and is often defined through the lens of an individual’s own perspective or experience of leadership. The literature available on leadership surmises that ultimately, leadership depends on the people and situation at hand (Syrett and Hogg, 1992).
Leadership in an occupational health (OH) context is defined as the ability to positively influence the working populations’ health and well-being while adapting to the ever-changing needs of the workplace. This is met by several challenges. For example, the ageing population, chronic conditions and the ever-increasing gap between demand and supply. Despite these challenges, clinical leaders within occupational health settings are tasked with the paramount responsibility of directing and influencing teams. (Al-Habib, 2020; McCauley and Peterman, 2017; Dodd, 2012; Michaud, 1984).
OH Nurse (OHN) leadership differentiates itself from other non-clinical organisational leadership in a few ways. OHN leadership is rooted in delivering high-quality care and ensuring patient/client safety while maintaining traditional caring skills, with the addition of focusing on business outcomes and cost efficiency (Nieuwboer et al., 2019); Major, 2019).
Leadership was once thought to be exclusive to individuals that possessed innate leadership traits and/or qualities. More recently, however, researchers have theorised that leadership is a trainable and transferable skill (Ancona et al., 2007).
Research reveals that there are several leadership styles evident in health care (See Table 1). To explore effective leadership in the OHN context, leaders should aim to understand the ways in which leadership skills can affect key OH stakeholders (See Table 2). Effective leadership skills are expected to be adopted and used interchangeably by the leader within an OH context.
Leadership Style (LS)
Transactional Leadership (directive/ delegative)
This leadership style is effective in clarifying followers’ roles and responsibilities. This leadership style can be used to achieve performance targets due to the incentives of rewards for high performers. conversely, those not achieving are at risk of consequences. This LS has been observed to possess more managerial traits than leadership ones. This is due to the reinforcement of tasks/goals and the exchanges in reward form following the completion of said task/goal. This LS has proved effective in a sales environment and is most effective in self-motivated individuals. However, it leaves little room for innovation and there is a risk of micromanagement and low staff morale.
Group participation, discussions and shared decisions are often observed with this leadership style. This leadership style helps build organisational flexibility and often allows team members to generate innovative ideas.
Authoritarian / Autocratic Leadership (directive)
This leadership style has been defined as one where the leader makes every decision with little-no input from others. although evidence suggests that this leadership style is effective in managing the deliverance of high output from workers, it has often been observed to cause low staff morale, reduced autonomy & high staff turnover. This style has been theorised to be more of a management style than a leadership one, as it is task orientated and creates followers and not future leaders Despite the negative connotations associated with this style, it has been proven to be effective during a crisis/emergency or when a decision needs to be made immediately.
Laissez– faire (delegative)
In contrast to the autocratic leadership style, the laissez-faire leader offers little to no direction/supervision to their subordinates, this style does very little to inspire/motivate team members to achieve a mission/goal. Lack of role clarity encourages passivity in team members and fosters an environment of low accountability.
Definition in OH context
The patient – also known as the employee or client within the OH context.
These are the main stakeholders – those at the receiving end of the OHN’s care, advice, and support.
This includes OH doctors, OH nurses, physiotherapists, psychologists, OH hygienists and OH technicians. These clinicians / allied healthcare professionals generally form the OH multidisciplinary team (MDT) and OHN’s are likely to work closely with a few – if not all these healthcare professionals, often.
This can be business leaders in organisations that provide funding for OH services. This includes employers /shareholders in the local government, varying health boards or independent organisations.
This includes accredited Health and safety organisations that focus on workers’ health. For example, the SEQOHS (Safe Effective Quality Occupational Health Service), aim to oversee the standards of care provided by occupational health services.
Knowing which skill to use and when is imperative.
The overall measure for effective leadership within OH, over and above the improved quality of workers’ health, is the positive organisational and societal implications. Effective OH leadership can aid in the building/maintenance of team morale, positive & productive workplace culture, the retainment of OH staff and trust in OH services (Cai et al, 2021; Murray & Hill, 1992).
Several leadership approaches are evident across all nursing disciplines. Two approaches are explored for the purposes of this article.
Servant leadership, an approach introduced by Greenleaf (1997) sets the premise of serving others first. This leadership approach optimises the relational aspect of the leader-subordinate dynamic. The servant leader often possesses excellent listening skills, has a long-term vision, and inspires team members to reach said vision by leading by example and encouraging the heart. Within the healthcare context, this leadership style can prove effective as it breeds an environment of trustworthiness and loyalty between the leader and fellow team members. (Trastek et al., 2014a).
Shared governance is essential in OH. This approach encourages shared leadership where decision-making is shared amongst the groups and others’ input is valid and welcomed. This allows for a culture of trust and empowerment within OH Nurses and other healthcare disciplines/partners. As a byproduct, servant leadership leads to cohesive interdisciplinary working, reduced staff turnover and high-value patient, or in the context of OH, employee care (Canavesi and Minelli, 2022; Cottey and McKimm, 2019; Gunnarsdóttir et al., 2018).
Despite a growing body of evidence indicating the effectiveness of servant leadership, this approach takes time to build due to the need for robust interpersonal relationships between a leader and team members. In addition, this approach relies heavily on the relational aspect of the leader-follower dynamic and collective decision-making, which will prove difficult in situations where decisions need to be made quickly such as a crisis (Aarum Andersen, 2009; Eva et al., 2019).
Transformational leadership (TL) is a leadership approach that has been theorised to be the gold standard approach in nursing. Transformational leaders have been defined as individuals that are able to encourage and motivate their followers to meet a shared vision or goal. In addition, Transformational leaders (TLs) provide opportunities for their followers/ subordinates to develop and often supersede their potential. Transformational leadership assists employees or members of a group in meeting their needs for self-actualisation, as per Maslow’s hierarchy (Cope and Murray, 2017; Akilu and Junaidu, 2015; Mulla and Krishnan, 2011).
In addition to these characteristics, transformational leaders serve as role models for their followers/subordinates. This leadership style has been shown to improve patient (employee) outcomes, staff satisfaction, and safety culture (Specchia et al., 2021).
According to the evidence reviewed, both servant and transformational leadership have effective characteristics that can be applied in OH and other nursing settings. However, transformational leadership would benefit OH and all its stakeholders because it promotes both organisational success and the empowerment and growth of individual employees. (Collins et al., 2020).
Changes in leadership styles during the pandemic
The World Health Organization declared the covid-19 outbreak a global pandemic in March 2020. Leaders in all healthcare disciplines faced multifaceted challenges because of this (Dadich and Mellick Lopes, 2022). Whether the crisis is physical, chemical, or biological in nature, OH plays a crucial role in crisis management. During the pandemic, OH played an important role in providing employers and employees with up-to-date government guidelines, facilitating contact tracing, undertaking risk assessments, and being at the forefront of vaccination rollout (Ranka et al., 2020). The COVID-19 pandemic highlighted the importance of OH services acting as a link between health and workplaces more than ever. As a result, good leadership during the pandemic became critical in enabling OH services to provide adequate care and support to individuals in the workforce. Healthcare leaders were responsible for guiding their teams and patients through a global health crisis, restructuring healthcare systems and services, and ensuring quality patient care. According to the evidence, rather than focusing on specific leadership styles, nurse leaders adopted a variety of leadership approaches in response (Hwang et al., 2020; Nicola et al., 2020). Nurse leaders were tasked with adhering to a clear chain of command and being a visible leadership presence within healthcare settings in order to prevent disease transmission, keep up with rapidly changing guidance, and the direct and indirect impact of the virus on healthcare staff and patients (Sihvola et al., 2022). There is little research on the role of relational leadership in crisis response. Most of the research on crisis leadership is focused on authoritarian leadership styles, also known as the command-and-control approach. This approach is thought to work best in situations where there is little time for group decision-making or where the leader is the most knowledgeable member of the group (Boin et al., 2014; Cook, 2021; Webster et al., 2020).
A study by Smithson (2022) on leadership styles during the height of the covid 19 pandemic found that the command-and-control leadership style elicited mixed reactions among healthcare leaders. This leadership style was necessary for managing the uncertainty of the complex and prolonged covid crisis, but leaders in this study discovered that it was stifling, causing stress to the staff, and affecting team morale. As a result, leaders adopted a more relational approach, allowing for a dual leadership approach to the ongoing crisis, which appeared to reduce staff anxiety.
This was consistent with the findings of a study conducted by Phillips et al., (2022) on the nursing workforce during the pandemic. According to this study, the command-and-control leadership style used during the pandemic clashes with nursing culture, where relational leadership produces the best results for staff satisfaction, team cohesion and quality patient care.
OH Nurses must develop the necessary leadership skills to be successful change agents, ultimately improving employee satisfaction and nurse retention. Leadership is a role that all nurses, regardless of job title or experience, are expected to fulfil. The key to encouraging leadership is to have experienced nurse leaders act as mentors for other nurses. Mentors should encourage mentees to continue their formal and informal education by attending leadership conferences/accredited training courses and obtaining a higher degree or certification. To maintain their own professional development, mentors should continue to learn tool (Cope and Murray, 2017; Major, 2019; Downey et al., 2011).
There are several healthcare leadership models and programmes that can be used to train and support healthcare leaders. The NHS compiled the healthcare leadership model which contains nine dimensions and was created to help healthcare workers from all backgrounds become better leaders. The dimensions include leading with care, sharing the vision, engaging the team, influencing for results, evaluating information, inspiring shared purpose, connecting our service, developing capability, and holding to account. These core concepts interlink with previously highlighted leadership styles/approaches and are essential in effective OH leadership (Kumar and Khiljee, 2016; Pearce, 2004).
Phina is an experienced nurse who is currently studying for a specialist community public health nursing qualification, focusing on Occupational health. She is particularly passionate about community health and is a trustee of a charity centred on tackling mental ill-health within the African / Caribbean communities – Baba Yangu foundation. She works for PAM group which she says has been instrumental in her growth as an OH practitioner.