Health leadership in New Zealand

Health-care delivery has eventually become more complex, expensive and there is a
high demand for dependable and safe care. New Zealand went through drastic reforms
in health and health care during the last ten decades in the same way as other developed
countries (New Zealand Parliamentary Library, 2009). Due to the advancements in
technology and increase in public awareness, health care expectation has increased
leading to an expansion in health services. Today, nurses and other health care
professionals need specific leadership skills and clinical developments to tackle the
rapidly changing health care environment (Ezziane, 2012).

There were many renowned leaders in the history of nursing leadership in New
Zealand. One among them was Hester Maclean. Her contribution in shaping the health
care in New Zealand, the way she had done that and the background factors influenced
her are analyzed in the first part of this paper. The development of nursing as a
profession and the influence of Maclean and other leaders are discussed further. Later
on, three leadership theories and their relevance are described along with critical
analysis of the application of transformational theory in nursing.

During the early 19th century, nursing began to be recognized more as a profession in
New Zealand (Wood & Nelson, 2013). In the preceding decades, people were
receiving health services from those who were willing to render it. Family members
took care of the other members and sick employees were taken care of co-workers in
the occupational settings. A system of rough care was prevailing in hospitals until a
few female nurses trained under Florence Nightingale came to New Zealand and took
the positions in various hospitals. Then onwards a constant urge for trained nurses
emerged and that led to the 1901 Nurses Registration Act (Nursing New Zealand
centenary souvenir, 2001). But even after that, there was a lack of unity and
communication among the nurses throughout the island. It was during this time Hester
Maclean, took over the reins from Grace Neill and paved the way for many historical
moments in the health care setting of New Zealand, especially in nursing profession
(Wood & Nelson, 2013).

Hester Maclean was born in 1863 in an Australian province. She completed general
nursing from Prince Alfred Hospital, Sydney in 1893. She served as matron and sister-
in-charge and held many higher nursing positions of nursing in Australia. After

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receiving her midwifery certificate from London, in 1906 she was appointed as the
assistant inspector of hospitals and deputy registrar of nurses and midwives in New
Zealand (Who was Hester Maclean?, 2008).

Soon after her appointment, Maclean understood that there was a lack of
communication between nurses of north and south islands. So, she published the
nursing journal Kai Tiaki in January 1908 which later became the New Zealand
Nursing Journal. She founded the journal with her own money and working in her own
times. Kai tiaki, in Mori, means guardianship and protection. Maclean said in the
inaugural editorial that the journal would help nurses as a means of exchanging the
ideas, interdependence and a means to enhance their professional work and knowledge
(National Library of New Zealand, 2001).

When Maclean took charge from Neill, there was no national organization for nurses.
During that time, there were four regional associations formed at Canterbury,
Wellington, Dunedin and Auckland. These four associations were united by Maclean
to form the New Zealand Trained Nurses Association with common aims, objects and
similar rules. Maclean was elected as the first president of the association in the
meeting conducted in Wellington in November 1909 (NZME educational media,
2009).

Through the Kai Tiaki and Trained Nurses Association Maclean gave nurses two
mediums for communicating and sharing their views and ideas and to develop nursing
practice. These, in turn, helped Maclean to increase her control in nursing beyond her
authorized roles. It was because of these two vehicles, nurses during that time got the
opportunity to understand what was happening nationally and internationally and they
also worked as a bridge to fill the gap between individual nurses (Nursing New
Zealand centenary souvenir, 2001).

With the leadership of Hester Maclean, the New Zealand Trained Nurses Association
fought to foster high professional ideals. The association was strong from the
beginning by making professional standards for nurses and representing the profession
well. Nursing during that period was mostly non-supervised. So, Maclean advocated
for training for nurses in hospitals and that should be supervised by carefully selected
persons. She believed that practical knowledge will be more beneficial for nurses than

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theoretical knowledge. This helped in improving the standard of care delivered by
nurses (Sargison, 2017).

Another important event that depicted the leadership quality of Maclean was her
attitude and imitativeness during the World War I. New Zealand declared to take part
in the war on 5 August 1914. There was indeed a shortage of nurses in the troopships.
In January 1915, under the constant pressure from Maclean, Government declared to
create a military nursing service. Maclean as Matron-in-Chief selected and led 50
nurses to London. Her presence made the nurses more energetic and happy (In coats
of grey and scarlet: New Zealand nurses at war, 2015). Thus, Maclean laid the
founding stone for the nursing profession that made its way to the present. The history
of nursing as a profession is needed to be discussed next to further correlate the role
of many great leaders in nursing including Maclean.

Nursing as a profession started in New Zealand during early 18th century. In 1850 first
hospital was built in Auckland (HealthTimes, 2015). The hospitals during that time
were informal with unskilled employees, that lacked trained nurses. Florence
Nightingales influence in nursing created a demand for skilled nurses. Consequently,
probationary nurses were introduced without any formal teaching. In 1883, Wellington
hospital introduced a one-year training program for nurses with a final exam. It was
Dr. Truby King, the medical superintendent of Wellington Hospital who introduced a
four months' formal training for probationer nurses in 1888 with issue of a Nursing
Certificate ( Victoria University of Wellington, 2016). Later New Zealands first
Voluntary District Nursing Association was found in 1896 by Miss Maude
Christchurch.

Nursing was not considered a legal entity until the introduction of Nurses Registration
Act (1901) which was drafted by Grace Neill who was the Assistant Inspector of
Hospitals. Nurses in New Zealand were the first to work under a Nurses Registration
Act. In 1904, for the registration of midwives, the Midwives Act was passed (Nursing
New Zealand centenary souvenir, 2001). After the retirement of Neill, Hester Maclean
took the charge in 1906. With her effort, in 1908 New Zealands first nurses journal,
Kai Tiaki was published and helped Dr MacGregor to form New Zealand Trained
Nurses Association in 1909 (Sargison, 2017). In 1912, the International Council of
Nurses approved this association in their conference in Germany. During World War

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I, New Zealand nurses were send to the army troops under the leadership of Maclean
who was matron-in-charge of the Army Nursing Service, which was formed in 1913.
To foster health of school children, School Nursing Service was formed in 1917. In
1925, Nurses and Midwives Board was established. The New Zealand Trained
Nurses Association changed its name as New Zealand Registered Nurses
Association in 1934 and later it became the NZNO (HealthTimes, 2015).

From then, the nursing profession progressively changed over the years. Around
1960s, the training programme for nurses in a hospital was extended to three years.
The lectures were conducted in schools attached to hospitals. By 1970s, polytechnics
and universities started to run nursing courses instead of hospitals. The study of
nursing was organized based on the Carpenter Report, which recommended a tertiary
based education. During 1990s, cultural safety was included in nursing curriculum,
considering the Mori people. The nursing study was comprised 50% of theory and
50% practical experience. Three-year nursing degree as comprehensive nursing was
introduced in 1995. Later, postgraduate studies were also started in various specialities
like leadership and management, primary health care and geriatric nursing (Papps,
2002).

Nursing Council of New Zealand (NCNZ) is the regulatory authority under which the
nurses in the country register to work. It was established in 1971 as a corporate body
under Nurses Act. It functions to protect the health and safety of members of the
public by making sure that the nurses are knowledgeable and skilled for practicing.
All nurses must apply in the NCNZ for a practicing certificate each year to get updated
with the changing work environment (HealthTimes, 2015). Another important
professional body that provided professional support and leadership is New Zealand
Nurses Organization (NZNO) which was formed in 1993 by the amalgamation of
Nurses Association and Union (New Zealand Nurses Organisation, 2014).

Presently, nursing is a popular profession that gives nurses distinguished career

opportunities even in managerial positions and they need to possess the required
knowledge and skills to work in these extended and expanded roles of nursing (Barr
& Dowding, 2012). As leaders, nurses should understand common leadership theories
in health care to perform her duties and responsibilities for patient safety and well-

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being. Three of the major leadership theories are described next, along with their
relevance in health care.

Transactional leadership is a generally followed leadership theory in which the

subordinates follows the commands of the supervisors and gives them the supreme
authority (Flynn, 2015). It uses rewards and punishments to motivate the followers.
Subordinates will follow the instructions of the authority in order to avoid punishments
(Barr & Dowding, 2012). If the task is achieved, those employees will be rewarded.
The full responsibility of the task will be on the subordinates, even if they lack
competency or necessary resources. Transactional leadership is used in all health care
settings in the form of providing salary to the employees in exchange of the services
provided by them (Taylor, 2009).

On the other hand, situational theories are developed on the idea that the organizational
behaviour is contingent on the environment or situation (Taylor, 2009). The leader
must select the plan of action after considering the situation on hand. So, a situational
leader should possess good ability to diagnose the situation (Huber, 2014). In the
modern context of health care which is dynamic, the situational leadership can be well
used. For example, in an emergency, a situational leader will become authoritative
rather than democratic (Taylor, 2009).

In contrast, transformational leaders are those who bring about a positive change in
the workplace and constantly motivates their subordinates for work excellence. They
transform the organization as well as the employees in the organization (Morton,
2012). Transformational leaders give more importance to their relationships with the
followers beyond their self-interest. Long term goals are met through developing and
empowering the employees potential through a charismatic approach (Taylor, 2009).
Transformational leadership qualities are more relevant in the context of healthcare,
especially in nursing leadership (Huber, 2014).

Effective leadership is crucial to for solving the complex problems in delivering

nursing care. It is observed that the transformational leadership has a keen focus on
various departments of the health care system (Daly, Speedy, & Jackson, 2015). A
transformative leader is the one which suits best for the nursing environment. The
Institute of Medicine stated that transformational leadership theory has a significant
role in developing a work climate that assures patient safety. Evidence from literature

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supports that transformational leadership theory can produce positive outcomes
among nurses working in institutional settings (Yoder-Wise, 2011).

Health care is now in a state of transformation. So, the nurse leaders needed to
transform their organizational values, rules and behaviours to put forward a better plan
(Marquis & Huston , 2012). Transformational leadership will help them for this. This
theory has been recognized by the American Nurses Credentialing Centre (ANCC) by
making it one among the five components of their Magnet model. This model helps to
find out the core concepts of successful nursing leadership and they recommend
transformational leadership for the nursing departments of a hospital to get Magnet
recognition (Huber, 2014).

Nursing is usually described as a profession with high work pressure and lengthy work
hours. Increasing work demand with less supportive relationships creates stress among
nurses and can eventually result in high turnover rates. Transformational leaders
support the employees and enhance their general well-being and job satisfaction (Lin,
MacLennan, Hunt, & Cox, 2015). Another study reveals that transformational
leadership creates greater responsibility, job empowerment, clarity of work and
continuity of care among nurses that leads to better teamwork and communication
(Yoder-Wise, 2011). Transformational leadership will help the nurse leaders to
develop a vision that in turn motivates the employees and results in better work output.
This leadership is usually applied in composite and dynamic working climates like
those in nursing departments (Kelly, 2010).

The writer would like to narrate a situation where transformational leadership was
successfully implemented. A merger of two medical wards was going on in a hospital.
Although the two wards were located on the same floor of the hospital and handled
similar conditions, they had a separate working styles, teams, culture and guidelines.
One of the ward in-charge became the transformational leader and identified the
possible issues related to merger and developed a plan of action to solve them. She
conducted regular staff meetings and training sections for team building and created
and communicated the vision to all of them. At the end of 16th week a schedule was
created for the working of new merged unit with a strong, dynamic health team. The
merger was successfully carried out by eliminating the possible obstacles.

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In conclusion, nurses in New Zealand have a rich heritage. Nursing has emerged into
a well-accepted profession with a wide scope. The development of nursing as a
profession happened with the efforts and challenging works of many great leaders
during that time. Hester Maclean was one eminent person among them. She was an
indomitable nursing visionary who led the nurses with her deeds and thoughts. First
nursing journal, Kai Tiaki and first national association for nurses, New Zealand
Trained Nurses Association were some of her valuable contributions.

Another key area of concentration was on three leadership theories in health care.
Transactional, transformational and situational leadership theories have their own
distinguishable characteristics that make them unique. They all can be applied in a
variety of health care settings. But the most relevant theory for health care, especially
in nursing is transformational leadership theory. Transformational leadership was
widely used to deal with critical issues in nursing units. This is supported well with
the evidence from the literature.

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