Transformational leadership in end-of-life care for Indigenous Australians

Abstract
Aboriginals and Torres Strait Islander (ATSI) people disproportionately bear the burden of chronic illness in Australia. Compared to non-indigenous Australians, ATSI people have four times the rate of chronic kidney disease and five times the rate of diabetes. In 2013-14, ATSI people were reportedly seven times more likely to suffer kidney failure and three times more likely to suffer diabetes as compared to non-indigenous people. Despite the huge burden, ATSI people are less likely, as compared to other Australians, to utilize healthcare services. A potential reason for this trend is the fear that healthcare systems would not adequately meet the health needs and expectations of ATSI patients. This report focuses on how leadership in an end-of-life care setting could refine the principles of care to be more acceptable, appropriate, and approachable for ATSI patients with chronic conditions. Two leadership styles - transformational and transactional leadership – are compared, alternative arguments set out, and a demonstration of why transformational leadership would be more plausible advanced. Management of Chronic Conditions Among Indigenous Australian Populations Introduction
The World Health Organization’s goal of universal health coverage is to ensure that all people live up to their full health potential and enjoy equitable access to health services regardless of their social and economic status (WHO Factsheet, 2019). Underlying this goal is the concept of health equity, which emphasizes the need to ensure fairness in the provision of health services regardless of an individual’s geographic, demographic, economic, or social standing (Li, 2017). In a bid to progress towards this goal, countries, including Australia, have adopted systematic approaches to reduce inequalities in health services and ensure equity. Access to primary healthcare for indigenous populations (Torres Strait Islander and Aboriginals – ATSI people), particularly in regard to chronic conditions, however, still remains a subject of concern.
The Australian Institute of Health and Welfare (AIHW) categorizes chronic illnesses as the leading cause of death in the country, accounting for 9 in every 10 deaths, and 85 percent of the total disease burden (AIHW, 2014). Worryingly, indigenous populations bear the greater share of this burden, despite making up only 2.5 percent of the country’s population (Rheault et al., 2019). Compared to non-indigenous Australians, ATSI people are reported to have four times the rate of chronic kidney disease and five times the rate of diabetes (Rheault et al., 2019). In 2013-14, ATSI people were reportedly seven times more likely to suffer kidney failure and three times more likely to suffer diabetes (Conway, Tsourtos & Lawn, 2017). Two-thirds of ATSI people reported having one chronic condition, while one-third had more than two chronic diseases as per a 2019 survey (Rheault et al., 2019). The high chronic disease burden affects life expectancy, which stands at an average of 10.6 and 9.5 years lower than non-indigenous Australians for men and women respectively (Rheault et al., 2019).
Despite the high chronic disease burden, ATSI people are less likely, as compared to other Australians, to utilize healthcare services (AIHW, 2008). Findings from the National Aboriginal and Torres Strait Islander People survey carried out in 2004-05 showed that one in seven ATSI people needed to see a doctor in the 12 months preceding the survey but had not done so, while 7 percent needed to go to hospital, but had not (AIHW, 2008). Asked why they chose not to seek healthcare services when they needed to, 20 percent of participants reported feeling that the model of care did not adequately address their health needs (AIHW, 2008). Eleven percent of respondents felt that health service providers did not understand them while 16 percent felt that health services treated them inferiorly to English-speaking Australians (AIHW, 2008). While systemic issues such as cost, long waiting times, and distance also affect healthcare access by ATSI people, it is evident that a sizeable proportion of indigenous populations voluntarily choose not to access health services for fear that their health needs would not be adequately met.
Levasque’s et al.’s (2013) model of access to healthcare identifies five facets that influence a population’s willingness to access healthcare: approachability, acceptability, availability, affordability, and appropriateness. Approachability is about how well a system meets the population’s trust and expectations; acceptability is about how well it aligns with personal, social and cultural values; and appropriateness has to do with the satisfaction that one derives from the consequences of healthcare (Levasque et al., 2013). With ATSI people twice more likely to die from chronic conditions than non-indigenous persons, ensuring equity is the positive first step towards improving access to palliative and hospice care for ATSI patients. This has a lot to do with leadership and organizational culture in individual healthcare facilities. This report focuses on how leadership in an end-of-life care setting could refine the principles of care to be more acceptable, appropriate, and approachable for ATSI patients with chronic conditions. Leadership Approaches: Transformational vs. Transactional Leadership The transformational leadership approach emphasizes the idea of establishing relationships among team members and motivating them to pool efforts towards a shared goal (Choi et al., 2016). Transformational leaders focus on inspiring confidence among team members and communicating loyalty through a shared goal (Choi et al., 2016). This leadership approach is characterized by four fundamental features: intellectual stimulation, individualized consideration, inspirational motivation, and idealized influence (Choi et al., 2016).
Intellectual stimulation involves empowering subordinates to develop rational thinking by engaging them in decision-making, allowing them to take part in team efforts and providing constructive feedback (Choi et al., 2016). Individualized consideration has to do with recognizing individual members’ unique strengths, talents, and values and providing support in the form of mentorship as well as training to help them develop their skills (Choi et al., 2016). Transformational leaders also practice inspirational motivation, which involves providing encouragement and emotional support to inspire subordinates to keep exerting effort towards realizing the team’s shared vision (Choi et al., 2016). Finally, transformational leaders practice idealized influence, which implies leading by example and serving as role models by engaging in behaviors they expect of their subordinates to gain their trust and confidence (Choi et al., 2016).
Based on these features, transformational leadership emerges as a process by which a leader gives subordinates a sense of belonging, establishes strong relationships between them and the organization, and provides the motivation and support that they need to realize the shared goal. Under the transformational leadership theory, subordinate performance is driven by the value that they attach to the organization, and how much they would love to see it succeed.
Transactional leadership, on the other hand, involves making exchanges with subordinates as a way of getting them to perform (Choi et al., 2016). A transactional leader will motivate and guide subordinates to complete their defined tasks without errors, in line with defined goals. To drive success, a transactional leader will employ contingent rewards such as bonuses, time-off, or praise, such that there is some form of transaction, where subordinates strive to perform well because they will get some form of reward from it. In essence, subordinates are not encouraged to change the status quo or exceed pre-defined goals. Rather, they are programmed to work towards a defined set of goals and will strive to perform because with it comes some form of reward (Gunzel-Jensen, Jain & Kjeldsen, 2016). Whereas a transformational leader drives good performance intrinsically by making subordinates feel valued and entitled to contribute towards a shared goal, a transactional leader achieves the same through extrinsic rewards focused on driving performance towards a defined goal. A Case for Transformational Leadership as a way of Addressing the Healthcare Challenge The four features of transformational leadership provide precursors for the structural empowerment of healthcare workers at the care facility, enhancing their ability to understand and address the health needs of ATSI patients. Studies have shown a strong correlation between transformational leadership and structural empowerment in healthcare settings. In their study seeking to establish the influence of leadership on employee empowerment among 200 nursing staff across sampled Malaysian hospitals, Chou et al. (2016) found that workers in settings exhibiting features of transformational leadership were generally more empowered in their decision-making than those in non-transformational environments. The study conceptualized empowerment as an option of strategic management that encourages employees to work in a flexible manner and outside the norm to provide swift responses to client demands (Chou et al., 2016). The intellectual stimulation feature of transformational leadership accords the leader an opportunity to share certain decision-making powers with their subordinates. This intensifies the workers’ sense of responsibility, pushing them to continually develop their knowledge and skills so as to make decisions that align with organizational success. In the context of the current challenge, the nurse leader’s delegation of decision-making powers would empower healthcare workers at different levels to equip themselves with information on the cultural, religious beliefs, and values of the ATSI people. This empowerment would consequently enhance their ability to understand and make decisions that maximize the health outcomes of the target group.
Further, one of the facets of transformational leadership is idealized influence, which requires a leader to serve as a role model and lead by example. In the spirit of idealized influence, the transformational leader will be required to model citizenship and patients’ care quality by demonstrating professionalism in their handling of ITSA patients. This is deemed to stimulate a productive environment for nurses and other healthcare providers at the subordinate level to demonstrate professionalism in their interaction with ATSI patients, thereby promoting such patients’ health outcomes. By leading from the front and demonstrating what they expect of their subordinates, the transformational manager obtains their subordinates’ confidence and serves as a dependable source of professional support and information whenever they are unsure about how to act when faced with ethical dilemmas in their interaction with ATSI patients.
Given the challenges in access to healthcare that have been reported with ATSI populations in the past; the outcome of the proposed program is uncertain and one cannot accurately predict how long it would take before it is accepted by the population of interest. In this regard there is need for a leadership approach that will inspire workers to manage work-related stress effectively. The effectiveness of transformational leadership in reducing work stress and increasing job satisfaction in clinical settings is well-documented.
In their study of 386 nurses across sampled hospitals in the US, Asif et al. (2019) found a positive correlation between transformational leadership and nurses’ job satisfaction and a further significant positive correlation between job satisfaction and nurse-assessed quality of care. Similar findings were reported by Al-Mailam (2004), in his study of 266 healthcare workers in Kuwait, which found higher levels of job satisfaction among employees working in transformational leadership settings, as compared to those in transaction leadership. The researchers concluded that transformational leaders harbor higher expectations towards their employees, and motivate them to work extra hard towards the shared vision (Al-Mailam, 2004). This increases subordinates’ commitment to their job, patients, and the organization. Further, transformational leaders use their charismatic leadership ability to inspire their followers to work beyond expectations. They make significant effort to allocate relevant resources and fulfill the needs of their subordinates. This enhances the subordinates’ ability to realize their full potential and feel more fulfilled in their job (Asif et al., 2019). Studies show that this fulfillment manifests in positive patient outcomes evidenced in reduced incidences of adverse events and improved quality of care (Asif et al., 2019).
Finally, collaboration is key in a program of this kind. There may be need to engage with stakeholders at the community level to obtain insights into not only the values and needs, but also the beliefs of the target population. Transformative leaders believe in the uniqueness of needs, values, and beliefs, and make significant effort to incorporate these differences in their decisions towards the realization of the shared goal. According to Asif et al. (2019), this kind of positive collaboration is key to establishing better working environments in projects whose acceptability touches on elements of culture. Based on this evidence, one would expect that the principles of transformational leadership would play a significant role in increasing collaboration and hence, enhancing the program’s acceptability among ATSI patients. Alternative Opinions Several studies cast doubt on the superiority of transformational leadership over transactional leadership in promoting patients’ health outcomes (Raup, 2008; Cummings et al., 2010). Studies have, for instance, shown the transactional approach to leadership to be more influential on positive patient outcomes in emergency departments (ED). Raup (2008), for instance, conducted a leadership survey of forty-five healthcare ED nurse managers to determine whether there were differences that could be deemed significant in the levels of patient satisfaction between hospitals that employed transformational leadership and those that employed the transactional approach. The study findings showed the transformative approach to be the most preferred leadership style in healthcare settings (Raup, 2008). However, there was no evidence to support the idea that transformational leadership had a greater influence on patient outcomes than transactional leadership (Raup, 2008). The author notes that a potential reason for the observed trend in ED is the circumstances under which leadership decisions are made in the ED. By their very nature, ED settings are characterized by spontaneous decision-making and may not lend themselves adequately to the principles of transformative leadership.
In another study, Cummings et al. (2010) sought to assess the impact of leadership style on 30-day mortality rates of patients in acute care settings in Canadian hospitals. The study findings showed the effect of leadership style on patient outcomes such as satisfaction, complications, and length of stay to be insignificant (Cummings et al., 2010). These findings are, however, highly contradictory given that the same study found a significant relationship between leadership style and 30-day patient mortality. Specifically, the study found that facilities that employing transformative leadership report significantly lower 30-day mortality rates vis-à-vis those that use the transactional approach (Cummings et al., 2010). The researchers advise that further studies be conducted to investigate the relationship after controlling for hospital nursing characteristics, comorbidities, and patient demographics.
While not disputing these alternative arguments, it is evident that they draw largely from acute care settings and other settings associated with spontaneous decision-making. The proposed program, however, seeks to offer end-of-life care, where transformational leadership may be more effective than transactional leadership. Further, transformational leaderships may be crucial to foster collaboration among stakeholders given the acceptability issues that surround the target population. Summary and Conclusion This argumentative essay sought to identify the most plausible leadership approach that a nurse leader in an end-of-life care facility could adopt to help ATSI people in the management of chronic diseases. Empirical data indicates that ATSI people in Australia bear a greater burden of chronic disease than the general population despite making up less than 3 percent of the country’s population. Worryingly, ATSI people with chronic conditions are less likely, as compared to their non-indigenous counterparts, to access healthcare facilities. A common reason cited by such patients is the fear that healthcare systems would not adequately address their health needs or that healthcare professionals would treat them inferiorly to non-indigenous patients. In light of this data, this text sought to identify ways through which leadership could be used to improve this population’s access to proper end-of-life care. Transformational and transactional leadership styles were chosen for analysis. The transformational approach is deemed more effective for the identified health challenge because it: i) results in better empowerment of staff, ii) allows leaders to serve as professional role models, iii) is more effective in reducing work stress and enhancing job satisfaction among staff, and iv) provides better platforms for stakeholder collaboration. For these reasons, the transformational approach is deemed more plausible in addressing the healthcare challenge. Facilities in remote populations could, therefore, adopt transformational leadership as a way of increasing indigenous populations’ access to end-of-life care.

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