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Leadership In Healthcare In New Zealand

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Critically analyse and Discuss the impact of Leadership in the Historical Development of Healthcare in New Zealand.


New Zealand is an island nation with a approximate population of 4.5 million people. It has a publicly funded healthcare system, that has universal coverage provided by non-governmental, public and private sectors. New Zealanders have enjoyed a high standard of life by international standards. Whether it be the Human Development Index (HDI) or a measure of education, GDP per capita and life expectancy New Zealand is standing high on the table. It is based on the Kiwi’s view that everyone should get a “fair go” at life. New Zealand healthcare system is only 79 years old which progressed after the Social Security Act in the year 1938. Like other advanced countries New Zealand has experienced numerous changes in its healthcare over the course of a century. The unpredictable nature of health in a dynamic environment can result in numerous challenges (Apekey, 2011).  Therefore strong leadership in healthcare and most importantly nursing is needed worldwide. Leadership is a hugely discussed aspect in the healthcare literature and it is important in the development of professional, clinical, strategic capacity of any profession in the healthcare setting. The task of any leader is to ensure alignment, commitment and direction within organizations and teams. This push in the right direction ensures pride and agreement in people to what their organization is planning to achieve, they support its values, vision and their strategy. (Bryder, 1991). In this essay we would learn about leadership and its impact on the healthcare system of New Zealand. The New Zealand nursing workforce have impacted the healthcare system widely, as it has changed from the 1800’s from being independent and unregulated untrained nurses to registered nurses of the mid/late 1900’s.


In New Zealand history, the work of trained nurses who had participated in the World War 1 and would be always remembered. Before the year 1901 setting controls and fighting for registration was a common plight for nurses. But Elizabeth Grace Neil changed this when she lobbied for the passing of laws asking to train the nurses and to register them. This passage of this Act in the year 1901 was the first Act of the parliament of New Zealand in order to provide registration to nurses. After this New Zealand became the first country to provide registration to nurses formally. Elizabeth Grace Neil was trained in Florence Nightingale’s ideals and believed that women with board education should only be allowed to train as nurses (Tennant, 1978). According to her “ The main job of a nurse is to serve others”. She was convinced that a uniform system is needed to transform nursing that should include national examination followed by state recognition for the nurses. She played a crucial part in drafting the Registration Act for the year 1901. This bill ensured that the nurses have to train for 3 years, then give a state examination and later they would be registered by the state. Grace Neil was also solely responsible in implementing the act which was the first registration act for the nurses. She decided the curriculum, appointed the examiners and also designed the medal for every registered nurse. It was recorded that within the first year itself 292 nurses registered and the first one was Grace Neil herself. While this bill solved many issues with the nursing profession but still midwifery was not involved in it (Al-Gasseer & Persaud, 2003). She realized how it is imperative that similar act was passed for the midwifery profession as well. She started promoting an identical act for the midwives but the implementation process of the midwives Act 1904 was complex. The reason for this complexity was that the institutions that provided formal training for midwifery were limited. There she faced the adversity of limited sources for formal training. She not only had to create a curriculum but along with that she had to set up maternity hospitals where the midwives could be trained. During last two years of her inspectorate at the St Helens hospitals, she decided that the hospital was meant for “respectable” wives of the working men. These women could not afford private maternity care but could easily pay a moderate fee. In these hospitals single women and medical students were not allowed as it was seen as a undermining factor for the hospital. She had no pity for the single destitute women as she herself was a widow raising a son. Grace was aiming to set up hospitals that were managed by women with women doctors. There she faced persistent opposition from the male doctors that saw this step as threat to their income and also to their family health. Finally in the year 1904 Midwives Registration Act was introduced by Richard Seddon. All her efforts were not always praised but many of her efforts met with all over criticism. Mainly her step to choose  hospital buildings quickly for the midwifery and nursing training. Many people complained that these buildings, that were chosen for this purpose were not suitable and were very old. Her sole purpose was to protect the profession of nursing from unqualified people who were mal-practicing. She displayed all characteristics of an effective leader who emphasize a high quality, safe and compassionate care as their top priority.


It was in the 1800s that nursing began in New Zealand. It was in the year 1850, that the first hospital was set up in Auckland. These hospitals included basic cottages run by unskilled and untrained women who were sometimes not more than servants. These hospitals were where the patients were treating patients. These hospitals did not even use disinfectant and were not clean. It was only in the year 1883 that trained and skilled nurses replaced the unskilled and untrained nurses. The Florence Nightingale’s approach was adopted by the nurses which made them realize that they have to maintain cleanliness and should have some training (Selanders, 2012). Lectures were provided to the nurses by the year 1888 in a twelve month training after which they had to clear an exam. It was in the year 1901 that the Nurses Registration Act was passed that enabled the nurses to get registered (Macdonald, 1991). Firstly only the female nurses worked in the female wards but later they were asked to work in the male wards as it was noticed that they had a soothing, healing and settling effect all the patients irrespective of gender (Schultz, 1992). This was the period of registration and proper training which also highlighted how nurses should have a uniform. In the year 1906 the New Private Hospital Act was passed that had put the hospitals in supervision of the Hospital Department (P., 2001), (R, 2001). Through this act it was monitored that a certain amount of registered midwives, registered nurses and certain number of beds are maintained in every hospital. During this period the new concept of public and social services was extended in which it was realized that “prevention is better than cure”. (Roth, 1985) In the year 1907 the first baby hospital and diabetic training center for infant welfare nurses was set up, that introduced nurses to a new role where they would visit homes and instruct mothers as how to take care of their babies. In the year 1913 the nurses from Army Nursing service were sent in the war. It was only in the year 1917 that nurses that were trained and registered visited kids at school to check whether their treatment is going as planned. In the year 1934 the New Zealand Trained Nurses Association was changed to New Zealand Registered Nurses Association  until the year 1971. (J. Godden, 1993)Gradually the training for nursing changed in the 1960’s when they have to train for 3 years in a hospital. In the 1970’s a registered nurse supervised the student nurses (P, 2001). It was also in this decade that the nursing training that was hospital based,  was changed to university based courses. Where nursing students undertook self-directed learning and also problem based learning. Currently nursing students undertake a 3 year bachelor degree that has fifty percent of theory and fifty percent of practical knowledge. These graduates can further select specific areas for their postgraduate studies such as management, gerontology and leadership. These nurses then apply to New Zealand Nursing Council for the practicing certificate. As nurse practitioners these registered nurses have to study more in the field of their choice before they would be allowed to practiced. This history shows how nursing has changed from those basic cottage hospitals to systemized healthcare. (McKimm, 2009)


James McGregor Burns introduced the “Transformational leadership” theory. This theory is defined in which a leader and his subordinates or followers help one another to climb a higher level with the use of morality and motivation. Bernard M. Bass further developed this theory in his book titled “ Leadership and Performance Beyond Expectations”. In his book he explained that this is a model of fairness and integrity. Leaders set clear goals, and set high expectations. They encourage others and provide recognition and support. They motivate others by stirring the emotions in them and encourage others to view past their self-interest. These kind of leaders inspire bonding, trust and loyalty in their team and followers. They inspire others to reach their goals and have high expectations. (Bass, 2003) Their vision is clear and motivate others to deliver the vision. They manage to develop trust based relationships. Transactional leadership is about the view that assumes that employees can be motivated by punishment and rewards. In this leadership theory the interest of the organization and that of the leader is above everything else. In this type of leadership there is a clear chain of command. When employees agree to do a job they cede all authority they hold to their manager. A transactional leader creates clear structures of what is required by his subordinates. If an employee agrees to do some work they are completely responsible for it. Failure to do so would result in punishment and some kind of corrective measure. This type of leadership theory has a “selling” style. It has some limitations as well as it is based on the assumption of a “rational man” thinking which states that people will always be motivated by rewards. In the end of the 1960’s Dr Paul Hersey formed the situational leadership model that states that leaders possess or demonstrate four competencies that are they first diagnose or understand the situation, next they adapt in response to their surroundings, later they communicate with their team members and lastly they advance and manage the outcome. These leaders maintain an acute awareness and have motivating conversations with their employees. They have a skillful influence across their organization that develop committed and engaged employees. 

Transformational leadership theory is the most important and influencial theory in the healthcare leadership research. Wong along with his colleagues  (2013) in his review clearly mentioned that out of nine studies six stated that transactional leaders are the most successful (Wong, 2013).  Gilmartin and D’Aunno in the year 2007 examined healthcare research from the year 1989 to 2005 in their systematic review (Gilmartin, 2007). They concluded that studies in healthcare show that transformational leadership is directly related to staff satisfaction, team and unit performance, turnover intentions and organizational climate. They also included that these effects were reported more strongly in junior staff in comparison to the senior staff. Benefits from the use of transformational leadership have included better work life balance, positive nursing outcomes, better error reporting, patient satisfaction, staff satisfaction and patient safety. They also noticed that vast majority of research was conducted on nurse managers and nurses. According to their review nurses always preferred managers that were emotionally intelligent, participative, and facilitative. These qualities in a manager was linked to high empowerment, lower stress levels, self-efficacy and team cohesion. Nurse leaders should be power sharing, flexible, and collaborative. They should demonstrate high personal values in order to promote quality performance in their subordinates. Meulemans, Van de Heyning, Van Bogaert, Clarke, and Roelant, (2010) studied about nursing environment and job burnouts that affected the quality of care for the patients (Van Bogaert, 2010). They concluded that nursing management was positively related to the staff satisfaction and perceived quality of care. They also found relationship between medication errors, turnover intention, staff burnout and wellbeing of the staff.  Ducharme and Cummings in the year 2013 found a relationship between nurse leadership style and medication error as well as mortality levels. Guneri, Gunay, Arabay and Karilnli (2008) examined the relationships between nurse managers and their staff using the leader member exchange theory (Katrinli, 2008). They also used nurse organizational identification, and job involvement as factors relating to the relationship between the staff and nurse leader. It was noted that when nurse leaders involved nurses in decision making there was a high levels of job performances and organizational identification. All these researchers have proved that empowerment bring quality improvement in a healthcare setting. Empowerment is a key factor in transformational leadership. As transformational leaders encourage others and provide recognition and support (Kim, 2012). This theory goes beyond the traditional style of leadership that involves group performance, supervision and organization. This theory focuses on the fact that people will work more effectively if they can sense a goal or mission. The leaders communicate their goals and vision to their staff and motivate them in a way that makes the goal exciting and meaningful. This gives the goal a collective and meaningful purpose. The current healthcare setting has been derived from the influence of many models, theories and cases. (McAlearney, 2008)


Training, education, and role development for nursing staff and healthcare professionals have the potential to influence service delivery and patient care. Collaborative practice, investment, recognition and equal partnership in a competent and skilled workforce is the key for better future in healthcare. In New Zealand reforms in health have to take into consideration the leadership over the disability system and health. Government have to take into consideration the impact of healthcare workforce and especially nursing on healthcare and quality of care is always significant. The healthcare in New Zealand has gone through major changes since the time of the basic cottages run by untrained women who were sometimes a little more than domestic servants. Contributions from people like Grace Neil have woven a system that has reported a decrease in the traditional clinical autonomy. Now clinical leadership has shaped in building a necessary culture of collaboration that converges the clinical values along with the corporate culture. Through these researches and studies we can denote that there is a clear need to develop clinical leadership along with managerial leadership including to set up centers that promote health leadership. There is also a constant need to develop an evaluation strategy in health leadership development. Actions are required to address the clinical quality and it can be achieved when initiatives are applied at a wider area in the system. To perform at a high standard the healthcare system requires more than skilled workforce they require a shared view and an overall purpose that combines with effective ways of working. This could be achieved with proper leadership skills as theories like transformational leadership can really help in further strengthening our healthcare system. Leaders like Grace Neil ensure that they offer empathic, empowering, fair, respectful, and supportive leadership. They ensure that the voice of the staff is heard and acted upon in the organization which provides practical support to the staff.



Al-Gasseer & Persaud, V. (2003). Measuring progress in nursing and midwifery globally . Journal of Nursing Scholarship , 309-315.

Apekey, T. A. (2011). Room for improvement? Leadership,innovation culture and uptake of quality improvement methods in general practice. Journal of Evaluation in Clinical Practice, 311.

Bass, B. M. (2003). Predicting unit performance by assessing transformational and transactional leadership. Journal of applied psychology, 207.

Gilmartin, M. J. (2007). Leadership Research in Healthcare: A Review and Roadmap. The Academy of Management Annals, 387-438.

Godden, G. C. (1993). The decline of Myths and Myopia? The use and abuse of Nursing History , 27-34.

Katrinli, A. A. (2008). Leader–member exchange, organizational identification and the mediating role of job involvement for nurses. Journal of Advanced Nursing, 354-362.

Kim, Y. &.-B. (2012). The Role of Leadership in Learning Culture and Patient Safety. International Journal of Organization Theory and Behavior, 151–175.

L, B. (1991). A Healthy Country: Essays on the Social History of Medicine in New Zealand. Wellington: Bridget William Books.

Macdonald, C. (1991). The Book of New Zealand Women. Wellington, New Zealand: Bridget Williams Books.

McAlearney, A. (2008). Using leadership development programs to improve quality and efficiency in healthcare. Journal of Healthcare Management, 319-331.

McKimm, J. R. (2009). Developing medical leadership: a comparative review of approaches in the UK and New Zealand. The International Journal of Leadership in Public Services, 10-23.

P, W. (2001). Nursing history: a shift in education In: Nursing New Zealand Centenary Souvenir: 1901 – 2001. Wellington: Nursing Council of New Zealand.

P., F. (2001). A study of the regulation of nursing in New Zealand 1901 - 1997. Wellington: Victoria University of Wellington.

R, G. (2001). Formation of the New Zealand health care system (1840-1970s. Wellington: Victoria University of Wellington.

Roth, M. (1985). "Archives:Association of Women Teachers in 1901". Women Studies Journal , 93-108.

Schultz, J. (1992). The Inhospitable Hospital:Gender and Professionalism in Civil War Medicine . Signs, 363-392.

Selanders, L. C. (2012). "The Voice of Florence Nightingale on Advocacy". OJIN: The Online Journal of Issues in Nursing , 23-44.

Tennant, M. (1978). 'Mrs Grace Neill in the Department of Asylums, Hospitals and Charitable Institutions. New Zealand Journal of History , 3-16.

Van Bogaert, P. C. (2010). Impacts of unit-level nurse practice environment and burnout on nurse-reported outcomes: a multilevel modelling approach. Journal of Clinical Nursing, 1664–74.

Wong, C. A. (2013). Authentic leadership, performance, and job satisfaction: the mediating role of empowerment. Journal of Advanced Nursing, 947–59.


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