For most of my career, I've been in leadership positions. Only 6 months after beginning my nursing career I was "promoted" to assistant head nurse, night shift. At the time, I was naive enough to think it was my innate skill and ability, when the reality was more likely the fact that no one else wanted the job. I continued to serve in leadership or managerial positions when I became a nurse-midwife. Several years ago, after many years serving as a director of various nurse-midwifery services, I had the disconcerting but ultimately rewarding revelation that I was not a very good boss. Sure, I was good at negotiating the budget, and getting the midwives decent working conditions, but I was autocratic and aggressive, not very desirable characteristics of a leader. I decided to shift into teaching, something I enjoyed and did not require that I be "in charge" of anyone but myself. To keep clinically active, I took a per diem position as a nurse-midwife at a local hospital. It is a position which I still hold today and one that gives me great pleasure. And it is in part because my current boss is such a skilled leader, a leader that I am proud to follow, that I became interested in the concept of followership.

It seems that a lot gets written about leadership in both business and healthcare. And, certainly we can all agree that leadership is critical to successful teamwork. In fact, teamwork seems to be the topic du jour in many healthcare organizations striving to become models of patient safety. But leaders need followers, so what about the issue of followership? After giving the concept of followership some serious thought and doing a bit of reading on the subject, I've concluded it's time to recognize just how crucial effective followers are to the success of any endeavor. I think this is particularly so when the endeavor involves the health and well-being of women, children, and families.

Followership is defined as "a position of submission to a leader,"1 which strikes me as tautological at best, and, at worst, inadequate for purposes of thoughtful discussion. Robert Kelley, a professor at Carnegie Mellon University, has provided a much better framework for discussion by identifying several different types of followers found in organizations. In his book, The Power of Followership, Kelley explains in detail how all of the ineffective followership styles ultimately fail to serve an organization. Kelley then explains how to recognize your own followership style and transform yourself into an exemplary follower.

Each type of followership style stems from 2 separate continuums: participation, which can range from passive to active; and thinking, which runs from dependent/uncritical to independent/critical. From one's functional placement on these 2 continuums come several types of ineffective followers as well as the exemplary or effective follower. Ineffective followers include "sheep" (passive, with dependent/uncritical thinking); "yes people" (active, yet still dependent/uncritical thinkers); the "alienated" follower (skilled at independent/critical thinking, yet passive in participation due to unresolved conflicts); and "pragmatists" (those whose actions and thought processes remain in the middle of the continuums, allowing them to shift with the currents and avoid conflict). These styles are in contrast to the "exemplary" or effective follower, a person possessing the traits of both independent/critical thinking and active participation.2 It is the exemplary follower that is most valuable to the organization, for the exemplary follower brings out the best in leadership.

Kelley's exemplary follower is personified in the perinatal/neonatal arena by the nurse who communicates assertively and actively when questions arise regarding a plan of care, as well as by the physician who is open to listening and adopting management suggestions from nursing colleagues. Case in point: At the hospital where I practice, any nurse or nurse-midwife can call for the C-section team to be assembled. Even though the decision to do the C-section will ultimately be made by the physician ("leader"), the nursing or midwifery staff ("followers") can, and are encouraged to, call for the team in an emergency, thus avoiding dangerous delays in time-sensitive situations. Exemplary followership both contributes to, and is a by-product of, systems that promote a flattened hierarchy as part of a culture of safety.

The Courageous Follower by Ira Chaleff provides another source of inspiration for those seeking to be either better followers or better leaders. Chaleff identifies qualities of effective followership in terms of courage: the courage to assume responsibility; the courage to serve, the courage to challenge; the courage to participate in transformation; and the courage to take moral action.3 While Chaleff's book focuses more on followership related to the support of a leader, it nonetheless provides significant insights into developing qualities beneficial to effective teamwork.

In reality, we are all both leaders and followers, assuming different roles within our team as the circumstances dictate. An exemplary leader promotes and encourages exemplary followers, and vice versa. But it is more often leaders who get credit when the organization succeeds. Let's take a little time at work to recognize the contributions of the followers, too. I'd like to close my parting thoughts with a quote from Christina Baldwin, author and educator, who said, "To work in the world lovingly means that we are defining what we will be for, rather than reacting to what we are against." I'm for followership, and for continuing my journey toward becoming an effective and exemplary follower. Feel free to join me.

Lisa A. Miller, CNM, JD

President, Perinatal Risk Management & Education Services Chicago, Ill

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