Leadership and Management in Nursing, Changing Nursing Practice - Essay Example

Leadership and Management in Nursing: Changing Nursing Practice ‘Change is a constant in the health care environment’ and as a result creating, leading and participating in change has become a part of nursing practice (Daly, Speedy and Jackson 2003) Since nursing is a clinical practice built on evidence based practices drawn from public health knowledge, nurses act as intermediaries in developing new strategies and promoting changes in healthcare delivery. Clinical pathways, which focus on changing strategies for reducing the length of stay and hospital expense, assign nurses to be pathway leaders and precursors of change. General strategies for effecting changes in human systems are power coercive strategy; empirical-rational strategy; and normative/re-educative strategy. Though there are many change strategies, and responsibilities of pathway leadership is challenging, successful change will materialize only with the cooperation and commitment of those involved in the change process. Under these circumstances a case study of the challenges faced by a registered nurse, newly posted in orthopaedic ward of a regional hospital, is attempted to identify efficacy of different change strategies. Leadership challenges and change strategies All professional nurses prefer autonomy and control of their practice and want to apply their nursing knowledge and skills without interference from nurse managers, physicians, or persons in other discipline. “Changing clinical practice involves addressing deeply held beliefs and traditional rituals” and “developing new services often involves changing professional roles, boundaries, and loyalties,” because each profession has a unique set of values (Ridout 2002). Leading change is the mainstay of leadership skill, and “the person responsible for moving others who are affected by the change through its stages” is identified as a change agent ((Daly, Speedy and Jackson 2003, p.195). “The ability to harness internal motivation, the readiness to take responsibility and to persist, and the drive to stretch for higher performance, take risks, and accomplish goals typify leaders high in achievement, orientation and initiative” (Roussel & Swansburg 2008, p.123). General strategies for effecting changes in human systems identified by Robert Chin and D. Benne (1976) that are based on reasons people change their behaviour are: (1) power coercive strategy; (2) empirical-rational strategy; (3) and normative/re-educative strategy (cited by Nickols, 2003) 1. power-coercive strategy “The power-coercive style is a top down dictatorial style to change” (Ridout 2002). The basic tenet of power-coercive strategy is that “people are basically compliant and will generally do what they are told or can be made to do so. Successful change is based on the exercise of authority of sanction” (Nickols, 2003). Coercive leadership power is based on fear, punishment, threats, and may be autocratic. Time and seriousness of the threat faced are two major factors influencing the choice of ‘power-coercive’ strategy. It is probable that all concerned in an organization may not be noticing the threat that is grave and the time for action is limited. Culture is found to moderate changes and members of compassionate bureaucratic culture are likely to participate in a sensible program. On the other hand culture tied with autonomy and entrepreneurship, and who are enjoying leisure will resist authoritarian moves. According to Curtis and White (2002) changes can disrupt the ‘status quo’ or balance within a group and resistance becomes inevitable. The reasons for resistance identified while introducing new nursing practices are primarily “increased stress; denial; self interest; lack of understanding, trust and ownership; uncertainty; motivation; and personality” (cited by Fowler, et al, 2006, p.42). Under such circumstances introducing a smooth transition of change through participation, education, facilitation, psychological ownership, and development of trust is paramount. When a person in the position of staff nurse gets promoted to a management role there will be new responsibilities and challenges. Demonstrating “emotional intelligence,” the ability to motivate oneself and persist in the face of frustration, competence to use and manage emotions appropriately with confidence, and ability to learn are the basic tenets of a successful leader(Cesta and Tahan, 2002, p.169) Meeting with others in the organization, gathering information necessary to succeed, collaboration and team work, vision for quality improvement at the hospital, and becoming a champion of change will make the new incumbent an influential and inspirational leader. A persuasive leader intentionally uses her or his emotional power to coerce the emotions of others, through good communications skills, a collaborative stance, trust, and influencing skills. 2. Empirical-Rational strategy The rational-empirical approach (via research) assumes that “people are rational and will adopt change if it can be demonstrated to be justified and in their self interest” (Ridout 2002). It is assumed that people are rational beings and will follow their self-interest, and hence, can be persuaded or can be purchased. It implies that through effective communication people could be persuaded to change, and by extending incentives it will be possible to purchase them and brought into the changing pattern. At the same time, humans being inherently rational they will oppose or resist the change—overtly or covertly. Thus, even if reason and incentive work in the way of change the benefits derived from such changes should be attractive and outweigh the consequences. According to Nickols (2003), the selection of a change “centres on the balance of incentives and risk management” under empirical-rational strategy. In the normal course the participants of change will not risk what is currently they have for an uncertain future that is only modestly better than the present. However, by casting doubt on the viability of the present state of affairs, and its short life span, in a convincing manner it will be possible to change outlook. Even if the propaganda succeeds in convincing some members to embrace change, it may not be possible to include all of them to the group taking into account their stature in the organization. Although empirical-rational strategy may help buy change, it is difficult to deploy when the incentives available are modest. Team composed of individuals with common beliefs and identical abilities may consider a task from a single perspective, whereas a diversified or heterogeneous team is found to perform better and offer innovative solutions. Using good judgement for the appropriateness of a member in the team, and keeping a productive mix of people with diverse exposure and experience is the prime solution to the successful composition of a clinical pathway team. Defining specific roles of each member, based on the individual expertise will reduce role ambiguity and eliminate anxiety among team members and enhance performance and personal satisfaction. A cohesive partnership between team leader, managers, and members is the driving force for handling complex tasks and the successful culmination of team building. 3. Normative-Re-educative strategy Daly et al (2003) opine that change can be exciting and challenging, but also can “provoke feelings of uncertainty, anxiety, anger and powerlessness” (Daly, Speedy and Jackson 2003, p.195). Normative-re-educative approach is a “bottom up approach” (Ridout 2002). People are social beings and will adhere to cultural norms and values, and most people ‘go with the flow.’ Normative strategy hypothesize that successful change is based on “redefining and reinterpreting existing norms and values, and developing commitments to new ones” (Nickols, 2003). Charismatic and dynamic leadership will be able to influence cultural norms and value judgements and bring changes to the communities of practice. The strategy is to manipulate culture, which ordinarily doesn’t change quickly, and change people’s behaviour. Since culture change takes long duration and an organization’s culture is in the hold of its framework, normative-re-educative strategy works only when the relationships between the formal and informal organizations are at least cordial and hopefully harmonious. Since almost all change efforts have long and short term change strategies, normative re-educative strategies can be adopted for long term change. Enlisting and involving the informal leaders of the organization and keeping them involved, without overlapping of organizations, is integral part of this strategy. In-service training is considered as beneficial as it provides an opportunity to discuss problem cases and share experience with others, support respondents when there are uncertainties in the management of certain cases, and enables them to replenish their knowledge. Training also helps develop and ensure competencies with more active knowledge shared between the participants. It is paramount for a team leader to set goals and establish standards, encourage positive interpersonal behaviours, maximizing idea contributions by the members and interpreting these ideas and suggestions for better problem solving, mediate during conflicting situations, and show disagreement, if any, in a constructive manner. Case study Leadership is perceived as a “process of influencing others within an organizational culture and the interactive relationship of the leader and follower,” and leadership styles are classified into “authoritarian, democratic, and laissez-faire” ( Marquis, 2008, p.38) Leadership effectiveness, according to Hollander, requires “the ability to use the problem solving process; maintain group effectiveness; communicate well; demonstrate leader fairness, competence, dependability, and creativity; and develop group identification”(cited by Marquis, 2008, p.41). The case study detailed here is related to establishing clinical pathway in orthopedic medical care ward of a regional medical centre which was following standard nursing care procedure earlier. Since the clinical outcome, cost of care, and discharge rate were found to be very poor it was proposed to introduce clinical pathways, which was the emerging trend followed by healthcare regionalization. Clinical care pathways, also known as critical care pathways, have varied definitions and interpretations, and it is a health care management plan that “demonstrates goals for patients and provides the corresponding ideal sequence and timing of staff actions to achieve those goals with optimal efficiency.” (Pearson, Fisher and Lee 1995, p.941-948). Clinical pathways are “care management tools” involving “multidisciplinary activities” that have “proven to control costs with pre-determined standards of care using replicable processes, based on a sound literature review and meta-analysis, without decreasing quality of care” (Heidenthal 2003; Gray, 2008; & Meleskie & Wilson, 2004, p.1). Even though “effectiveness of clinical pathway is under debate”, up to 80 percent of hospitals in the U.S already use clinical pathways for at least some indications. (Rotter et al 2008, p.265). It is experienced that senior leadership support is essential for the success of clinical pathway approaches, and there must be physician and nurse campaigners. A multidisciplinary team was structured to develop a critical pathway and physicians were projected to supply leadership for such programs as they provide ‘credibility to the pathways and builds a foundation of support among all clinicians. At the first stage CEO of the hospital was approached and apprised about the prevailing condition, necessity for change, and feasible methods under clinical pathway approach. Though many of the staff was eager to learn about benefits of clinical pathways, majority were skeptical about new approach and preferred to follow existing standard nursing care pattern. Convincing the existing long term staff was the major challenge and changing their perceived notions required tactics. After deliberations with administrative, clinical, technical, and support staff a clinical pathway steering committee was constituted. Existing practices model and handy literature reviews helped in giving adequate training to the pathway team before deploying them with new task. Adopting the three fundamental change approaches detailed in preceding paragraphs helped to convince the benefits of clinical pathway and constitute a clinical pathway steering committee and formulate appropriate clinical pathway. Conclusion: A capable leader who considers any aspect of change as his or her personal priority and admits it in public, arrange resources, and assist surmounting any resistance is essential for bringing change. Any change initiative requires enlightening others in an organization about the impending threat and realities in the organization and justification for change followed by a vision for the future. Identifying those who favour the move and those oppose it and developing strategies to influence stakeholders should be the primary objective of a capable leader. Effective and timely communication related to change will eliminate any negative propaganda that may impede change initiative, and maintaining the tempo of activities already initiated will speed up change implementation. Bibliography CESTA, Toni.G., CONOVER, Mary.Boudreau and TAHAN, Hussein A. (2002). The Case Manager’s Survival Guide: Winning Strategies for Clinical Practice. [online]. Elsevier Health Science. P.169. Last accessed 14 March 2009 at: http://books.google.com/books?id=Y-Hqst31NwoC&pg=PA11&lpg=PA11&dq=three+categories+of+change+strategies+used+in+clinical+pathways+of+nursing+care&source=bl&ots=Z3imn8bxdv&sig=3XJENF5acpPoRHYkraFSRv_N-B0&hl=en&ei=ceS0SZHHF9K1kAXny9GqBA&sa=X&oi=book_result&resnum=4&ct=result#PPA7,M1 DALY, John., SPEEDY, Sandra., & JACKSON, Debra. (2003). Nursing Leadership. 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