Leadership in Nursing - Essay Example

Leadership in Nursing Introduction: NHS Hospitals have been devising standards against which performance of nurses are to be measured in order improve lives [DH press Release, 2001]. In view of legislative changes and shortages in the allocation of funds that is coupled with a rising number of patients requiring care, there is a need to improve utilization of existing resources and skills through the exercise of effective leadership, which is also flexible and responsible to constant change. When two district nursing terms are merging, the need for effective leadership is even more vital and the grouping into teams needs to be carried out on the basis of complementing of individual skills. Leadership Theories: As pointed out by Hughes et al(2002), “Leadership is a complex phenomenon involving the leader, the followers and the situation.”(p 6). Therefore leadership cannot be assumed to be a position, rather it is a process of interaction between a leader, followers and the situation. In maintaining a competitive advantage, organizational leadership in health care districts must ensure efficient utilization of funds and other resources, ensure patient safety while also providing a positive health care environment to effectively manage health care services.(Waters 2005). The deficiencies that exist in both districts must be identified and addressed before formulating the new team. Peter Senge (1990) presented several ways of thinking and acting of the leadership of an organization in such a manner that learning systems within it can be changed to address the weaknesses. Cathon(2000) has applied these principles in a health care context, through the perspective of an interdepartmental health manager. On this basis, he challenges first all the preconceived notions of job limitations – for example, once a radiologist for example, always a radiologist. While moving into a new context, redefinition of roles may be necessary. As pointed out by Glen (2003), increased technological advances have also introduced the concept of physician intervention through video conferencing, which enables a physician to attend to several of his patients at various stages of recovery at one time. This has necessarily imposed greater responsibility on nurses who now make triage decisions, perform minor surgical procedures, administer drugs and manage treatments, some of which were the exclusive province of a physician’s job [Glen, 2003]. From 1996, the Government has empowered nurses to fill the gaps that have resulted as a result of reduction of hours for junior doctors, which has called for additional skills from nurses in carrying out in part, those functions and skills ascribed to the physician [Glen, 2003]. Therefore, staying circumscribed within the fixed boundaries of a particular role may be ineffective and need re-learning, as suggested by Senge. Secondly, Cathon (2000) also points out the myths of learning from experience and the management team, applying Senge’s theory in demonstrating that while changes may occur in leadership and there has supposedly been a learning from the experience, the reality often a missing out of the long range effect of these changes and its impact upon the organization. Similarly, management teams may be involved in power and ego battles, avoiding anything that might make them look bad on a personal level. This negates their actual function, which is to identify and solve problems. Girvin (1998) has also highlighted the need for revised leadership roles for nurses and a change in existing nursing practice while merging two teams, to make it more patient focused rather than administration focused. Kassean and Jagoo (2005) examined the practical applications of a process of change in the handover system among nurses on shifts, who were originally members of different teams. They were able to pinpoint the need for re-learning among nurses. The traditional mode of handover ignored the psychosocial aspects of care and was a source of dissatisfaction for patients and their families. During the process of learning to hand over at the patient’s bedside to provide opportunities for interaction and reassurance to the patient about his/her care, the study found that a great deal of training, persistence and time was required for nurses to re-learn traditional methods and adopt new ones as they learnt to work in different groupings.. Transformational leadership: The transformational leadership approach as advocated by Bernard Bass (1985) states that a good leader will try to transform the attitudes and relationships between the people who work under him. For example, as opposed to attempting to control the behavior of their subordinates, transformational leaders are more interested in coaching staff and providing guidelines for conduct rather than exerting high levels of control. As a result, the atmosphere created within the workplace is a more relaxed, supportive environment where there is scope for individual differences and high levels of communication between leaders and their subordinates, since the leader is willing to listen and help her subordinate to improve and adapt her conduct and skills to the requirements of dealing with different kinds of situations. Bass and Avilio (2000) have pointed out the differences between transactional and transformational leaders – although most leaders may display both kinds of characteristics, they tend to gravitate in one direction or the other. A transactional approach to leadership is one where the leader’s actions and relationships with subordinates/followers arise in response to a particular situation. A transactional leader is not so heavily concerned with morals or ethics, neither is he overly concerned with bringing about deep down changes within the existing system and orienting himself and his organization towards long term goals (www.bgfl.org). However, in the modern day organizational context where conflict of interest and ethical standards are increasingly under scrutiny, especially within hospitals, it is vital that nurse leaders possess moral integrity and high levels of honesty, which is associated with the transformational style of leadership. A transformational leader seeks to inspire and elicit desirable conduct from subordinates through the use of ideals, inspirational tools, intellectual stimulation and paying attention to individual differences in order to motivate employees to be committed to their work. In this way, a transformational leader also seeks to bring about long term changes within the organization rather than merely reacting to a particular situation or crisis. Such leaders possess the ability to move beyond consideration of their own interests and power play towards a deeper understanding of organizational problems and employees. In the nursing context within NHS hospitals, transformational leaders are likely to be much more useful than transactional ones, especially when two separate teams must learn to work together - a situation where flexibility and a creative approach will be necessary. With the introduction of the Human Rights Act into UK law, it is now necessary for public bodies to uphold the individual freedoms such as the right to life, privacy, protection from degrading treatment, discrimination, etc that are contained within Articles 2-12 and 14 to 18 of the First and Sixth Protocols of the European Convention of Human Rights. Moreover, the percentage of sick people using NHS hospitals in the UK now has a significant percentage of minorities. A research report was prepared by Shah and Priestley (2001) examined the experiences of black and minority disabled patients in Leeds hospitals and highlighted some of the specific concerns of Asian and black disabled patients, such as the obstructions to their health care that resulted from the lack of sensitivity of health care providers to language, religious and cultural issues. Therefore, the merging of two district teams of nurses will need to be sensitive to the patient concerns of both districts. One of the most notable features that needs to be assessed in today’s clinical setting is the need for possession of computer skills, since working in a clinical setting mandates the use of several sophistical electronic machines and gadgets and information systems are a vital part of any public hospital/clinic setting. This is also an instance where nurses may have to re-learn traditional practices to adopt a more techno savvy, multi tasking role (Girvin, 1998). Redman et al (1999) state that nurses must be assessed on their ability to work with data and to develop cost effective alternatives for practicing in a clinical environment. Therefore, basic accounting and technological skills are mandatory advanced skills that are required, in order to make the transition from novice to expert nurse. Therefore, without a transformational leadership style and the ability for multi-tasking, nurses are unlikely to be fully effective in the modern day clinical setting or function cooperatively as a team. As a result, in the context of two district teams of nurses merging, a transformational approach to leadership can bring about constructive responses to the changing medical environment and health care needs. A team based approach: Unlike small private clinics that may be controlled by a single individual, two district teams of nurses cannot successfully employ a top down, hierarchical approach, which may be too rigid and inflexible in dealing with situations where quick thinking and fast action are called for, such as those experienced by critical care health care professionals, for example. Some of these competencies which are essential for advanced health care are critical thinking, problem solving, communication and effective assertiveness.[Redman et al, 1999]. Since many health care services involve the interaction of several health care providers and professionals, a team based approach where individual competencies are harnessed and utilized within a composite framework of group skills are likely to achieve good results. For instance, Belbin has identified nine separate roles with an individual team or group of people working together (ww.changingminds.org). Functionally, the roles are divided into three categories (a) doing (action) (b) thinking (problem solving) and (c) People (feelings). Under the first category, Belbin identifies there distinct roles (i) Implementer – who takes basic ideas and makes them work (b) Shaper – who is energetic and challenges others to move forward and (iii) Completer – who is able to ensure that the task is completed and irons out the wrinkles. Similarly, in the problem solving category, Belbin identifies there separate roles (i) the Plant – who is able to come up with original, creative ideas, but may ignore details (ii) Monitor – who is able to assess the larger picture and think carefully about it and (iii) Specialist – who has special skills in problem solving in a particular area and will tend to ignore other aspects. Within the last category of dealing with people the (i) Coordinator – is the overall leader who assists everyone in focusing on their tasks (ii) team workers – who cares for others and works well with them but may not be able to make difficult decisions and (iii) Resource Investigator – who is able to explore new possibilities with others. According to Belbin, a team must be well balanced in terms of primary roles if it is to function together effectively. In order to achieve the best balance, she recommends that there should be a Coordinator or Shaper who must be the leader of the group, one Plant to stimulate new ideas, one Monitor to assess the big picture and maintain honesty and one or more Team Workers, Investigators, etc to carry out the necessary duties. In this manner, individuals who are well suited and possess the skills to fulfill a particular role can be assigned those tasks and the team functions well as a group because all elements are covered. Robert Blake and Anne Adams McCanse (1999) have also advocated a team approach by identifying a leadership grid, based upon which a team management approach is advocated and these authors believe that this approach is ideal. Such a team management approach identifies leadership as a grid in which the various parts of the grid are interlinked with each other and various employees within a firm work together on a cooperative basis with an equitable allocation of responsibilities on the basis of the skills possessed by each individual employee. In order for the organization to achieve its entire potential, the underlying premise is that all the parts of the system , i.e, the people in the organization, must work together in order to achieve a common objective and piece meal objectives are unlikely to work. The authors recognize however that implementing an integrated system may be difficult in practice and have therefore recommended that managers in the organization foster team work and encourage employees by motivating them to reach higher levels of achievement. Such a team based approach may therefore be seen to be very effective in the health care context. Responding to a health care crisis or a lack of funds with piece meal solutions will not be effective and will function in the nature of magic bullet ideas that may work temporarily but will not be effective in the long run. For example, fostering cooperation and team work will involve flexibility on the part of the managers/leaders and they must first of all understand the need for deep change and then go ahead and adopt the kind of measures that will bring about those changes. By grouping individuals from both teams on the basis of their special skills, individuals can focus on what they are good at, thereby improving overall efficiency of operation in the long run. This may involve a mixing and matching of individuals from different districts, however the grouping must be done on the basis of roles, such that nurses complement each other in the skills and competencies. The successful constitution of teams will depend to a great extent upon the characteristics of the leader and her/his ability to discern and correctly assess the skills of individual team members and direct them appropriately. According to the theory of leadership advocated by Hershey and Blanchard (1996), the dimensions of leadership are as follows: (a) leaders show task behavior and relationship behavior. As a result, a good leader will be oriented towards achieving maximum output and productivity in terms of getting a particular job done, while at the same time, he/she is also concerned with the relationship between the various members of the system. (b) The effectiveness of a leader will be determined by how effectively he/she is able to interrelate with the situation on hand and at the same time, how effectively the leader is able to take into consideration the willingness of employees and team members to perform their designated tasks. The nurse’s role today is not restricted to provision of care, but also involves significant levels of interaction with patient families, maintaining confidentiality of patient health records, management of insurance and such financial aspects, a keen attention to ethical practice, and other similar qualities. Therefore, leadership models that are likely to be effective are those that are communicative and interactive rather than a strict, top down approach. Every team must therefore include individuals who are skilled at communication and there must be a high level of interaction among nurses, patients and their families for the best standards of care. The role of mentorship in nursing: The relevant literature in this regard points to the fact that quality nursing practices need to be based on current knowledge [Francis et al, 2001] and traditional theoretical, text based learning is inadequate to prepare a nursing graduate for the real world and the changing face of health care [Goode and Krigman, 2001]. A well informed, practicing mentor who is experienced in clinical procedures while simultaneously being aware of the requirements in the teaching field functions as an effective teacher for a nursing graduate, to orient her into clinical practice [Reid, 1994]. On the job performance appraisals are an important learning tool for a nursing student [Black, 2000, pp 37,38]. Feedback provided by a mentor serves as a valuable tool for the student to understand what he or she is doing wrong or right, so that corrections may be made appropriately. It provides an opportunity for the student to reflect every day upon what he or she has learnt and apply the principles in actual practice [Glover, 2000]. The importance of the need for reflection in a nursing graduate has been stressed by many professionals [Stockhausen 1994; Glaze 1998; Greenwood 1998]. The mentor performs a vital role in the education of a nursing student and in preparing her to face the challenges of the health care environment. He/she is able to impart to the student, knowledge of a critical nature, knowledge that is likely to be the most useful and practical that the potential nurse is likely to find throughout her nursing education. While working in a clinical situation under the experienced guidance of a mentor who is also qualified as a teacher, a nurse is able to receive educational benefits coupled with professional experience as well. Studies have shown the benefit that students acquire in a professional sense from training acquired in a clinical situation under the guidance of a mentor [Reid, 1994]. Nursing candidates demonstrate an enthusiasm for learning under these circumstances, in a real clinical environment which is likely to be beneficial in refining their nursing skills [Edgecomb et al, 1999]. Such knowledge goes towards refining the skills of a student nurse and helping to orient her into the professional scenario that she will face once she graduates. This apprenticeship under a mentor is of value to the student in a professional sense, since it provides practical knowledge and an intuitive medical sense through self assessment and the development of critical thinking skills in real life situations. This training acquired under a mentor could also qualify as valuable on-the-job experience, which will also enable the student to be better prepared for the job market, since she is already armed with some training acquired on the job. Mentorship is not however, restricted only to novice nurses who are fresh graduates. Mentors have also been found useful in situations where nurses have been practicing for some time and are enhancing their skills in other areas of nursing [May et al, 1997]. The nursing profession has become increasingly specialized and basic level nursing is now becoming specialized to deal with midwifery, orthopedics, geriatrics and a variety of disciplines which apply basic nursing standards but are enhanced to add skills in specialized cases of treatment. It is in this professional area that the role of mentors is even more important. Qualified mentors are able to provide valuable, practical training and offer insights into specialized treatments based upon their own skills and knowledge, which is of great benefit to the nurse trainees. Conversely, mentors are also able to better evaluate their students in this one on one situation rather than as a part of an entire class of student nurses. Mentors also need training in responding to the ever changing demands of the nursing field, in order to better prepare their candidates to face the real world of medical problems. In a survey conducted in early 1999 on mentor preparation at Glasgow [The Nurse, 2000], some of the participants were unsure of all the requirements of their mentor’s role and felt that they needed more preparation. Additionally, some mentors are ill prepared for their role as teachers [May et al, 1997] and there appears to be a need to organize effective lecturers for mentors as well, in order to enable them to emerge as well integrated individuals, who are able to perform their professional role in coordination with their teacher’s role in evaluating and assessing their candidates’ performances and skills. Thus, when the two groups of nurses work together, a judicious mix of students can also be included within the teams, so that there is less financial outlay while the students also get the opportunity to learn skills in a clinical setting. Conclusions: Health care is a rapidly changing field, positive ethical, legislative and moral challenges which mandate responsible, innovative and flexible leadership. Traditional conceptions about medical services and health care professionals have been changing in recent years, in view of the increasing onset of diseases and the changing needs of the public within the UK, which also includes a significant minority population. According to Dr. Benner (1984), knowledge and skills in nursing practice can be acquired without ever learning the theoretical aspects, although a sound educational base is undoubtedly an asset. Through the experience a nurse has gained and her ability to assess the entire picture, she is able to effectively perform her duties without undue risks to the patient or unnecessary panic in an emergency. Recognizing the value of experience, the NHS has also initiated research into ageing and a reassessment of its recruiting and employment policies.[www.nhsemployers.job, n.d.]. In recent times, patient inflow into hospitals has been increasing however financial resources and programs available to cope with health needs have been declining. As a result, creative leadership is necessary to reorganize and utilize existing resources in a more efficient manner. Health care is adopting an increasingly patient centered approach, while the nurse’s role has been changing into a multi faceted one. As a result, mentoring is very helpful to a student nurse in order to grasp the realities of the workplace and the need for critical thinking, quick reflexes and a steely nerve to ensure that the health of the patients is not compromised. Therefore, when this is applied to two nursing teams from different districts which are in the process of merging, the rearrangement into teams must be done with care and skill, such that skills of individuals are complemented while the financial cost of such an exercise is also minimized by including mentors who can guide nurses in making the right decisions to preserve patient safety. Moreover, re-learning of many traditional practices may become necessary, since what was workable in one district team may need to be changed to suit a larger framework of nurses, dealing with a larger patient base. Technological skills may also have to be acquired and the more skilled nurses can be paired with students to achieve a workable combination and effectively satisfy patient needs within existing resources available for nurse salaries. As Girvin and Senge have proposed, one of the major aspects of eliminating the detrimental effects of change within organizations is to adopt flexibility and re-learn traditional practices in order to make them more suitable for the changed environment, such as the change in the handover practices described above. A team based approach is likely to be extremely helpful in promoting efficiency in the health care system. Nurses and doctors working in small teams that are grouped together in such a way that their talents and skills complement each other, will ensure that more time is spent on productive work and less on arguments or jostling for power. Each individual’s special skills in a particular area can be identified and utilized for maximum efficiency in operations. . References: * Bass, Bernard, 1985. “Leadership and Performance beyond expectations” New York: Free Press. * Bass, B.M, 1998. “Transformational leadership”. 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